HomeMy WebLinkAbout30493 / 79-22Dece�er 6, 1979 � 22 gESpy�IpN
PURt''C1S�: CJtJTRACI' WIZii STATE DE�AHITff�]T OF i�i,1H AND SOCIAL SERVIC�'S
� �: �• ��•� � t
WHF.:f�'�S, �e State of Wiscor�5� h_as maxlated that �icipalities wnduct
outmarh a-� ^eal'rh screening programs for eligible individuals; and
WHEI�FLS, _z.is pmqram is 100$ reimbursable by the Stabe of Wiswnsin;
NOW, Tf�""?_'�RE, BE IT RFSOLVED by the Ccamnn Coimcil of the City of Oshkosh
that the procer City officials are hernby authorized anci directed tn enter into
the attached Agreez[pnt with the State of Wisoonsin, Depart�rent oE Health and Social
Senrices, for an early and periodic screening, diac�x�sis a�ttl t,rnatrrent program
(EI'SI7r) , which will include PR�7EC.T WI'REACfi and referral services.
SIILC.:.TTTP,D B°
- 22 -
/ ~_� J
::
Agreement made this
lst day of October
1979 by and
:.:. , ._.. ..... .., :.ar<:-.
a�--
.�
between the State of Wisconsin acting by and through the Wisconsin Department.
of Health and Social Services, hereinafter referred to as the Department, and
Osh};osh City Health and Welfare Department, 215 Church
Wisconsin, hereinafter refezred to as Contractor.
�., P.O. Box 1130, O�hkosh,
Wisconsin 54902
WHEREAS, the Department is the single state agency responsible for the
administration of Wisconsin's Medical Assistance Program; and
WHEREAS, the Department in that capacity is mandated under State and
Federal law to administer [he provision of ear2y periodic screening, diagnosis
and treatment (EPSDT), of Medical Assistance recipients under the age of 21
for the purpose of ascertaining physical or mental defects and providing
trea[ment to ccrrect or ameliorate defects and chronic conditions found; and
WFIEREAS, t'-:>_ Department is of [he opinion that achievement of 1ts
administrative t?SDT responsibilities and attainment of objectives of the
EPSDT program caa most effectively, economically, and expeditiously be
procured through contract; and
{dEiEREAS, Contractor has demonstrated both an ability and willingness
to render the Department the type and quality of services it requires;
NOiJ, THEREFORE, it is agreed by the Department and Contractor that
Contractor shall perform those services speciiied in Appendix A in accordance
with the terms and conditions set forth therein. This agreement and Appendix A,
attaehed hereto and incorporated herein by reference, comprise the e�tire
contract between the parties. Unless terminated as set forth in Section K, '
Appendix A, this contract shall continue in effect from date of execution
for a period of 6 months.
IN WITNESS idHEREOF, the parties have executed Chis agreement this �
day c: , 1979.
State of Fiisconsin
(Name of Agenc.�? Department of Health and Social Services
(Address)
(Signature of :._=�orized Agent)
(Title)
�:' ....,.._. ,
h.. � . . . �+�i . �— .
sy :
�z�(,
� --�- � \� �� ��r.. � � �
� ' �: ..% 1*^ 'P �''� ..r'
- ✓ .. _ 4+'�R.:i L . _
I...sa. . � .._.. �� . ..... � ... ...� _ . / — .
/ -
., A.
General Obligations of Contractor: ��
1. Contractor in accordance with the sCandards and performance requirements
2.
3.
4.
5,
specified in Sections B through K shall initiate contact
with individuals eligible to receive beneffts under Wisconsin's Medica7.
Assistance Program for the purpose of notifying those persons of Lhe
existence, nature, and availability of Early and Periodic Screening,
Diagnosis and Treatment (hereinafter referred to as EPSDT) services
under the Medical Assistance Progracrt and to encourage Yhem to avail
themselves of those services. In the event a person contacted elects
Lo procure screening, diagnosis or treatment services thro.ugh the
EPSIIT program, Contrac[or shall offer, and provide if zequested,
assistance in the scheduling of the services sought and assist in
effecting the conveyance of person to and from the location o£ those
services.
In the performance of its obligations under th3s contract, Contractor
shall ^.ot engage the services of any person or persons now employed by
the Scate of Wiscansin, including any department, commission or board
thereof, without the prior writien consent of the emp2oyer of such
person or persons and of the departmen£.�
Sect3on 26.765 of the Wisconsin Statutes requires the following
provision be included in every contract execnted by an ageney of the
State of Wisconsin. Accordingly, Contractor agrees as follows:
In connection with the performance of work with this contract,
Concractor agrees not to discriminate against any employee or
applicant For employment because of race, religion, edlor or
national origin. The aforesaid provision shall include, but hot
be limited to the following: employment, upgtading, demotion or
transfer; recruitment or recruitr�ent advertising; layoff determination;
rates of pay or other forms of compensation; and selection £or
training including apprenticeship. Contractor agrees to post in
conspicaous places, available for employees and applicants for
e�ployment, notices to be provided by the contracting officer
setting forth the provisions of the discrimination clause.
Cor.c==_ctor shall at all times comply with and observe all Federal and
Sta�e laws and regulations 1n effect during the period of the cotttract
ahz�= in any manner affect Contractors performanee under the terms of
t�> =��tract.
Co-c-=_c*_or shall be responsible for the perforr.ance of and shall
su?e—ise the EPSDT outreach effort contemplated under this contract,
Con�ra�tor shall have the authority to coatrol and ditect the performance
of t'�>_ services which are the subject o� the cantract, the Department
i?'E'r�a:.�.. .. .
