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PR 21545: CONTRACT BETWEEN THE HEALTH AND HUMAN SERVICES COMMISSION AND THE CITY OF PORT ARTHUR (NO CASH MATCH)
1 Energy City of -- crry o rtfllll' Texas Date: August 24, 2020 To: Ron Burton, City Manager From: Judith A. Smith, RN, BSN, Director of Health RE: Approval To Approve the Contract Between The Health and Human Services Commission and the City of Port Arthur. NO CASH MATCH Nature of the Request: This is a request to approve the contract between The Health and Human Services Commission and the City of Port Arthur. The total amount of this Contract will not exceed $311,500.00 with $62,300 being allocated toward the contract period of September 1, 2020 through August 31, 2021. This Primary Health Care contract provides preventive health services, including immunizations, diagnosis and treatment of acute illnesses, health education, and diagnostic tests including lab and x-rays for eligible participants at or below 150% of the current federal poverty guidelines. Analysis, Considerations: The contract period starts 09/01/2020 and ends 08/31/2021 and provides for salaries and fringe benefits for one full-time eligibility/billing clerk, office supplies and travel expenses. Recommendations: It is recommended that the City Council approve P.R. No. 21545 for the FY 2020-2021 contract between the Health and Human Services Primary Health Care Program and the City of Port Arthur program to provide primary and preventive health care services. Budget Considerations: The total budget is $311,500.00. The breakdown for this grant includes $62,500 for a five year period. This is to cover the cost to operate the Primary Health Care clinic for the City of Port Arthur. "REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR" P.O.BOX 1089•PORT ARTHUR,TX 77641-1089.409/983-8101•FAX 409/982-6743 P.R. No. 21545 08/24/2020-j s RESOLUTION NO. A RESOLUTION APPROVING THE FY 2021 CONTRACT BETWEEN THE CITY OF PORT ARTHUR AND THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIMARY HEALTH CARE PROGRAM, FOR THE AMOUNT NOT TO EXCEED $311,500, OF WHICH $62,300 IS ALLOCATED TOWARD THE CONTRACT PERIOD SEPTEMBER 1, 2020 THROUGH AUGUST 31,2021. NO CASH MATCH REQUIRED. WHEREAS, this program provides preventive health services including immunizations, diagnosis and treatment of acute illnesses, family planning, health education, and diagnostic tests including lab and x-rays for eligible participants at or below 150% of the current federal poverty guidelines: and, WHEREAS, the total amount of the contract is not to exceed $311,500.00 with $62,300 being allocated for FY 2021. This budget covers the cost of the operations of the Primary Health Care Clinic. This contract period is from September 1, 2020 through August 31, 2021. NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR: Section 1. That,the facts and opinions in the preamble are true and correct. Section 2. That, the City Council of the City of Port Arthur hereby approves the contract between the City of Port Arthur and the Department of Health and Human Services Commission. Section 3. That, the City Council deems it is in the best interest of the City to approve and authorize the City Manager to execute the contract between the Department of Health and Human Services Commission and the City of Port Arthur for Primary Health Care Services, as delineated in Exhibit"A." P.R. No. 21545 08/24/2020 j s Section 4. That, a copy of the caption of this Resolution be spread upon the Minutes of the City Council. READ,ADOPTED,AND APPROVED, this day of September, 2020 A.D., at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the following Vote: AYES: Mayor: Councilmembers: • NOES: Thurman Bill Bartie, Mayor ATTEST: Sherri Bellard, City Secretary APPROVED AS TO FORM: Val Tizeno, City Attorney APPROVED FOR ADMINISTRATION: Ronald Burton, City Manager Judith Smith, RN, BSN, Director of Health P.R. No. 21545 08/24/2020 js EXHIBIT "A" DocuSign Envelope ID:2DAB07B4-A920-4608-131A4-CCFFDBODF809 HHSC Contract No.HHS000697900024 SIGNATURE DOCUMENT FOR TEXAS HEALTH AND HUMAN SERVICES CONTRACT UNDER THE PRIMARY HEALTH CARE GRANT PROGRAM I. PURPOSE The Health and Human Services Commission ("HHSC"), an administrative agency within the executive branch of the state of Texas, and CITY OF PORT ARTHUR ("Grantee"), each a "Party" and collectively the "Parties," enter into the following contract for Primary Health Care Grant Program Services (the "Contract"). II. LEGAL AUTHORITY This Contract is authorized by and in compliance with the provisions of the Texas Health and Safety Code Chapter 31, Texas Administrative Code ("TAC") Title 25, Part 1, Chapter 39, Subchapter A, §39.1 -§39.11 and is authorized by and in compliance with the provisions of the Texas Government Code Chapter 531. III. STATEMENT OF SERVICES TO BE PROVIDED Grantee shall perform or cause to be performed Primary Health Care Program services ("Program") and other contract requirements in accordance with the Contract, including the Statement of Work, which is attached and incorporated herein as Attachment A. IV. DURATION The Contract is effective on September 1,2020 and terminates on August 31,2021 unless renewed, extended, or terminated pursuant to the terms and conditions of the Contract. HHSC, at its sole discretion, may extend this Contract for any period(s) of time, provided the Contract term, including all extensions or renewals,does not exceed five years.Notwithstanding the limitation in the preceding sentence, HHSC, at its sole discretion, also may extend the Contract beyond five years as necessary to ensure continuity of service, for purposes of transition, or as otherwise determined by HHSC to serve the best interest of the State. V. PAYMENT FOR SERVICES PROVIDED The total amount of this Contract will not exceed$311,500.00. Expenditures for Fiscal Year 2021 will not exceed $62,300.00. Grantee is not required to provide matching funds. All expenditures under the Contract will be in accordance with Attachment B, Budget. All payments shall be made on a cost reimbursement basis. Indirect Cost Rate: The Grantee's acknowledged or approved Indirect Cost Rate ("ICR") is contained within HHSC Hourly Rate and either the ICR Acknowledgement Letter, ICR Acknowledgement Letter—Ten Percent De Minimis, or the ICR Agreement Letter is attached to this Contract and incorporated as Attachment H,Indirect Cost Rate Letter. DocuSign Envelope ID. 2DABO7B4-A920-46Q8-B1A4-CCFFDBODF809 If an indirect Cost Rate Letter is required but it is not issued at the time of Contract execution,the Parties agree to amend the Contract to include the Indirect Cost Rate Letter as Attachment H and revise HHSC Hourly Rate when the Indirect Cost Rate Letter is issued. If HHSC, at its sole discretion, approves or acknowledges an updated indirect cost rate, the new rate,together with the revised ICR Acknowledgement Letter, ICR Acknowledgement Letter—Ten Percent De Minimis, or the ICR Agreement Letter, will be included in the amended Attachment H and revised HHSC Hourly Rate. VI. REPORTING REQUIREMENTS Grantee shall satisfy all invoice and reporting requirements as set forth within in Attachment A. All invoice and reporting requirements will survive the termination or expiration of this Contract. VII. CONTRACT REPRESENTATIVES The following will act as the designated Representative authorized to administer activities, including, but not limited to, non-legal notices, consents, approvals, requests, or other general communications provided for or permitted to be given under this Contract. The designated Party Representatives are: Grantee HHSC Judith A. Smith Lily Ferris 449 Austin Ave. 1100 W. 49th Street; Mail Code 1938 Port Arthur, TX 77640 Austin, Texas 78756 409.983.8832 (512) 776-3487 Judith.smith@portarthurtx.gov Iily.ferris@hhsc.state.tx.us VIII. LEGAL NOTICES Any legal notice required under this Contract shall be deemed delivered when deposited by the HHSC either in the United States mail, postage paid, certified, return receipt requested; or with a common carrier,overnight, signature required,to the appropriate address below: Grantee HHSC City of Port Arthur Health and Human Services Commission Attn:Judith A. Smith Attn: Office of Chief Counsel 449 Austin Ave. 4900 N. Lamar Boulevard; MC 1100 Port Arthur, TX 77640 Austin, Texas 78751 with copy to: Health and Human Services Commission Attn: Lily Ferris, PHC Contract Manager 1100 W. 49th Street; Mail Code 1938 Austin,Texas 78756 DocuSign Envelope ID 2DAB07B4-A920-4608-B1A4-CCFFDBODF809 IX. NOTICE REQUIREMENTS Notice given by Grantee will be deemed effective when received by HHSC. Either Party may change its address for notices by providing written notice to the other Party.All notices submitted to HHSC must: A. include the Contract number; B. be sent to the person(s)or department(s) identified in the Contract; and, C. comply with all terms and conditions of the Contract. X. GENERAL INSURANCE REQUIREMENTS Grantee shall carry insurance in the types and amounts indicated in Attachment G, General Insurance Requirements, for the duration of this Contract. The insurance shall be evidenced by delivery to HHSC of certificates of insurance executed by the insurer or its authorized agent stating coverages, limits, expiration dates, and compliance with all applicable required provisions. Upon request,HHSC,and/or its agents,shall be entitled to receive without expense,copies of the policies and all endorsements. XI. PRIVACY,SECURITY,AND BREACH NOTIFICATION Grantee certifies that it is, and shall remain for the term of this Contract, in compliance with all applicable state and federal laws and regulations with respect to privacy, security, and breach notification in accordance with the Texas Health and Human System Data Use Agreement, attached as Attachment F and incorporated in this Contract by reference. XII. SIGNATURE AUTHORITY Each Party represents and warrants that the person executing this Contract on its behalf has full power and authority to enter into this Contract. Any Services or Work performed by Grantee before this Contract is effective or after it ceases to be effective are performed at the sole risk of Grantee. SIGNATURE PAGE FOLLOWS DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 SIGNATURE PAGE FOR SYSTEM AGENCY CONTRACT No. HHS000697900024 HEALTH AND HUMAN SERVICES CITY OF PORT ARTHUR COMMISSION DocuSigned by: -DocuSigned by: By: (iik-61,Sau1 VOLt-rS By: .!6(A, 0lit --29D47C49FD07403. 