- 1 -
. •..s . � .��3 __ . ..
�_ . .. . �.. . �.?!YS ��.. .
.�.�
,.� -... s? �?..a -
�X�^. y: �
6.
7.
8.
_ _ __.-. . - - _ .�,,. _
. ". . .. _ , .. � r,;.z r�-._,:,., - -
be3ng interested only in the result obtained. Hocaever, the Contractor'
. . - -- ' -
performance of the contemplated tasks mus[ meet wlCh the approval of .
the Department and shall be subject to the Department's general right
of inspection and supervision to secure satisfactoxy and timely comp2etion_
No person acquired or c.mployed by Contractor to perform the services
which are the subject of the contract shall be deemed to be an employee,
an agent, or servants of the State of Wisconsin or the Department.
Accordingly, noae of the benefits provided by tlie State or the Department
to its employees, including but not Iimi.ted to workman's compensation
and une�ployment insurance, are available to the employees o£ Contractor
employed to perform the work conCemplated under this contract.
Any coatroversi.es or disputes between the Department and Contractor
regardi�g the quality, quantity or timeliness o€ the services rendered
Dy Co�__zc[or pursaant to this contract shall ba submitted to arbitration
in acc:.='_ance with the provisions of Chapter 298 of the Wisconsin
Sta[ut=s.
All materials, records, or other documentation developed, utilized or
maintained by Contractor pursuant to this contract shall be the exclusive
property of the Department of Aealth and Social Services, and shall
not be u[32ize3 by Contractor for any purpose other than for the
pursuit and fulfillm ,t of its contractual responsibiZities.
9. Contractor shall, in acwrdance with State and Federal law, preserve
10
11
the conFidentiality of recipient related data it utilizes in per.formance
of services under this contract. Contractor shall not disclose to any
person information identifying the Medical Assistance recipients which
are the subject of its efforts except whzn necessary to per£orm its
obligations under the contract and when directly connected with the
admi�s:ration of Wisconsin�s Medical Assistance Program.
Con�=>:�or shall not, without prior written approval of the Departnent,
suDcv-==act for the perfoxmance of any Contractoz's obligations under
this --�tract. Notwithstanding approval by the Department, no subcontract
sha'__ =a:.:.inate or any way effect the primary legal responsibility of
Cont__c a r[o the Department for the timely and satisfactory performance
of tce :Sligationg contemplated by this contract..
The De:>rtnent shall notify Contractor of scteening providers it has
certi:`_=_? to provide EPSDT screening servi.ces within the geographic
area specified in Section A
_"_� . ' . -. . ,.. ' .. . . ._ Fo= ....
Contractor sha12 enter inta written
- 2 -
9
� . � . . � . � . -' -yir
._.____.�-..J._--.__��_ _ .ie"=w:.
�--..i ...�
. . . _ �.�_�. _' 's. 7c..=
{ �
_ _ .,. . : �`- .. . . . . ._. r_. _ . . ...
s s,'i�
. . .. ___. _ .__ '�.2'� i��ydYi..'1`�
- '_..'__—___—'— '—_ _ " -.. ' ,:.�r_1-_-.
, arrangements with one or more certified EPSDT sczeening providers to
secure timely and.convenient delivery of screening services to all �
recipients requesting sereeniccg.
B. Contractor.'s Internal StaffinQ:
1. To perform Contractor's obligations under the contract, Contractor
shaZl procure by contract or retaiu in its enploy_
(a) Health care professionals, field workers, clerical, and other
personnel in adequate numbers to insure the satisfactory and
ti�ely completion of its contractual responsibilities.
(b) At leasC one skilled health care professional, who shall direct
(c)
and supervise'the efforts of personnel engaged 3n the performance
of s�rvices under this Contractor. .Gontractor shall notify the
De:a=tnent of the name, eredentials and relevant experience of
th>_ '_�dividual that the Contractor desires to perform this supervisory
role. Said person may include a physician, dentist, nnrse,
nursing home or hospital administrator, licensed under the laws
__��
of the State of Wisconsin. Other health care professionals may
qualify for this supervisory position if possessed of education,
training and experience which in the opinion of the Department
reflects their ability to serve in that capacity. The Department
may not unreasonably withhold approval of personnel who have been
" selected to serve in the supervisory position contemplated by
this paragraph.
Contractor shall cause to be prepared written instructional
materials, which in conjunction with verbal instructions, shall
be utilized to orient Contractor's personnel of (i) the nature
2:� extettt of EPSDT services avaiZab2e under the Medical Assistance
Pra_am; (ii) the criteria employed to establish an individual's
e=�__ewznt to receive those services; (iii) tha contractual
re__=e;�eats which must be adhered to by Contractor's persoanel
F_ _=espec[ to the performance of their respective duties;
a-_ i-c) the internal procedures to be adhered to in the performance
of -'S?I' outreach services contemp2ated by this coatract.
.. Location & Pre_ses of Contractor's Base of Overation:
1. Contractor shall whenever possible locate a base of operatfon in the
- 3 -
! a4 _. . .. . . . . . _. . . -. ..
� .
, . , _"_
- . -- - y= �.�
-.,.�.t ..?-. = �N
. .p.a.,Y. _ . ..�.. .._.�.1�. ..._. .'}.. � .
D.
`.-
2.
3.
�__ _.
.: . , . .r- . :
_ . _,_--_ ,
geographic region within which resides the riedica2 Asslstance recipient��r .
populat3on that are the subject of Contractor`s serv3ces under this �-
con[ract. To the extent economic feasibility and space avai2ability
permit, Cantractor shall locate wi[hin sald region to enable affected
recipients ready access to Contractors fac3lity, and to faciliCate
face-to-face contact with recipients with a mini�mum of travel by
Contractor's personnel.
The physical premises af Contractor bases of operation shall be of
sufficient size to accoimnodate the in-house con[acts caith the targeted
recipient population. Said premises shall be maintained 6y Contractor
3n compliance with state and local building and safety codes. The
physica� environmeni of the premises shall be structured in a way
that p= �'ts privacy and confidentiality in cotmuunications between
_�
recipie==s and Contractor's personnel.
1
Confracc_= shall provide telephones, office equipment aad supplies
suffici=_== to support the needs of its personnel in the performance o£
their res�:ctive duties. Contractor shall �^aintain in locked filing
cabinets all case management records relating to the Medical Assistance
recipients which are the subject of it's.contraetual efforts.
fiotification to Person's Eligible for EPSDT Services
1. Medical Assistance Recipient Listings_ The Department, through its
fiscal agent for the �tedical Assistance Progra�a, shall on a monthly
basis prepare and submit to Con[iactor three separate listings of
Medical Assistance rec3pients eligible to receive EYSDT services.
Each ].ist sha21 provide the name and other material inforaation
pertaiaing to eligible recipients uader the age of twenty-one residing
withi^ =ie geographic region specified in Section H. The lists,
cateo� _=ed by the nature and extent of the recipients previous involvement
srlth _a EPSIIT program, are as follows:
(a) '�=_?c21 AssisCance recipients certified or recertified £or eligibiLity
_ _ :g the previous month.
(b) '_'=c`_caZ Assistance recipients who previosssly received screening
se-^ ces via the EYSD2 program and are due for res�reening under
t^=_ ?rogram within one mon[h, in accordance with their position
c- =ne periodicity schednle adopted by the DepartmenC for the EPSDT
Pz^gram.
—4—
_.. ._�, ...v.� .
_. _ �. : .
� � Y�::
_ � _._.!`t_� ti ��,;-`..
� � �
2.
. . .�;. ��.� .-�::�;_�.
(c) Medical Assistance recipients who have not previously been successfally
contacted and informed of the availability of EPSDT services or
refused or failed to avai2 themselves of EPSDT services when �
contacted eleven months previous.
Utilizing the recipient listing described above, Contractor shall
locate, contact and inform the individual identified thereon of the
availability and scope of EPSDT services offered under Wisconsin's
piedical Assistance Program. As more fu11y described below, the extent
of Contractor's responsibility in notifying to [hose lndividuals shall
vary depznding on the list upon which the individual appears.
Notification to Persons Certified or Recertified for Medical Assistance
Benefits=
(a) Co=_ractor shall imnediately, on receipt of the eligibility
lis;ing described in paragraph 1(a) above, locate and attempt to
cc_�ct via First Class, United States Mai1 the listed individuals.
Sa`_'_ =ailing sha1L incZude written material, (the format and
con:eat'of which/has been prevlously approved by the Department),
which in clear and non-technical term9 informs the subject individual
of tie following:
(1) The scope of preventive health services available under the
EPSDT Program and the bene:its the individual can expect to
derive by exercising his or her right to those services.
(2) The manner by which the preventive health serv3:ces offered
under the E°SDT program may be procured by the individual.
(3) How the individual may obtain additional informat3on relating
to the EPSDT program and the services i[ ofters.
(4) Screening services available to the individual under the
EPSDT program with an eacplanation that said screening entails
the application of quick, effective and simple medical
procedures to detect diseases or disabilities, some of which
c:ould not, without the use of screening, manifest themselves
in obvious symptoms for considerable periods of time.
,_. A brief su�mnar� of the period3city sehedule adop*_ed by the
Sta[e of Wisconein for its EPSDT program, with an explanation
that eligible individuals are entitled to receive both
initial and periodic screening in accordance with the periodicity
schedule.
- 5 -
,.�:: '.. ,.K�....- _`��„�:
- - *-.- w-
- 4 ^�,-x "� � � �s
. . : . _ . ._ .;.. -4 - _ --" �-�.:'=zy;-
, �:�.?.r, .
(6) That
� . '� -
the extent covered under Wisconsin's Medical Assistance f�
Program. medicaI, services required to address conditions
detected as a result of screening w3.11 be provided, at no
cost to [he ind�vidnal.
(7) That in the event screening detects medical problems, the
treatment of which requires medical services not reimbursable
under the Medica2 Assistance Program, the Contractor will
provide assistance 3n referring the subject individual [o a
health care provider capable of providing the medical services
required.
(8) The individual has the right to select a provider of his or
her choice to provide the EPSAT services the ind3vidual
desires to receive and that in the eveut the provtder the
individual selects does not offer a Full range of availahle
EPSDT setyices, the services the provider does not offer may
be obtained by contacting Che Contractor.
(9) The Contractor will, upon request, assist the individual in
the scheduling appointments for screening, diagnostic and
tzeatment services.
(10} The Contractor will upon reques[, provide assfstance in
transpor[ing the individual to and from schedaled EPSDT
related appointments. (The scope of the transportation
assistance the Contractor is authorized to provide is
specified in Section E2.) �
(J.1) The individual retains the right to avail himself or herself
of EPSDT sezvices as Iong as the individua7. retains his ar
her eligibility for Wisconsin Medicai Assistance benefits.