224C7424DD8A48C... Name: Lindsay Rodgers Name: Ron Burton Title: Associate Commissioner, Health and Eilty&JopriatmtNlaSeigvaces Date of signature: August 31, 2020 Date of signature: August 31, 2020 The following Attachments to this Contract are attached and incorporated by reference: Attachment A- Statement of Work Attachment B- Budget Detail Attachment C-.HHSC Uniform Terms and Conditions-Grant (Version 2.16.1) Attachment D- HHSC Additional Provisions—Grant(version 1.0) Attachment E- Contract Affirmations(Version 1.6) Attachment F- Texas HHS Data Use Agreement Attachment G- General Insurance Requirements Attachment H- Indirect Cost Rate Letter Attachment I- Program Policy Manual Attachments Follow DocuSign Envelope ID 2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment A Statement of Work 1. Program Purpose The purpose of this Program is to provide preventive and primary health care(PHC)for individuals who reside in the state of Texas with a gross family income at or below 200 percent of the federal poverty level (FPL). Grantee shall provide services regardless of race, color, national origin, sex, age, religion, disability, political beliefs, sexual orientation, and family income. 2. Grantee Responsibilities To participate as a provider under this Contract, the Grantee must: 2.1 Ensure compliance with this Contract, including these Grantee requirements; 2.2 Ensure compliance with all applicable federal and state laws, rules, regulations, standards, guidelines, and policies in effect on the beginning date of this Contract unless amended, including, but not limited to, Texas Health and Safety Code Chapter 31; 2.3 Ensure compliance with all state and federal statutes and regulations, HHSC rules, policies, procedures, and guidelines governing the Program, included but not limited to, TAC Title 25, Part 1 Chapter 39, and - Subchapter A, §39.1 -§39.I I. The foregoing rules in TAC Title 25 - as they relate to the Program may be further modified and revised-within their existing title-during the term of the Contract. In the event of such modifications or revision, Grantee shall be required to comply with said rules; 2.4 Ensure compliance at all times with the current Program Policy Manual that is available online and incorporated into this Contract as Attachment I,Program Policy Manual. The provisions of the Program Policy Manual may be further modified and revised- within their existing title- during the term of the Contract. In the event of such modifications or revision, Grantee shall be required to comply with said rules; 2.5 Comply with all requirements under the Uniform Grant Management Standards ("UGMS"), currently available online at: https://ctgprod-alb.comptroller.texas.gov /purchasing/grant-management/. The Texas Comptroller of Public Accounts ("CPA"), from time to time and in its sole discretion, may revise the online link provided in this subsection. Grantee is responsible for contacting CPA at any time that Grantee is not able to access the online materials to request the updated link. Grantee is always responsible for complying with the UGMS, including any revisions to the standards during the Contract term; 2.6 Ensure compliance with the HHSC Grant Technical Assistance Guide, currently available online at: https://hhs.texas.gov/doing-business-hhs/grants. HHSC, from time to time and in its sole discretion,may revise the online link provided in this subsection. DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Grantee is responsible for contacting HHSC at any time that Grantee is not able to access the online materials to request the updated link. Grantee is always responsible for complying with the Grant Technical Assistance Guide, including any revisions to the standards during the Contract term; 2.7 Maintain an appropriate contract administration system to ensure that all terms, conditions, and specifications of this Contract are met; 2.8 Enroll eligible -Texas residents in accordance TAC Title 25, Part 1, Chapter 39, Subchapter A, §39.1 -§39.11 and the requirements established in the Program Policy Manual. 3. PHC Services To meet the mission and objectives of grant funds awarded under this Contract, Grantee must meet the following requirements: A. Provide comprehensive preventive and primary health care(PHC)services to Texas residents with a gross family income at or below 200 percent of the federal poverty level (FPL). Grantee, at a minimum, shall provide the following priority services: diagnosis and treatment, emergency medical services, family planning services, preventive health services, including immunizations, health education,and laboratory, x-ray, nuclear medicine, or other appropriate diagnostic services. In addition to priority services, Grantee may provide the following optional PHC services: nutrition services, health screening, home health care, dental care, transportation, prescription drugs, environmental health, podiatry, and social services. B. Grantee will provide services meeting the service parameters described in accordance with the Program rules and the requirements established in the Program Policy Manual.Grantee will screen all individuals considered for the PHC program to determine eligibility using a System Agency- approved screening process in accordance with the Program Policy Manual, as amended. Grantee may not alter System Agency eligibility forms or use another eligibility form unless it is submitted to and approved by System Agency. For an individual to receive PHC services, three (3) criteria shall be met: 1. Texas resident; 2. Gross family income at or below 200%of the adopted Federal Poverty Level (FPL); and 3. Not eligible for other non-HHSC programs/benefits providing the same services. 3.1 Grantee will maintain documentation of all services provided in accordance with the Program rules and the requirements established in the Program Policy Manual. 3.2 Grantee will administer treatment protocols in accordance with the Program rules and the requirements established in the Program Policy Manual. DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 3.3 Grantee will maintain client and family participation requirements in accordance with the Program rules and the requirements established in the Program Policy Manual. 3.4 Grantee will assist HHSC in performing a client satisfaction survey in accordance with the requirements established in the Program Policy Manual. 3.5 Grantee will comply with Texas Family Code§261.101,which requires reporting of all suspected cases of child abuse to local law enforcement authorities and to the Texas Department of Family and Protective Services. Grantee will ensure that all program personnel and sub-contractors are properly trained and adhere to this Contract requirement and compliance with Texas Family Code §261.101. 3.6 Grantee will cooperate fully with HHSC investigations of any complaint received from families or other parties regarding Grantee's PHC services, and when applicable as determined by HHSC and any other entity on behalf of HHSC, develop a corrective action plan to address identified issues in accordance with Program Policy Manual. 3.7 Grantee shall maintain an emergency evacuation plan that complies with all applicable local, state, and federal laws, rules and regulations governing provision of services under this Contract. 4. Telehealth and Telemedicine Medical Services 4.1 Grantee may use telehealth services ("a health service, other than a telemedicine medical service, delivered by a health professional licensed, certified, or otherwise entitled to practice in the state of Texas and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology,") and telemedicine medical services ("a health care service delivered by a physician licensed in the state of Texas, or a health professional acting under the delegation and supervision of a physician licensed in the state of Texas, and acting within the scope of the physician's or health professional's license to a patient at a different physical location than the physician or health professional using telecommunications or information technology") as defined in Texas Government Code §531.001(7)(using the meaning assigned by Texas Occupations Code §111.001) as provided through Texas Medicaid. 4.2 Grantee must comply with all of the following: a. Families must give written consent that they agree to receive services via telehealth and telemedicine; b. Telehealth and telemedicine services must comply with all Texas Medicaid requirements for telehealth, as well as the licensure/practice act requirements for each provider; and DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 c. Technology used to provide telehealth services must be compliant with the Family Educational Rights and Privacy Act of 1974 (FERPA) and the Health Insurance Portability and Accountability Act(HIPAA). 5. Eligible Population 5.1 Program eligibility is determined by applicable law set forth in Program rules and the requirements established in the Program Policy Manual. 5.2 The unduplicated number of Clients for PHC services is 249. This represents the Grantee's projected number of unduplicated Clients to be served during the Contract period. If during the Contract period it is foreseen that the Grantee might be unable to serve the contracted number of children, HHSC may reduce the Grantee's grant award amount. 6. Personnel Standards and Requirements 6.1 Grantee must maintain qualified staff in accordance with Program rules and the requirements established in the Program Policy Manual. 6.2 Grantee must conduct a criminal background checks in accordance with Program rules and the requirements established in the Program Policy Manual. 6.3 Grantee must provide staff training and development in accordance with the requirements established in the Program Policy Manual. 6.4 Grantee must notify HHSC of changes in CEO, CFO, program director, and key personnel,of a vacancy funded under this contact. in accordance with the requirements established in the Program Policy Manual. Grantees contract award may be subject to a decrease equal to the salary savings (salary and benefits) realized as a result of the vacancy. Cost Reimbursement, Client Co-Pays 6.5 Contract funds must be expended within the current Contract period. Rollover of unexpended funds to the succeeding Contract periods will not be allowed. 6.6 Grantee will be reimbursed for costs according to Attachment B-Budget Detail and PHC 225 Report Forms submitted monthly no later than the last business day of the month following service. 6.7 Grantee may assess a Client Co-Pay in accordance with Program rules and the requirements established in the Program Policy Manual. Grantee may not deny a service due to inability to pay. The Grantee shall waive the fee if a client self-declares inability to pay. Grantee shall submit the PHC client co-pay and fee schedules to the PHC mailbox (PHCReports(a),hhsc.state.tx.us) for review and approval by September 30 of each Contract year. DocuSign Envelope ID:2DAB0754-A920-4608-B1A4-CCFFDB0DF809 6.8 HHSC is "payer of last resort" in accordance with Program rules and the requirements established in the Program Policy Manual. Grantee shall make reasonable efforts to investigate and apply for all other sources of third party funding available to, or identified by, the patient before submitting claims for allowable costs. 6.9 HHSC, in its sole discretion, may approve fund transfers between categories upon Grantee's written request that must include a detailed explanation that supports the need for the fund transfer.Grantee must seek HHSC's written approval prior to making any fund transfers. 7. HHSC Reimbursements and Invoicing Processes 7.1 HHSC will reimburse Grantee for all charges determined and invoiced in accordance with the terms and conditions of this Contract. All payments by HHSC under this Contract will be made in accordance with the "Texas Prompt Payment Act," Chapter 2251 of the Texas Government Code. 7.2 Grantee must properly submit its invoice or Purchase Voucher by the last business day of the month following service, using HHSC Program Purchase Voucher ("Form 4116"). 7.3 Electronic Purchase Voucher. Grantee must submit vouchers to HHSC for review and concurrence in a secure,non-alterable electronic format(pdf is acceptable)emailed to: PHCReportshhsc.state.tx.us with the "Grantee's full name, month and year of invoice" in the subject line. Voucher will not be paid until the corresponding monthly PHC Report Form 225 is also received and approved. Upon concurrence, HHSC will submit the Purchase Voucher to Accounts Payable. 7.4 Voucher Requirements.Each invoice submitted be in accordance with be in accordance with TAC Title 34, Part 1, Chapter 20, Subchapter F, Division 1, §20.487, Invoicing Standards, which should include, but is not limited to,as applicable: • Grantee's Legal Name; • State of Texas vendor number or federal tax identification number; • Grantee's Telephone number; • HHSC Contract Number; • Total amount of invoice • The name and telephone number of a person designated by the Contract to answer questions regarding the invoice. 7.5 All services shall be performed to the satisfaction of HHSC. HHSC shall not be liable for any payment for services that HHSC deems unsatisfactory,that fail to adhere to the terms of this Contract, or that have not been approved by HHSC. 7.6 Grantee must submit a final invoice at the end of each Contract period by October 15th DocuSign Envelope ID:2DAB07B4-A920-4608-B1 A4-CCFFDBODF809 7.7 Grantee must comply with HHSC's rules,policies,Contract provisions,and applicable instruction manuals regarding the collection and timely submission of complete and accurate data. 8. Reporting Requirements and Monitoring 8.1 Grantee shall report financial and programmatic information to PHCReports@hhsc.state.tx.us as follows: Report Title Submission Frequency Due Date PHC 225 Report Monthly The last business day of the month Form following service. Staff Training Plan Annually—within 45 days October 15 of the beginning of the contract year Grantee's Co-pay One time (beginning of September 30th Policy and Fee contract year) Schedule Purchase Voucher Monthly The last business day of the month (Form 4116) following service. Financial Status Quarterly Report(FSR) Ql: September 1 —Nov 30 Q1: December 31 Q2: December 1 —February Q2: March 31 28/29 Q3: June 30 Q3: March 1 —May 31 Q4: October 15 Q4: June 1 —August 31 PHC 325 Annual Annually - within sixty October 30 Report (60)days after the end of the contract term 8.2 The Grantee and/or any subcontractors associated with this Contract agree to permit on-site monitoring visits and desk reviews, as deemed necessary by HHSC to review all financial or other records and management control systems relevant to the provision DocuSign Envelope ID 2DAB07B4-A920-4608-B1A4-CCFFDBODF809 of goods and services under this Contract. The Grantee will include this requirement in any subcontract associated with this Contract. 9. Performance Measures HHSC will actively monitor Grantee's performance under this Contract including, but not limited to, the requirements as set forth in Attachment A to this Contract. All services and deliverables under the Contract shall be provided at an acceptable quality level and in a manner consistent with acceptable industry standard,custom, and practice. 9.1 Additionally, the following specific performance measure will be used to assess, in part, Grantee's effectiveness in providing the services described in this Contract, without waiving the enforceability of any of the other terms of this Contract: • For FY 2021, Grantee shall provide services to a minimum of 249 unduplicated clients at an average cost per client of$250.00 for clients who live or receive services in the following county: Jefferson 9.2 System Agency will monitor Grantee's performance measure activity. If the number of unduplicated clients served is less than that projected in Grantee's final approved Application, Grantee's funding award may be subject to a decrease for the remainder of the Contract year. (Remainder of Page Intentionally Left Blank) DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment B - PHC Budget Detail DocuSign Envelope ID:2DABO7B4-A920-4608-81 A4-CCFFDBODF809 General Instructions for Completing Budget Forms In preparing the budget, you must budget all costs that your organization will incur in carrying out the Primary Health Care Program for FY21. Instructions for completing the budget template follow: Only respondents with cost reimbursement contracts need to complete Forms B and B-1 through B-7. * Enter the legal name of your organization in the space provided for "Legal Name of Respondent" on the budget summary page. Doing so will populate the budget category detail templates with the organization's name. * Complete each budget category detail template. If a primary budget category detail template does not accommodate all items in your budget, use the respective supplemental budget temples at the end of this workbook. The total of each supplemental category detail budget template will automatically populate to the last line of the respective primary budget category template. The definition of each category can be found in the HHSC Grant Technical Assistance Guide (GTAG) located at the following web site: Beginning on page 13 of PDF Grant Technical Assistance Guide - (Document page# 10). * After you complete each budget category detail template, go to the Budget Summary. * Distribute the total amount in column 1 in each budget category manually amoung the various funding sources (columns 2 and 3). * Refer to the table below the