(b) __.= initial mailing referred to above must also include a separate
cr detachable interest card on which the recipient of the mailing
c_: dzsigaate whether they desire to avail themselves of the
__?: services offered. The mailing r.�ust also include a preaddressed
ce__� envelopa, wi[h suffzcient postage affixe@, to ettabZe the
_-_cidual to return the aforementioned card by u�ail to the
Ccctractor. - ' . ' � �
(c) I' :-ithin ten (10) days of the initial mail3ng Contractor has not
rec_ived a response from the recipient of the mailing, Contractor
shall attempt to initiate persoreal contact with the subject
. _ .� .
— 6 — � - '
. . _ . _. - 'r=' -�__-
... . _ . ' ; -� "`,tiw+�'v.r . �-�.-',7"ir _"'
.
. � �:: .. . :.. .. : . ..
�.' . ��_.. _� . . �: :-. r_'�- �.,;
. _.,,:
-.�-e.._. ...�-un�. ,.->.,.� �-.>:.' .. _.�-.+... .:= - - - ._ _ � .��.�
�
�
�
4.
5
6.
\,
individual to ascertain whether the individual desires EPSDT
services. Contractors 3nitial attempt to 3nitiate personal
contact sha11 be made via telephone. If the subject individual
does not have a telephone at their residence, or the Contractor
�
Is unable to effect teZephone contact within 10 days, Contractor's
personnel shall immediately attempt to effect contact Witti the
individual through a personal visit to the person's place of
residence, Contractor sha21 maintain records identiEying the
manner, time and date of all attempts to effect persona2 contact
tirith the subject individual.
Notification to Recipients ldho Previous2y Received Screening Services
Via the E?SDT Program. Upon receipt of the eligibility listing referred
to in pa=>_�raph 1(b) above, Contractor shall notify the individuals
lis[ed t=a�eon, that in accordance wi[h the Departmeat's periodicity
schedula, ::ey are due for rescreening services within one months
time. Sz`_c notification may be made by mail, telephone or face-to-
face cont=_:t. Contractor shall fndicate in the individuals case .
management file the date and manner 6y which the individual was contacted
and advised of the rescreening.
Notification to Medical Asszstance recipients who refused failed or
were o[herwise unable to avail themselves of EPSDT services eleven months
�revious. Contracior shall upon receipi of [he eligibility listing
described in paragraph 1(c) above locate and contact by mail the
individuals listed. Said mailing which shall be sent to the 3ndividua2s
last known place of residence must include written material which
satisfies the reqairements of pazagraphs 2(a) and (b) above. Contractor
shall indicate in the individual�s case management fi.le the date of
said � __ing.
Comm�cations crith I11.iterate Bliad Deaf or Non-EnQlish Speaking Recipients.
For t:e p;::pose of conveying EPSDT related informat3on [o elig3b2e
indi�==-�s under paragraphs (2), (3) and (4) above, Contractor must
deve_c_ _-ocedares and resources to allow efFective communlcation with _
non-=-_�;a speaking persons or Qersons who are i213terate, b11n3, or
deaf.
Noti�__acion o£ Entitkeaent to Maternal and Child Health and CrippTed
Childrec 5>_rvices under Tit1e V of [he Social SecuritY Act. .
(a) i= Department shall notlfp Contracto� of the location of agencies -
_ � _
. , . .t.�-4•_..
- -- ----- _ `-----_-_;
. . � . . _ -.._..;_ '_.;:.�.. ._:�:r`.:�
� ` �' r
' ' _ ' "'r �... ni r.�i"`�..��� � �.�r
.. . _"'< . .. , ��-a.:. h. .��-y
. ' �
funded under Title V of the Social Securfty Act to provide servicL�
within the geographical acea Contractor serves. Said notification
shall also specify'the services offered by those agencies and the
cri[eria 3ndividua2s must meet to establish eligibility for those
services.
(b) Contractor shall develop a working knoraledge of the information
prov3ded under subparagraph (a) above such [hat it can determina
phether 3ndividuals identified on the HPSDT eligibility lists
that are the subject of paragraph D(1) would be entitled to
services from Title V funded agencies.
(c) Coatractor shall inform individuala qualifled for both EPSDT and
Title V benefits, of the services available to them through the
Ti:le V funded agencies, and shall refer individuals desiring
such services to the appropriate agency.
g. A'ssistance to Individuals Who Desire EPSDT Services
1, �pointr=_n[ Scheduling. Contractor shall in its written and peXSOnal
2.
contact c:ith recipients offer assistance in schednling of appointments
for EYSDT services. In the event an eligible individual requests
assistance, the Contractor shall assist the individual in scheduling
appointments foz screening, diagnostic or treatment servicea with a
certified EPSDT service provider of the individuals choice. Contractor
shaYl verify with the subject provider that the'appointment schednled
was kept by the individual and the prov3der: In_the event the 3nitial
appointmznt was not kept for any reason, Conkractor shall attempt to
reschedule the appointment, for a time and date mutually acceptable to
the in3i�-idual and the provider. In no event shall the Contractor be
respoa-b3e to provide appointment scheduling assistance, where the
indiv'_c_a1 has missed two appointments previously scheduled by Contractor
for t�° sane EPSIYt service.
/ ~
Tran�_====_tion Assistance.