budget template table to verify that the amounts distributed (Distribution Total) in each budget category equals the "Budget Total" for each respective category. Next, verify that the overall total of all distributions (Distribution Totals) equals the Budget Total. * Fill all budget forms out in WHOLE DOLLARS. DocuSign Envelope ID.20A80784-A920-4608-81A4-CCFFDBODF809 FORM B: BUDGET SUMMARY(REQUIRED) Legal Name of Respondent: 'City of Port Arthur Total Primary Health HHSC Share Patient Co-Pays Budget Categories Care Budget Categorical Award To Be Collected (1) (2) (3) A. Personnel $29,050 $29,050 B. Fringe Benefits $8,791 $8,791 C. Travel $525 $525 D. Equipment $0 $0 E. Supplies $534 $534 F. Contractual $23,400 $23,400 G. Other $0 $0 H. Total Direct Costs $62,300 $62,300 $0 I. Indirect Costs $0 Total(Sum of H and J. I) $62,300 $62,300 $0 NOTE: The"Total Budget"amount for each Budget Category will have to be entered manually among columns 2 and 3. Enter amounts in whole dollars. After amounts have been entered for each funding source,verify that the"Distribution Total"below equals the respective amount under the"Total Budget"from column (1). Budget Distribution Budget Budget Distribution Budget Catetory Total Total Category Total Total Check Totals For: Personnel $29,050 $29,050 Fringe Benefits $8,791 $8,791 Travel $525 $525 Equipment $0 $0 Supplies $534 $534 Contractual $23,400 $23,400 Other $0 $0 Indirect Costs $0 $0 TOTAL FOR: (Distribution Totals $62,300 Budget Total $62,300 DocuSign Envelope ID:2DABO7B4-A920-4608.131A4-CCFFOBODF809 FORM 13-1: PERSONNEL Budget Category Detail Form Legal Name of Respondent: City of Port Arthur PERSONNEL Certification or Total Average Number Salary/Wages Functional Title+Code Vacant License(Enter NA if Monthly of Requested for E=Existing or P=Proposed Y/N Justification FTE's not required) Salary/Wage Months Project Responsible for interviewing patients for Eligibiltiy Clerk(E) N service and preparing all reports and billing 0.8 N/A 53,026.00 12 $29,050 for Primary Health Care. $0 $0 $o $0 $0 $0 $0 $0 $0 $0 $0 $0 TOTAL FROM PERSONNEL SUPPLEMENTAL BUDGET SHEETS $0 ISala ryWage Total $29,050 FRINGE BENEFITS Iltemize the elements of fringe benefits in the space below: FICA 7.65,INSURANCE 22%,WORKER'S COMP 0.15%,TMRS.31%,TERMINATING PAY.15% 1 Fringe Benefit Rate% 30.26% I DocuSign Envelope ID:2DAB07B4-A920-4608-131A4-CCFFDB0DF809 IFringe Benefits Total I $8,791 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFOBODF809 FORM B-2:TRAVEL Budget Category Detail Form Legal Name of Respondent: 'City of Port Arthur Conference/Workshop Travel Costs Description of Number of: Location Conference/Workshop Justification Travel Costs City/State Days/Employees Mileage 2 days,1 night Airfare DSHS PHC Eligibility Training To receive program updates Austin for 1 employee. Meals $90 This includes car Lodging $300 rental and gas Other Costs $135 Total $525 Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total SO TOTAL FROM TRAVEL SUPPLEMENTAL CONFERENCE/WORKSHOP BUDGET SHEETS $D Total for Conference/Workshop Travel $525 DocuSlgn Envelope ID 2DABO7B4-A920-4608-131A4-CCFFDBODF809 Other/Local Travel Costs Number of Mileage Justification Miles Mileage Reimbursement Rate Cost Other Costs Total (a) (b) (a)+(b) $0 $0 $0 SO $0 $0 $0 $0 $0 $0 $0 SO $0 $0 TOTAL FROM TRAVEL SUPPLEMENTAL OTHER/LOCAL TRAVEL COSTS BUDGET SHEETS SO Total for Other/Local Travel $0 Other/Local Travel Costs: $0 Conference/Workshop Travel Costs: $525 Total Travel Costs: $525 Indicate Policy Used: Respondent's Travel Policy State of Texas Travel Policy DocuSign Envelope ID 2DAB07B4-A920-4608-B1A4-CCFFDBODF809 FORM B-3:EQUIPMENT AND CONTROLLED ASSETS Budget Category Detail Form Legal Name of Respondent: City of Port Arthur Itemize,describe,and justify below. Equipment is tangible nonexpendable personal property costing$5,000 or more and a useful life of more than one year. Approved equipment must be purchased within 90 days of contract start date. Number Cost Per Description of Item Purpose&Justification of Units Unit Total $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $o TOTAL FROM EQUIPMENT SUPPLEMENTAL BUDGET SHEETS $O Total Amount Requested for Equipment: $0 DocuSign Envelope ID 2DA80784-A920-4608-61A4-CCFFDBODF809 FORM B-4:SUPPLIES Budget Category Detail Form Legal Name of Respondent: City of Port Arthur Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each supply item. Costs may be categorized by each general type-office,computer,medical,educational,etc. Supplies can be consumable-paper,drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers,printers,phones,medical and lab equipment,etc. Description of Item [If applicable,provide estimated quantity and cost(i.e.it of boxes&cost/box)] Purpose&Justification Total Cost Copier paper, Ink Cartridges for printer, File folders, General office supplies to support the operation of the Primary Ink pens. ($44.50 monthly x 12 mths) Health Care Clinic. $534 TOTAL FROM SUPPLIES SUPPLEMENTAL BUDGET SHEETS $0 Total Amount Requested for Supplies: $534 DocuSrgn Envelope 10:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 FORM B-5:CONTRACTUAL Budget Category Detail Form Legal Name of Respondent: (City of Port Arthur List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates$100,000 or more of the scope of the project in the respondent's funding request,must be attached behind this form. METHOD OF RATE OF PAYMENT #of Months, PAYMENT ll.e., CONTRACTOR NAME DESCRIPTION OF SERVICES (Agency or Individual) (Scope of Work) Justification (i.e.,Monthly, Hours,Units, hourly rate,unit TOTAL Hourly,Unit, etc. rate,lump sum Lump Sum) amount) Lab Corp Lab Services for PHC Clients This is the outside lab that is used to perform the lab test for PHC Monthly 12 clients $1,950.00 $23,400 $0 $0 $0 $0 $0 $0 $0 $0 TOTAL FROM CONTRACTUAL SUPPLEMENTAL BUDGET SHEETS $0 Total Amount Requested for CONTRACTUAL: $23,40, DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 FORM B-6:OTHER Budget Category Detail Form Legal Name of Respondent: City of Port Arthur Description of Item [If applicable,include quantity and cost/quantity(i.e.U of units&cost per unit)] Purpose&Justification Total Cost TOTAL FROM OTHER SUPPLEMENTAL BUDGET SHEETS $0 Total Amount Requested for Other: $0 DocuSign Envelope ID 20AB0784-A920-4608-B1A4-CCFFDB0DF809 FORM B-7 Indirect Costs Legal Name of Respondent: City of Port Arthur Total amount of indirect costs allocable to the project: Amount: Indirect costs are based on(mark the statement that is applicable): The respondent's most recent indirect cost rate approved by a federal RATE: cognizant agency or state single audit coordinating agency. Expired rate BASE: agreements are not acceptable. Attach a copy of the rate agreement to this form(Form I-7 Indirect) Applies only to governmental entities.The respondent's current central RATE: service cost rate or indirect cost rate based on a rate proposal prepared in TYPE: accordance with OMB Circular A-87. Attach a copy of Certification of Cost BASE: Allocation Plan or Certification of Indirect Costs. Note:Governmental units with only a Central Service Cost Rate must also include the indirect cost of the governmental units department(i.e.HHSC). In this case indirect costs will be comprised of central service costs(determined by applying the rate)and the indirect costs of the governmental department. The allocation of indirect costs must be addressed in Part V-Indirect Cost Allocation of the Cost Allocation Plan that is submitted to HHSC. A cost allocation plan. A cost allocation plan as specified in the DSHS Contractor's Financial Procedures Manual(CFPM),Appendix A must be submitted to HHSC within 60 days of the contract start date. The CFPM is available on the following internet web link: http://www.dshs.state.tx.us/contracts/ GO TO PAGE 2(below) DocuSign Envelope ID 2DAB07B4-A920-4608-01A4-CCFFDBODF809 Page 2, FORM B-7 Indirect Costs baa: If using an central service or indirect cost rate,identify the types of costs that are included(being allocated)In the rate: Organizations that do not use an indirect cost rate and governmental entities with only a central service rate must identify the types of costs that will be allocated as indirect costs and the methodology used to allocate these costs in the space provided below. The costs/methodology must also be disclosed in Part V-Indirect Cost Allocation of the Cost Allocation Plan that is submitted to DSHS. Identify the types of costs that are being allocated as indirect costs,the allocation methodology,and the allocation base: DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 SUPPLEMENTAL FORMS INSTRUCTIONS The budget templates (two per budget category)that follow are intended to supplement cost reimbursement budgets when there are too many items to fit on the primary budget template. Applicants that have utilized all the lines on the primary budget template must use the supplemental templates to list detail information for the respective budget category. For example, after all the lines on the primary budget template for Personnel (tab labled Form B- 1 Personnel) have been used,go to the supplemental template labled "Form B- la Personnel Supp" and if all the lines are used on this template,go to the next template labled "Form B- lb Personnel". The amounts on each supplemental template will automatically total and the total from both templates will automatically be inserted on the last line of the primary budget template. Form B-1 Personnel Supplemental Form B-2 Travel Supplemental Form B-3 Equipment Supplemental Form B-4 Supplies Supplemental Form B-5 Contractual Supplemental Form B-6 Other Supplemental DocuSign Envelope ID:2DAB07B4-A920-4608-131A4-CCFFDBODF809 FORM B-la:PERSONNEL Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur PERSONNEL Certification or Total Average Number Salary/Wages Functional Title+Code Vacant License(Enter NA if Monthly of Requested for E=Existing or P=Proposed Y/N Justification FTE's not required) Salary/Wage Months Project so $o so $o so $o $o $o $o So So So So So Salary Wage Total $0 DocuSign Envelope ID 2DAB0784-A920-4608-81A4-CCFFDBODF809 FORM B-lb:PERSONNEL Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur PERSONNEL Certification or Total Average Number Salary/Wages Functional Title+Code Vacant License(Enter NA if Monthly of Requested for E=Existing or P-Proposed Y/N Justification FTE's not required) Salary/Wage Months Project So $0 50 $o $o So $o so So so so so $o $o Salary Wage Total SO DocuSign Envelope ID'.2DAB07B4-A920-4608-B1A4-CCFFDB0DF809 FORM B-2a:TRAVEL Budget Category Detail Form (Supplemental) Legal Name of Respondent: !City of Port Arthur Conference/Workshop Travel Costs Description of Location Number of: Conference/Workshop Justification (City,State) Days/Employees Travel Costs Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare _ Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total SO Mileage Airfare Meals Lodging Other Costs Total SO Mileage Airfare Meals Lodging Other Costs Total $0 Total for Conference/Workshop Travel $0 tOther/Local Travel Costs I 1 I Number of I ! Mileage I I I DocuSign Envelope ID 20AB0784-A920-4608-91A4-CCFFDB0DF809 Justification Miles I Mileage Reimbursement Rate CostOther Costs Total (a) I (b) (a)+(b) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 SO $D $O Total for Other/Local Travel $0 Other/Local Travel Costs: $0 Conference/Workshop Travel Costs: $0 Total Travel Costs: $0 DocuSign Envelope ID:2DAB07B4-A920-4606-B1A4-CCFFDBODF609 FORM B-2b:TRAVEL Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur Conference/Workshop Travel Costs Description of Location Number of: Conference/Workshop Justification (City,State) Days/Employees Travel Costs Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total $0 Mileage Airfare Meals Lodging Other Costs Total $0 Total for Conference/Workshop Travel $0 (Other/Local Travel Costs I r l Number of I I Mileage DocuSign Envelope ID.2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Justification Miles Mileage Reimbursement RateCost Other Costs Total I (a) (b) I (a)+(b) s0 $0 $0 $0 $0 $0 $0 SO $0 $0 $0 $0 $0 $0 $0 $0 $0 so Total for Other/Local Travel $0 Other/Local Travel Costs: $0 Conference/Workshop Travel Costs: $0 Total Travel Costs: $0 DocuStgn Envelope ID-2DA807B4-A920-4608-81A4-CCFFDBODF809 FORM B-3a:EQUIPMENT AND CONTROLLED ASSETS Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur Itemize,describe,and justify below. Equipment is tangible nonexpendable personal property costing$5,000 or more and a useful life of more than one year. Approved equipment must be purchased within 90 days of contract start date. Number Cost Per Description of Item Purpose&Justification of Units Unit Total $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Total Amount Requested for Equipment: $0 DocuSign Envelope ID:2DAB07134-A920-4608-81A4-CCFFDB0DF809 FORM B-3b:EQUIPMENT AND CONTROLLED ASSETS Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur Itemize,describe,and justify below. Equipment is tangible nonexpendable personal property costing$5,000 or more and a useful life of more than one year. Approved equipment must be purchased within 90 days of contract start date. Number Cost Per Description of Item Purpose&Justification of Units Unit Total $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Total Amount Requested for Equipment: $0 DocuSign Envelope ID.2DAB07B4-A920-4608-81A4-CCFFDBODF809 FORM B-4a:SUPPLIES Budget Category Detail Form(Supplemental) Legal Name of Respondent: (City of Port Arthur Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each supply item. Costs may be categorized by each general type-office,computer,medical,educational,etc. Supplies can be consumable-paper,drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers,printers,phones,medical and lab equipment,etc. Description of Item (If applicable,provide estimated quantity and cost]i.e.#of boxes&cost/box)] Purpose&Justification Total Cost Total Amount Requested for Supplies: $0 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 FORM B-4b:SUPPLIES Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each supply item. Costs may be categorized by each general type-office,computer,medical,educational,etc. Supplies can be consumable-paper,drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers,printers,phones,medical and lab equipment,etc. Description of Item [If applicable,provide estimated quantity and cost(i.e.#of boxes&cost/box)] Purpose&Justification Total Cost Total Amount Requested for Supplies: $0 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 FORM B-5a:CONTRACTUAL Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates$100,000 or more of the scope of the project in the respondent's funding request,must be attached behind this form. RATE OF CONTRACTOR NAME DESCRIPTION OF SERVICES METHOD OF #of Months, PAYMENT (Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hourly rate, TOTAL Monthly,Hourly, etc. unit rate,lump Unit,Lump Sum) sum amount) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Total Amount Requested for CONTRACTUAL: $0 DocuSign Envelope ID 2DABO7B4-A920-4608-B1A4-CCFFDBODF809 FORM B-Sb:CONTRACTUAL Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates$100,000 or more of the scope of the project in the respondent's funding request,must be attached behind this form. RATE OF CONTRACTOR NAME DESCRIPTION OF SERVICES METHOD OF #of Months, PAYMENT (Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hourly rate, TOTAL Monthly,Hourly, etc. unit rate,lump Unit,Lump Sum) sum amount) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Total Amount Requested for CONTRACTUAL: $0 DocuSign Envelope ID.2DAB0784-A920-4608-81A4-CCFFDBODF809 FORM B-6a:OTHER Budget Category Detail Form(Supplemental) Legal Name of Respondent: City of Port Arthur uesi.npuon or nem [If applicable,include quantity and cost/quantity(i.e.#of units& cost/unit)( Purpose&Justification Total Cost Total Amount Requested for Other: $0 DocuSign Envelope ID.2DAB07B4-A920-4608-B1A4-CCFFDBODF809 FORM B-6b:OTHER Budget Category Detail Form (Supplemental) Legal Name of Respondent: City of Port Arthur uescnpuon or item [If applicable,include quantity and cost/quantity(i.e.S of units& cost/unit)] Purpose&Justification Total Cost Total Amount Requested for Other: $0 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C HHSC Uniform Terms and Conditions Version 2.16 Published and Effective:March 26.2019 Responsible Office:Chief Counsel ........ lie VGA \J�•..': : v TO TEXAS % �►� &'.. Health and Human Services Health and Human Services Commission HHSC Uniform Terms and Conditions-Grant Version 2.16.1 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C TABLE OF cow F,NTS ARTICLE I.DEFINITIONS AND INTERPRETIVE PROVISIONS 4 1.1 Definitions 4 1.2 Interpretive Provisions 6 ARTICLE H.PAYMENT METHODS AND RESTRICTIONS 6 2.1 Payment Methods 6 2.2 Final Billing Submission 7 2.3 Financial Status Reports(FSRs) 7 2.4 Use of Funds 7 2.5 Use for Match Prohibited 7 2.6 Program Income 7 2.7 Nonsupplanting 8 2.8 Allowable Costs 8 2.9 Indirect Cost Rates 8 ARTICLE III.STATE AND FEDERAL FUNDING S 3.1 Funding.. 8 3.2 No Debt Against the State 8 3.3 Debt and Delinquencies 8 3.4 Recapture of Funds.. 8 ARTICLE IV.ALLOWABLE COSTS AND AUDIT REQUIREMENTS 9 4.1 Allowable Costs. 9 4.2 Audits and Financial Statements 10 4.3 Submission of Audits and Financial Statements 11 ARTICLE V.AFFIRMATIONS,ASSURANCES AND CERTIFICATIONS 11 5.1 General Affirmations 11 5.2 Federal Assurances 1 5.3 Federal Certifications 11 ARTICLE VI.INTELLECTUAL PROPERTY 11 6.1 Ownership of Work Product 11 6.2 Grantees Pre-existing Works 12 6.3 Agreements with Employees and Subcontractors 12 6.4 Delivery Upon Termination or Expiration 12 6.5 Survival 12 1111..undue Uniform Terms and Condition Page 2 of 21 v.2.16.1 Gfttclive 03Q6R019 II DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment C ARTICLE VII.RECORDS,AUDIT,AND DISCLOSURE 13 7.1 Books and Records 13 7.2 Access to Records,Books,and Documents 13 7.3 Response/Compliance with Audit or Inspection Findings 13 7.4 SAO Audit 14 7.5 Confidentiality 14 ARTICLE VIII.CONTRACT MANAGEMENT AND EARLY TERMINATION 14 8.1 Contract Remedies 14 8.2 Termination for Convenience 14 8.3 Termination for Cause 14 ARTICLE LY.MISCELLANEOUS PROVISIONS 15 9.1 Amendment 15 9.2 Insurance 15 9.3 Legal Obligations.... 15 9.4 Permitting and Licensure 16 9.5 Indemnity 16 9.6 Assignments 16 9.7 Independent Contractor . 