(a) 5co>> of Assistance - Contractor shall in its written and personal
co��=_ct with recipients offer to provide assistance in transportation
o` racipients to and from ap�ointmznts for the delivery of EPSDT
se�rices. In the event an indivldual recipient requests such
assistance, Contractor shall provida or make arzangements for
conveyance of the individual by the least expensiva of the following
. � . . means: . .. . . . ... . . .. - [>
_. . . . . _ _ �,:r.:
- ;cC� ' .. . . � � - H - - . ' '
_�-- _ _
.. . : :_:C__ �. :� .,..:':� -�. :.: - _ — ='
-.- ._._....- .�:_ .. .�_ . ., ....: ,. _� - _ _ '
. � �- .... .� _.�._:'. ... .�.._r.. __.
' ... :_. � -v '_"'
:a:.,. �.: �.., � . - . . . r,,. �,-
t
_. : -. _
-- _. � _. ,, .
(i) sus . ; � � - - - �
(2) Taxicab �
(3) Automobile owned or leased by Contractos
(4) Yrivate or public automobile conveyance by individual or an
enti[y wi[h whom Contractor has arranged for auch
conveyance.
(b) Reimbursement for Transporiation Assistance rendered by Contractor.
In considerat�.on of the [ransportatlon assistance provided by
Contractor pursuant to this section, tihe Department agrees to
reinburse the ConCractor as follows:
(1) Bus: Yayment for the cost of bus fare actually incurred by
ihe recipient in [raveling from the recipients residence to
the providers place of business and back. Pagment ahall not
exceed the sum of $2.00 for any single or round trip conveyance
of the recipient by bus to any appointment.
(2) ?axi.cab: Yayment of up to $3.50 of the actual taxifare
incurred by a recipien[ in a one way or round trip conveyance
by taxi between [he resident's residence and the providers
place of business.
(3) Automobile Conveyances: Yayment under Section E2(a)(3) or (4),
at the rate of 17.SC per mile for mileage accumulated in one
way or round :rip conveyanca of the recipient by automobile
betcreen [he recipients residence and the providers place of
business. Payment shall not exceed $I5.00 for a conveyance
for any single appointment.
a. Contractor shall procure and maintain adequate insurance
coverage for liability that might arise through transportation
of individuals via automobile. In the event Contractor
subcontracts for private conveyances under this paragraph,
Contractor shall requixe the subcontractor to maintain -
adequate liability insurance coverage.
b. Contractor shall maintain, or require its subcontractor
to c�aintain, a log reflecting the identity of all
individuals conveyed as well as the time, date, point
of departure, destination, and the total mileage claimed
for any comayance.
(c) Coa_=actor shall endeavor to provi.de assistance in conveying
recipients by the least expensive of the available modes of
. • .
- 9 - _ -
_ � � _ . . - -,_ . ��. � ..e�
. ��.., ._ . . . . . .. . _
._.-,.... � � �_� � -:_ -�- . �,. . -,......
'
... ,.._-_.. - - - -- ' -.-, .«>..
F.
��
t #,, , ,:;
�. a ',��'?
�� �
wc�
transpoYtation auChorized under subparagraph 2(a) above, �-
(d) For conveyances by taxicab or automobiie, Contractor shall attempt
to schedule appointments for one or more recip3ents
in a manner which maxiroizes the opportunity for simultaneous
conveyances to a providera place of business_ Payment for.multiple
conveyances by taxicab oY au[omobile shall not exceed the respective
single or Xound txip limitation set forth above. For tecordkeeping
and reimbursement purposes, Contractor shall prorate the cost of
mulCiple conveyance� between the recipienCs conveyed and enter
the prorata transportation cost on the case managemeat claim form -
zelating to the recipients conveyed.
(e) Reinbursement [o Contractor for mileage under subparagiaph 2(a)(3)
shz11 be applicable only to mileage accumulated �n single or
ra•.=:3 trip conveqance between the ree3pients residence and the
pro^ der's place of business. ilileage incurred by Con[ractor in
separate3.y
traveling to and from the recipiente residence is not�reimbursable,
it being unders[ood reirabursement for such costs is a component of
the reimbursec�en[ rates set for[h in Section I.
(f) Contractor shall not claim nor ba reimbursed for more than one
conveyance of a recipient per successful outreach, or more than
one conveyance for each success£ul referral of a recipient. Said
limitation shall apply to conveyances bp any of the means authorized
under subparagraph 2(a) above.
Con[ractor's Performance S[andards. in the perforcnance of the contractual
obligations contemplated under this contract, Contractor shall neet ot
exceed the follosing performance regui.rements:
1. No late: :han sixty (60) days from the date of receipt of the monthly
Medical vsistance eligibility listing described in Section D1(a),
Contra�=:= must 3n accordance wi[h Sectian A2 contact each individual
infor�-= -hem of the availabiliey of EPSDT services.
2. Each i�_::=dua1 requestin� screening services pursuant to Contrac[or`s
efforts •—'=_r Section D2 and D4 must receive and complete the screening
reques[e? w-ithin sixty (60) days of the date of their request „unless
1�/ �
;:�- ..
`:
Contrac�o_ can shov with supporting evidence that crithin 60 days of
the date o: the subject, either: :
(a) The :��ily or individual requesting screening lost eligiMlity
for EPSIYf services; or
- 10 -
, • ��
� �
- -- �x_ '
- �; � .,-� � :-
. . . .. . _ . � n � �. . . ��i4 �
h"a- . ' "' . ' ' _ ' . _.��
�
♦
3.
4
�
�.�.�. �-�-�:
. " . . n �. Sa3- _
. �
(b) Contractor was unable to loca[e the individual or fam3ly requesting
the services despite a good faith eFfort to do so; or
(c) The requesting individuals failure to receive or complete screening
was due to an action or decision by the individual as opposed to
a failure of Contractor to meet its contractual obligations,
including but not limited to [he provision of the supportive
services described i.n Secfions E1 and E2. �
Each individual request3ng rescreening pursuant to Contractors efforts
under Section D3 receive and complete such rescreening within aixty
days of the date rescreening uas due under the Department's periodicity
schedule unless Contractor can show with supporting evidence that
within sixty (60) days of the date on which rescreening was due,
either. �
(a) i^a iamily or individual requesting screening lost eligibility
fo: E°SDT services; or
(b) Co:tractor was unable to locate the individua� or family requesting
the services despite a good faith effort to do so; or
(c) The reques[ing individuals failure to receive or complete screening
was due Co an action or decision by the individual as opposed to
a failure of Contractor to meet its contracival obligatiqns,
including but not limite3 to the provision of supportive services
addressed in Section F.1 an3 E2.
That diagnostic or treatment services reqi�ired to address medical
conditions detected as a result of screening of an individual•are
provided within sixty (60) days of the date screening wa� completed,
unless [he Contrac[or can shoca with supporting evidence that wi.thin 60
days o` the date on which the screening was completed, either:
(a) S-� fa�:ily or individual requesting diagnosis or [reatment
s=�ice9 lost eligibility for EPSDT services; or
(b) C..,=:actor wa& unable to lacate the individua2 or famiZy requesting
_=e =ervices despite a good faith effort to do so; or
(c) _c=_ .>_questing in�lividuals failure to receive or complete referral
F� ?�e to an actton or decis3on by the individual as opposed to
a,".�:lure of Contrac[o[ [o meet its contractual obligations
�� .
ir.:_n3ing the provision of supportive services described in '
Sec_:on E1 and E2.
—11— - •
� '. �':_;;;
s' . --
r.a . . _ . -. . . .
i ::.�
, s, ; .
- � 5 , �,-
� ".. �. �-a —._i:.::
� . .
- - b a�
"_ -j::� �'�i.a
,_ - � ..� ..ih a- _..� .._. k� _ h � _._ _ ..
��?�`-�� ` � �� - � � � �� � rov3der oP the recipients ° � �'�
ointment with a p ' y-_;
effect scheduling of an app . _
,..choice or another appropriate provider within the sixty day , r_,
period following completion of screening. - �
Re uirements. Contractor shall prepate and maintain such ' �'
G; Recordkeeping 4 --
records, documents, reports and other material in accordance with the
=equirements set forth within the "EPSDT Program 4ianual" prepaYed by the
Department, receipt of which Contractor acknoWledges by execution of this _
Contract. The recordkeeping requirements of Contractor specified in the .
ram ifanual are incoz orated herein by reference. Any and all
EPSDT Prog P
records maintained.by Contractor in accordance with the provisians of said
manual sha11 be made available for audit or inspectlon by authorized DeparCmenC
personnel upon requ2st.
g, Territorial Sco�e of Coutractor�s 661i ations. '
The listings o� Medical Assistance recipients described in Section D1
which shall b'- the subject of Contractors efforts under this Contract shall
include only "-edical Assistance recipients residing within the following
geographic area:
7'hat portion of zip code 54901 that is within the city
� limits of the City of Oshkosh. The Contractor shall
transfer the listings of eligible recipients �aho xeside
outside of the city limits to the 1Vinnebago County Public
Health Nursino Service within 3 days from the xeceipt
of said listings. Other than the above requirement, the
Contractor shall have no legal responsibility to the
Department for the timely and satisfactory performance
� of the obligations contemplat:ed Uy this contract, for.
' those eligible recipients appearing on said listings
who xeside outside of the city limits of the City of Oshkosh.
�
I, Reimbutse=e=� to Contractor
�. In cccsiceration of outreach services rendered by Contractor pursuant
�
� to t^-> �=�tract, the Depax[ment agrees to reimburse Contrac or a
� fo±=�zs: .
1 b entitled to reimbursement
�a� c-•c�>�3fu1 Outreach: Contractor shal e
— of S32.00for each eligible Medical Assistance recipient successfully
. outraached. A reclpient shall be deemed as having been successfully
-12-
- ----
------ __
----_ _ .---
__ _
_._ .. ----- _ . ..-.�,:.a
— _ . _ _- - --
--_----__ - - . _ ..v..,� -�=
_ - . -rsc :- � . . ti';
, - _ � >..X.:-. ' _4;' _ .i.a.3�,-v''.-2 'F.r�''i"-
-. - . o-�-� ... - - �'r-� -
_' ' . _ . . . - �,l . � . �'
. � �..� �, _y y � �., .,
'r" �";" � Yc�'��' �:�m-7..z- F `C,c'"` .'<;! r � .,, :? tit'`�.
3-y:Y.\r _. ' ..r� _ r _� � _='�l `�' - r � - .+. ' � . � _
' ' " �ni
�..., --- n " �-..�r.CT 'rr* c� �. .,. . - � - -
'v'S _ ,._ . -:-'^c""' . _ , . — _ . _, _,...s� ___..._�_ . _. . .. .... .. _. . , . .. . . . :. -
c
�
' outreached if Contractor vezifies screening services reqaested by
the recipient s�ere, in fact, provided the recipient by a certified • -
EPSDT screening provider.