17 9.8 Technical Guidance Letters 17 9.9 Dispute Resolution 17 9.10 Governing Law and Venue 17 9.11 Severability 17 9.12 Survivability 18 9.13 Force Majeure 18 9.14 No Waiver of Provisions 18 9.15 Publicity 18 9.16 Prohibition on Non-compete Restrictions 19 9.17 No Waiver of Sovereign Immunity 19 9.18 Entire Contract and Modification 19 9.19 Counterparts 19 9.20 Proper Authority 19 9.21 E-Verify Program 19 9.22 Civil Rights 19 9.23 System Agency Data 21 fiflSC Grantee Uniform Teens and Conditions Page 3 of 21 v.2.16.1 Effective 03126/2019 111 DoouSign Envelope ID:2DABO7B4-A920-4608-B1 A4-CCFFDBDDF809 Attachment C ARTICLE I.DEFINITIONS AND INTERPRETIVE PROVISIONS 1.1 DEFINITIONS As used in this Contract,unless the context clearly indicates otherwise,the following terms and conditions have the meanings assigned below: "Amendment"means a written agreement,signed by the Parties,which documents changes to the Contract other than those permitted by Work Orders or Technical Guidance Letters. "Attachment"means documents,terms,conditions,or information added to this Contract following the Signature Document or included by reference. and made a part of this Contract. "Contract"means the Signature Document,these Uniform Terms and Conditions,along with any Attachments,and any Amendments,or Technical Guidance I.ettets that may be issued by the System Agency,to be incorporated by reference for all purposes. "Deliverable"means the work product(s),including all reports and project documentation, required to be submitted by Grantee to the System Agency. "Effective Date"means the date agreed to by the Parties as the date on which the Contract takes effect. "Federal Fiscal Year"means the period beginning October] and ending September 30 each year,which is the annual accounting period for the United States government. "GAAP"means Generally Accepted Accounting Principles. "GASB"means the Governmental Accounting Standards Board. "Grantee"means the Party receiving funds under this Contract,May also be referred to as "Contractor"in certain attachments. "Health and Human Services Commission"or"HHSC"means the administrative agency established under Chapter 531,Texas Government Code,or its designee. "HUB" means Historically Underutilized Business, as defined by Chapter 2161 of the Texas Government Code. "Intellectual Prooertv Rights"means the worldwide proprietary rights or interests,including patent,copyright,trade secret,and trademark rights,as such right may be evidenced by or embodied in: i. any idea, design, concept,personality right,method,process,technique,apparatus, invention,discovery,or improvement; ii. any work of authorship,including any compilation,computer code,website or web page design,literary work,pictorial work,or graphic work; iii. any trademark,service mark,trade dress, trade name, branding,or other indicia of source or origin; iv. domain name registrations;and v. any other proprietary or similar rights. The Intellectual Property Rights of a Party include all worldwide proprietary rights or interests that the Party may have acquired by assignment,by exclusive license,or by license with the right to grant sublicenses. HHSC thanttc Gmfonn Terms and Ce dita ns Page 4 or21 r.2.16.1 &ffedive 03;207019 Iv DocuSign Envelope ID: 2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment C "Mentor Protege"means the Comptroller of Public Accounts' leadership program found at:http:Jswww.window.state.tx.usiprocurement!prog/hublmentorprotegc "Parties"means the System Agency and Grantee,collectively. "Party"means either the System Agency or Grantee,individually. "Program"means the statutorily authorized activities of'the System Agency under which this Contract has been awarded. "Project"means specific activities of the Grantee that are supported by funds provided under this Contract. "Public Information Act"or"PIA"means Chapter 552 of the Texas Government Code. "Signature Document"means the document executed by both Parties that specifically sets forth all of the documents that constitute the Contract. "Solicitation" or "Request for Applications (RFA)" means the document (including all amendments and attachments)issued by the System Agency under which applications for Program bunds were requested,which is incorporated by reference for all purposes in its entirety. "Solicitation Response" or "Application" means Grantee's full and complete response (including any attachments and addenda) to the Solicitation, which is incorporated by reference for all purposes in its entirety. "State Fiscal Year"means the period beginning September 1 and ending August 31 each year,which is the annual accounting period for the State of Texas. "State of Texas Textravel"means Texas Administrative Code,Title 34, Part I.Chapter 5, Subchapter C,Section 5.22,relative to travel reimbursements under this Contract,if any. -=Statement of Work"means the description of activities performed in completing the Project, as specified in the Contract and as may be amended. "System Agency"means HHSC or any of the agencies of the State of Texas that are overseen by HHSC under authority granted under State law and the officers,employees,authorized representatives and designees of those agencies. These agencies include: HHSC and the Department of State Health Services. "Technical Guidance Letter"or`TGL"means an instruction,clarification,or interpretation of the requirements of the Contract,issued by the System Agency to the Grantee. "Work Product" means any and all works, including work papers, notes, materials, approaches, designs, specifications, systems, innovations. improvements, inventions, software, programs, source code, documentation, training materials, audio or audiovisual recordings, methodologies,concepts, studies, reports, whether finished or unfinished, and whether or not included in the deliverables, that are developed, produced, generated or provided by Grantee in connection with Grantee's performance of its duties under the Contract or through use of any funding provided under this Contract. "Uniform. Grant Management Standards" or "UGMS" means uniform grant and contract administration procedures, developed under the authority of Chapter 783 of the Texas HHSC C,rmntec Uniform'lams and Conditions Page of 21 c.2.16.1 Effective 03/26/1019 V DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment C Government Code,to promote the efficient use of public funds in local government and in programs requiring cooperation among local,state,and federal agencies. 1.2 INTERPRETIVE PROVISIONS A. The meanings of defined terms include the singular and plural forms. B. The words "hereof," "herein," "hereunder," and similar words refer to this Contract as a whole and not to any particular provision,section,Attachment,or schedule of this Contract unless otherwise specified. C. The term "including" is not limiting and means "including without limitation" and. unless otherwise expressly provided in this Contract.(i)rete rences to contracts(including this Contract) and other contractual instruments shall be deemed to include all subsequent Amendments and other modifications, but only to the extent that such Amendments and other modifications are not prohibited by the terms of this Contract, and (ii) references to any statute or regulation are to be construed as including all statutory and regulatory provisions consolidating,amending,replacing,supplementing, or interpreting the statute or regulation. D. Any references to"sections,""appendices,"or`attachments"are references to sections, appendices,or attachments of the Contract. E. Any references to agreements,contracts,statutes,or administrative rules or regulations in the Contract are references to these documents as amended, modified. or supplemented from time to time during the term of the Contract. F. The captions and headings of this Contract are for convenience of reference only and do not affect the interpretation of this Contract_ G. All Attachments, including those incorporated by reference,and any Amendments are considered part of the terms of this Contract. H. This Contract may use several different limitations,regulations, or policies to regulate the same or similar matters. All such limitations, regulations, and policies are cumulative and each will be performed in accordance with its terms. I. Unless otherwise expressly provided,reference to any action of the System Agency or by the System Agency by way of consent, approval, or waiver will be deemed modified by the phrase"in its sole discretion." J. Time is of the essence in this Contract. ARTICLE H.PAYMENT METHODS AND RESTRICTIONS 2.1 PAYMENT METHODS A. Except as otherwise provided by this Contract,the payment method will be one or more of the following: i. Cost Reimbursement. This payment method is based on an approved budget and submission of a request for reimbursement of expenses Grantee has incurred at the time of the request; ii. Unit raterfee-for-service.This payment method is based on a fixed price or a specified rate(s) or fee(s) for delivery of a specified unit(s) of service and acceptable submission of all required documentation,forms and/or reports;or iii. Advance payment. This payment method is based on disbursal of the minimum necessary funds to carry out the Program or Project where the Grantee has I it Ise Utantee Uniform Terms and Conditions Page 6of21 v.2.161 Effective 03/26/2019 vi DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C implemented appropriate safeguards. This payment method will only be utilized in accordance with governing law, state and federal regulations, and at the sole discretion of the System Agency. B. Grantee shall bill the System Agency in accordance with the Contract.Unless otherwise specified in the Contract,Grantee shall submit requests for reimbursement or payment monthly by the last business day of the month following the month in which expenses were incurred or services provided. Grantee shall maintain all documentation that substantiates invoices and make the documentation available to the System Agency upon request. 