(1) In the event, a recipient contac[ed by Contractor pursaes
and procures, through his or her own efforts EYSDT screening
services without ass3stance of Contractor, the sczeening of
that recipient shall be deemed a successEul outreach provided
the Contractor verifies the screening was perforned by a
ceztified EPSDT screen3ng pravider.
(2) The refusal of.a recipient to submit to each aE the screeaing
tests offered by a EPSDT screening provider, sha11 not serve
to deny the Contractor Yeimbursement for successful outreach
of the recipient, if Contractor verifies the recipiettt
;eceived a porLion of the screening services, and Conttactor
��ssesses documenta[ion wh3ch reflects the xecipient's
et�ress refusal of the other available screening services.
(b)_ Unsucceasful Ontreach: Contractor shall be entitled to reimbursement
of $10.00far each eligib2� Medical Assistance recipient who is not
successfully outreached. Unsuccessful auCreach for reimbursement
purposes is defined as occuring when despite Contractors full
performance of its contractual responsibilities under Section D,
the recipient who is the subject of those efforts fails or retuses
to be screened by a certified EPSDT screening provider. �
(c) Outreach Reimbursement - Limitations:
{1) Contractor shall not clair,� or be reimhursed reore than once
C`
per perlo@fciCy interval for ouCZeach services provided t_he
folloaing categories of recipients:
e. Re�ipients appearing on the recipient listing described in
Section D1(b), and
S. Recipients under the age of twenty Ywo months appeating
on the recipients listings described in Section D1(a)
and (c) .
?zriodicity intervals applicable to said lfmitation are
=�ecified in the prevlously referenced periodxcity schedu7,e
a�opted by the Department. Contractor`s entitlement to
claim reimbursement for outreach serv3ces to the above
- 13 -
,,. .. ... _- - .. _
�.. - :: . _ a .
.
_.._..;_r � . . , � r --�.. .�,.,. _.�
. _
_::,.-s>� __._. -,..z.},..;�. _ _ _, �_: �.v--=
�___��:�,.-..__-�_._•�- p � _ .•_
.
,..� j4
--^--- ��;
, ::,,_. »
;-�:..�«:''J � -_
-�' �
.��..
�
�
,i
:i
i
�
�
. . ' .. .-.s,... _"
.. � -. '�C- . � '
� categories of recipients shall advance as the recipient �,
advances to another interval on the periodicity schedule. ;•
, The one claim, per interval, per iecipient, limitation shall •
apply to Contractor's claims for successful outreach and
�
unsaccessEu2 outreach as respectively defined in subparagraphs
(a) and (b) above:
(2) Foz recipients over the age of .twenty-two months, appearing
on the recipient 2isting described in Section D1(a) and {c),
Contractor shall be ent3tled to teimbu=sement for services
resulting in unsuccessfu� outreach only once evety 365 days.
In consideration of services rendered by Contractor for purposes o£
procurin3 for a recipient diagnastic and treatment services deemed
necessaxp as a result of EPSDT screening, the Department agrees to
reimbur>� Contractor as follows:
(a) Sc_c_ssful Dental Referrals: Contractor may claim and 6e reimbursed
$10.00 foz each recipient who following an EPSDT screening is
Veriiied as having received diagaostic or [reatment services from
a deatist certified as a provider under the Medical Assistance
Program.
(b) Successful Referral to Other Hea2th Care Professionals: Contractor
may claim and be reimbursed $6.00 for each referral of a recipient,
who fol2owing an EPSDT screening is verified as having received
diagnostic or treaCment services deemed necessary as a resuZr, of
said s�reetting. Contractor may claim such reimbursement only
when the services are veri£ied as having been provided by a
health care professional certiEied to provide the sabject sezv�.ces
uader Wisconsin's Medical Assistance Yrogram for claim form reFerral
co?es 03, 04, D5: 06, and 11; and non-certified providers under
cL=ia form teferral codes 07, 09, Z0, and 12.
(c) L=s_ccessful Referrals: In the event none of the referrals of a
_ez'_�ient for diagnostic or treatment services deemed necessary
�__ resu2t of a successful EPSDT screening are verif3ed as
�.-= �g been completed, Contractor may claim and be reimbursed the
s•.= of $3.00. Contractor may not claim any reimbursement for �
tca�scessfuZ reEerral if Contxactor claim9 reimbursement for a
secess;ul referral of the subject recipienC.
• - 14 -
: ;,.... . _ ._ :
::
, . �-. _ .: _ ..: , ...: _. _, _ ._ ...__.. _ .:... _ �-'',_
-� • _._... °- .. .-_ . -._ .� - -� . .. .
� , �d)
3.
t+
5
.__�r''.
Reimbursement for Successful Re;errals - Limitations:
(1) Contractor may claim and be reimbursed under subpazagraphs (a)
and (b) only if the subject recipient has been successfully
outreached or descrihed in Section I 1(a), and Coatractor .
has verif3ed the services were, in €act, provided the recipient.
Reimbucsement may be claimed only for the initiai eacoun[er
between the health care professional and the recipient for
necessary diagnos[ic or treatment services, and not £or any
subsequent visits for services.
(2) Contractor may claim and be reimbursed for a successful
referral of a recipieat to a denta! provider under subparagraph (a)
or other health care providers under subparagraph (b) only
once during each periodicity interval applicable Co that
reaipient.