2.2 FINAL BILLING SUBMISSION Unless otherwise provided by the System Agency, Grantee shall submit a reimbursement or payment request as a final close-out invoice not later than forty-five(45)calendar days following the end of the tern of the Contract. Reimbursement or payment requests received after the deadline may not he paid. 2.3 FINANCIAL STATUS REPORTS(FSRs) Except as otherwise provided,for contracts with categorical budgets,Grantee shall submit quarterly FSRs to System Agency by the last business day of the month following the end of each quarter for System Agency review and financial assessment.Grantee shall submit the final FSR no later than forty-five(45)calendar days following the end of the applicable term. 2.4 UsE OF FUNDS Grantee shall expend funds under this Contract only for approved services and for reasonable and allowable expenses directly related to those services. 2.5 IJSE FOR MATCH PROHIBITED Grantee shall not use funds provided under this Contract for matching purposes in securing other funding without the written approval of the System Agency. 2.6 PROGRAM INCOME Income directly generated from funds provided under this Contract or earned only as a result of such funds is Program Income. Unless otherwise required under the Program, Grantee shall use Program Income, as provided in UGMS Section HI, Subpart C, .25(gX2), to further the Program. and Grantee shall spend the Program Income on the Project.Grantee shall identify and report Program Income in accordance with the Contract,applicable law, and any programmatic guidance.Grantee shall expend Program Income during the Contract term, when earned, and may not carry Program Income forward to any succeeding term. Grantee shall refund Program Income to the System Agency if the Program Income is not expended in the term in which it is earned.The System Agency may base future funding levels, in part,upon Grantee's proficiency in identifying, billing,collecting,and reporting Program Income,and in using Program Income for the purposes and under the conditions specified in this Contract. MSC lirantec Unitbnn Tema and Conditions Page 7 01 21 v.2.16.1 Effective 03/26+3019 VII DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C 2.7 NONSUPPLANTING Grant funds may be used to supplement existing.new or corresponding programming and related activities. Grant funds may not be used to supplant(replace)existing funds in place to support current programs and related activities. 2.8 ALLOWABLE COSTS Allowable Costs are restricted to costs that comply with the Texas Uniform Grant Management Standards(t CMS)and applicable state and federal rules and law. The Parties agree that all the requirements of the UGMS apply to this Contract,including the criteria for Allowable Costs. Additional federal requirements apply if this Contract is funded,in whole or in part,with federal funds. 2.9 INDIRECT COST RATES The System Agency may acknowledge an indirect cost rate for Grantees that is utilized for all applicable contracts. Grantee will provide the necessary financial documents to determine the indirect cost rate in accordance with the Uniform Grant Guidance(UGG)and Uniform Grant Management Standards(UGMS). ARTICLE ILI.STATE AND FEDERAL FUNDING 3.1 FUNDING This Contract is subject to termination or cancellation,without penalty to System Agency, either in whole or in part,subject to the availability of state funds.System Agency is a state agency whose authority and appropriations are subject to actions of the Texas Legislature. If System Agency becomes subject to a legislative change,revocation of statutory authority,or lack of appropriated funds that would render either System Agency's or Grantee's delivery or performance under the Contract impossible or unnecessary, the Contract will be terminated or cancelled and be deemed null and void. In the event of a termination or cancellation under this Section, System Agency will not be liable to Grantee for any damages,that are caused or associated with such termination,or cancellation. and System Agency will not be required to give prior notice. 3.2 NO DEBT AGAINST THE STATE This Contract will not be construed as creating any debt by or on behalf of the State of Texas. 3.3 DEBT AND DELINQUENCIES Grantee agrees that any payments due under the Contract shall be directly applied towards eliminating any debt or delinquency it has to the State of Texas including,but not limited to, delinquent taxes,delinquent student loan payments.and delinquent child support. 3.4 RECAPTURE OF FUNDS A. At its sole discretion,the System Agency may i)withhold all or part of any payments to Grantee to offset overpayments,unallowable or ineligible costs made to the Grantee,or if any required financial status report(s)is not submitted by the due date(s),or ii)require Grantee to promptly refund or credit-within thirty(30)calendar days of written notice- Ht1SC Terms and Conditions Page 8of2l v.2.16.1 Effective 03/26/2019 VIII DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment C any funds erroneously paid by System Agency which arc not expressly authorized under the Contract. B. "Overpayments" as used in this Section include payments (i) made by the System Agency that exceed the maximum allowable rates:(ii)that are not allowed under applicable laws, rules, or regulations; or (iii) that are otherwise inconsistent with this Contract, including any unapproved expenditures.Grantee understands and agrees that it will be liable to the System Agency for any costs disallowed pursuant to financial and compliance audit(s)of funds received under this Contract.Grantee further understands and agrees that reimbursement of such disallowed costs shall be paid by Grantee from fluids which were not provided or otherwise made available to Grantee under this Contract. ARTICLE IV.ALLOWABLE COSTS AND AUDIT REQUIREMENTS 4.1 ALLOWABLE COSTS A. System Agency will reimburse the allowable costs incurred in performing the Project that are sufficiently documented. Grantee must have incurred a cost prior to claiming reimbursement and within the applicable term to be eligible for reimbursement under this Contract.At its sole discretion, the System Agency will determine whether costs submitted by Grantee are allowable and eligible for reimbursement. The System Agency may take repayment (recoup) from funds available under this Contract in amounts necessary to fulfill Grantee's repayment obligations. Applicable cost principles, audit requirements,and administrative requirements include,but are not limited to: Applicable Entity Applicable Cost Audit Administrative Principles Requirements Requirements State,Local,and 2 CIR Part 200 and 2 CFR Part 200, 2 CFR Part 200 and Tribal UGMS Subpart F and UGMS Governments UGMS Educational 2 CFR Part 200 and 2 Cllt Part 200, 2 CFR Part 200 and Institutions UGMS Subpart F and UGMS UGMS Non-Profit 2 CFR Part 200 and 2 CFR Part 200, 2 CFR Part 200 and Organizations UGMS Subpart F and IJOMS UGMS HHSC Cirantec Uniform Terms and Conditions Page 9 of 21 v.2.16.1 Effective 031202019 ix DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C For-profit 48 CFR Part 31, 2 CFR Pail 200, 2 CFR Pail 200 and Organization Contract Cost Subpart E and UGMS other than a Principles and UGMS hospital and an Procedures,or organization Uniform cost named in OMB accounting Circular A-122 standards that (2 CFR Part, comply with cost 230)as not principles subject to that acceptable to the circular. federal or state awarding agency B. OMB Circulars will he applied with the modifications prescribed by UGMS with effect given to whichever provision imposes the more stringent requirement in the event of a conflict. 