(3; Coatractor may claim and be reimbursed for unsuccessful
zeferral only once during each periodicity intezval applicable
to the subject recipient.
(4) Contrac[or may not claim or receive reimbursement for referrals,
successful or unsuccessful, unless the subject recipient has
been verified as having been successfullp outreached as
described in Section I 1(a), and the EPSDT screening of the
recipient indicated a need for diagnostic or [reatment
services.
Disbursements for Trans�ortat3on of Recipien[s. Conttactor shall be
reimburs�d for all disbursesents ma3e for transportation of recipients
to and from appointments for the provision of EPSDT servicea, provided
reimbursz�ent claimad by Contractor is in compliance r.rith the conditions
and rz:=s set forth in Section E2.
Contra���:'s claims for reimbursement for services rendered pursuant
to th:s contract shall be submitted on preprinted fom�s pres�ribed and
suppl=== �y the Department_ Contractor in the preparation oE said
clai_ s-:_11 adhere to procedural and substantive guidelines specified
�aithi= ==e cPSDT Program Manual furnish2d Contractor by [he Aepartmenl'.
To qua__-- for payment, Contractor mi�st submit its claims for reimbursement
withi� s_x:.y days of the date of the service Which 3s the subject of
the c1=�. Payment on any cZaim subm3tted after said sixty day period
shall ba cenied unless Contractor can demonstrate, to the satisfaction
- 15 - -
- _ ., wT�'�
--
---- - _ _ __ -- . _ _ . ____ _-----
^-y-- _ �,. -
' _ � �" �. .., y
' . - . . . ' . s+S+.+' F s c .r.�. �'�+� �
- . . - .,,. �.. Y .: � -ia . '-- ...,k� ��,.. z r � . `".' r �'� + �'.:
� r>-..._ ,> <:.+.? `• • �.
�._ . .. -t-...�:... _-.. _. -_• +_ _�- . _, r ___ T•.l
�
E
I
�
: .�.,.:..., : -
of Ctre Department, unusual circumstances beyond its contro2 prevented -
timely submission of the claim. ,
6. The Depattment sha11 pay all claims properly comp2eted and timely �
submitted by Contractor within sixty days of recefpz. Contractor '�
7.
shall accept payments made in accordance with the reimbuzsement rates
above described as payment in full for the services rendered. Under
no circumsLances shall Contractor attempt to procure from the Medical
Assistance rec3pients who are the subject of fts services moneiary
payment or o[her consi,deration for [hose services.
The DeparCment may recover the amnunt of any improper or excessive
claim payulent made to Gontrac[or by deducting the amount of such
improper or excess payment fzom future amounts owed the Contractor.
Yrior to t�aking any.such deduction, the Aepartment shall provide
Contrac_o: written notice of its intent, setting forth the amount of
the de��==ion, and the reasons therefore.
J. Obligations e' the Department
1. The Depa:ta.ent shall on a monthly basis provide Contractor with the
Medi�al Assistance recipient listxngs described in Section D1.
2. The Department sha21 provide time2y notification to the Contractor of
any changes in State or Federal law ef£ecting, Contractor's performance
under Chis contract.
3. The Department shall provide Contractor with advance notification of
any changes in or modiEications of the EPSDT Program Manual..�
4. The Department shall within sixty days of receipt of any claim pzoperly
completed and timely submitted by Contractor, issue payment on said
claim in accordance with the reimbursement rates specified in Section I.
K. Duration o` Contract
1. Unless earliez terminated as pmvided belou, this contract sha11
October 1, 1979
re�a`_� ia effect from �xx�fr:c�d�oncfor a period of 6 months
fro_ _`_>_ date of execation. By mutual written conseat of the parties
ther=_ -_; be up to twa extensions of the contract of 2 months
each.
2. The c.:�=:act may be terminated by either party upon ninety (40) days
cnitt_� aotice.
:L.. � l^-- .. .' ...- „- 'i--� ' ^..w.�,.n
—16—
s
e
±FY',
�
r
IN WIT�ESS WHEREOF the part3es have executed this agreement this day
of , 1979.
�
�
(Name of Aoency)
(Address)
(Signature of Autho:ized Agent)
(Title)
�6 ` � ,
j
State of Wisconsin
Department of Health and Social Services
By:
. . ' - . . . .. - =:.�v.
' . . . - . . . _ . ._. .l��h�Y}_'
"� -
...,_ � . .�... � .'.. ,. �.': •:C! ...eV... ..1.�..�.. -i. �l* ��} t''
' ..: . '... .. _ -.. :.._ . r . . ' _. . f �
~ � �^�
_�a✓-c--�1-",._.�_. "._+ a_.. . ..� ..�.., . .. ' .. - '_'.. � .� � _ t ., l..e`X
_. i _
�-x. �
��
� '
.. ......_. .' � . .._ . �'_� . -..�.. -�.-r '.�r . .'i riia _.. .. . . .,
N ��
N U
� �
3k $-i
-� x
� E
oa
U�
>x
ow
�. o
"_� a,
`- �
, : a3 � m
C1 N
(F . O N U
�u q �r�i
e. �
� N i-i
O N N
rl c�J f/�
1� J �
� � �
O s', rl
Vl N -G
N rl O
cz 3 �
1
ti
v
N
a�
a
� •
o a�i
d �
O �d
Ei U
�
O
.�
J�
O
�
t
�
_- . �
�
ti
�
r-1
� �
s�
� � v
a� �
� U
U ���\ 1>
N •ri
A U