4.2 At errs AND FINANCIAL STATEMENTS A. Audits i. HHS Single Audit Unit will notify Grantee to complete the Single Audit Determination Form.If Grantee fails to complete the form within thirty(30)calendar days after receipt of notice,Grantee will be subject to the sanctions and remedies for non-compliance with this Contract. ii. If Grantee,within Grantee's fiscal year,expends at least SEVEN HUNDRED FIFTY THOUSAND DOLLARS($750,000)in federal funds awarded,Grantee shall have a single audit or program-specific audit in accordance with 2 CFR 200. The federal threshold amount includes federal funds passed through by way of suite agency awards. iii. If Grantee,within Grantee's fiscal year,expends at least SEVEN HUNDRED FIFTY THOUSAND DOLLARS ($750,000)in state funds awarded, Grantee shall have a single audit or program-specific audit in accordance with UGMS, State of Texas Single Audit Circular.The audit must be conducted by an independent certified public accountant and in accordance with 2 CFR 200,Government Auditing Standards,and UGMS. iv. For-profit Grantees whose expenditures meet or exceed the federal or state expenditure thresholds stated above shall follow the guidelines in 2 CFR 200 or UGMS,as applicable,for their program-specific audits. v. Each Grantee that is required to obtain a single audit must competitively re-procure single audit services once every six years. Grantee shall procure audit services in compliance with this section. slate procurement procedures. as well as with the provisions of UGMS. B. Financial Statements Each Grantee that does not meet the expenditure threshold for a single audit or program- specific audit,must provide financial statements. tii15L Ur;mtce Liu tom l.cnmu and LbtldltiMtn Page 10 o1'21 v.2.16.1 Effective 03/26/2019 X DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C 43 SUBMISSION OF AUDITS AND FINANCIAL STATEMENTS A. Audits Due the earlier of 30 days after receipt of the independent certified public accountant's report or nine months after the end of the fiscal year,Grantee shall submit electronically one copy of the single audit or program-specific audit to the System Agency via: i. IIIiS portal at:or, https://hhsnortal.hhs.state.tx.us/heartwehextr/hhscSau ii. Email to:single_audit_report@hhsc.state.tx.us. B. Financial Statements Due no later than nine months after the Grantee's fiscal year end,Grantees which arc not required to submit an audit,shall submit electronically financial statements via: i. HHS portal at: httpsJ/hhsportal.hhs,stale.tx,us/heartwebextr/hhscSay,or, ii. Email to:single_audit_report(thhsc.state.tx.us. ARTICLE V.AFFIRMATIONS,ASSURANCES AND CERTIFICATIONS 5.1 GENERAL AFFIRM.%T IONS Grantee certifies that,to the extent General Affirmations are incorporated into the Contract under the Signature Document,the Grantee has reviewed the General Affirmations and that Grantee is in compliance with all requirements. 5.2 FEDERAL ASSURANCES Grantee further certifies that, to the extent Federal Assurances are incorporated into the Contract under the Signature Document, the Grantee has reviewed the Federal Assurances and that Grantee is in compliance with all requirements. 5.3 FEDERAL CERTIFICATIONS Grantee further certifies that,to the extent Federal Certifications are incorporated into the Contract under the Signature Document, the Grantee has reviewed the Federal Certifications and that Grantee is in compliance with all requirements.In addition,Grantee certifies that it is in compliance with all applicable federal laws,rules,and regulations,as they may pertain to this Contract. ARTICLE VI.INTELLECTUAL PROPERTY 6.1 OWNERSHIP OF WORK PRODUCT All right,title, and interest in the Work Product, including all Intellectual Property Rights therein,is exclusively owned by System Agency.Grantee and Grantee's employees will have no rights in or ownership of the Work Product or any other property of System Agency.Any and all Work Product that is copyrightable under United States copyright law is deemed to be"work made for hire"owned by System Agency,as provided by Title 17 of the United States Code. To the extent that Work Product does not qualify as a"work made for hire" under applicable federal law, Grantee hereby irrevocably assigns and transfers to System Agency, its successors and assigns, the entire right,title, and interest in and to the Work Product.including any and all Intellectual Property Rights embodied therein or associated liIISC Janhc Link=1 mill Ind Cunditiuns Pnge I l 4l'21 v.2.16.1 Effective 03/26/2019 Xi DocuSign Envelope ID:2DAB07B4-A920-4608-B1 A4-CCFFDBODF809 Attachment C therewith, and in and to all works based upon, derived from, or incorporating the Work Product,and in and to all income,royalties,damages,claims and payments now or hereafter due or payable with respect thereto,and in and to all causes of action,either in law or in equity for past,present or future infringement based on the copyrights,and in and to all rights corresponding to the foregoing. Grantee agrees to execute all papers and to perform such other property rights as System Agency may deem necessary to secure for System Agency or its designee the rights herein assigned. In the event that Grantee has any rights in and to the Work Product that cannot be assigned to System Agency, Grantee hereby grants to System Agency an exclusive, worldwide, royalty-free, transferable, irrevocable, and perpetual license, with the right to sublicense, to reproduce, distribute, modify. create derivative works of,publicly perform and publicly display,make,have made,use,sell and offer for sale the Work Product and any products developed by practicing such rights. 6.2 GRANTEE'S PRE-EXISTING WORKS To the extent that Grantee incorporates into the Work Product any works of Grantee that were created by Grantee or that Grantee acquired rights in prior to the Effective Date of this Contract ("Incorporated Pre-existing Works"), Grantee retains ownership of such Incorporated Pre-existing Works, and Grantee hereby grants to System Agency an irrevocable,perpetual,non-exclusive,royalty-free,transferable,worldwide right and license, with the right to sublicense, to use, modify, copy, create derivative works of, publish, publicly perform and display,sell,offer to sell,make and have made,the Incorporated Pre- existing Works, in any medium, with or without the associated Work Product. Grantee represents,warrants,and covenants to System Agency that Grantee has all necessary right and authority to grant the foregoing license in the Incorporated Pre-existing Works to System Agency. 63 AGREEMENTS WITH EMI'I,OYEES AND SUBCONTRACTORS Grantee shall have written,binding agreements with its employees and subcontractors that include provisions sufficient to give effect to and enable Grantee's compliance with Grantee's obligations under this Article VI. 6.4 DELIVERY UPON TERMINATION OR EXPIRATION No later than the first calendar day after the termination or expiration of the Contract or upon System Agency's request,Grantee shall deliver to System Agency all completed,or partially completed,Work Product,including any Incorporated Pru-existing Works,and any and all versions thereof.Grantee's failure to timely deliver such Work Product is a material breach of the Contract.Grantee will not retain any copies of the Work Product or any documentation or other products or results of Grantee's activities under the Contract without the prior written consent of System Agency. 6.5 SURVIVAL The provisions and obligations of this Article VI survive any termination or expiration of the Contract. 1111SC Cirunttc Uniform Terms and Conditions Page 12 of 21 v.2.16.1 Effective 03/26/2019 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment C ARTICLE VII.RECORDS,AUDIT,AND DISCLOSURE 7.1 BOOKS AND RECORDS Grantee shall keep and maintain under GAAP or GASB, as applicable. full, true, and complete records necessary to fully disclose to the System Agency, the Texas State Auditor's Office, the United States Government, and their authorized representatives sufficient information to determine compliance with the terms and conditions of this Contract and all state and federal rules,regulations,and statutes. Unless otherwise specified in this Contract,Grantee shall maintain legible copies of this Contract and all related documents for a minimum of seven(7)years after the termination of the Contract period or seven(7) years after the completion of any litigation or dispute involving the Contract,whichever is later. 7.2 ACCESS TO RECORDS,BOOKS,AND DOCUMENTS In addition to any right of access arising by operation of law, Grantee and any of Grantee's affiliate or subsidiary organizations, or Subcontractors shall permit the System Agency or any of its duly authorized representatives, as well as duly authorized federal, state or local authorities, unrestricted access to and the right to examine any site where business is conducted or services are performed, and all records, which includes but is not limited to financial,client and patient records, books, papers or documents related to this Contract. If the Contract includes federal funds, federal agencies that shall have a right of access to records as described in this section include: the federal agency providing the funds, the Comptroller General of the United States,the General Accounting Office,the Office of the Inspector General, and any of their authorized representatives. In addition, agencies of the State of Texas that shall have a right of access to records as described in this section include: the System Agency, HHSC, HHSC's contracted examiners,the State Auditor's Office, the Office of the Texas Attorney General, and any successor agencies. Each of these entities may be a duly authorized authority.If deemed necessary by the System Agency or any duly authorized authority, for the purpose of investigation or hearing. Grantee shall produce original documents related to this Contract. The System Agency and any duly authorized authority shall have the right to audit billings both before and after payment, and all documentation that substantiates the billings. Grantee shall include this provision concerning the right of access to, and examination of, sites and information related to this Contract in any Subcontract it awards. 7.3 RESPONSE/COMPLiANCE WITH AUDIT OR INSPECTION FINDINGS A. Grantee must act to ensure its and its Subcontractors' compliance with all corrections necessary to address any finding of noncompliance with any law, regulation, audit requirement. or generally accepted accounting principle, or any other deficiency identified in any audit, review, or inspection of the Contract and the services and Deliverables provided. Any such correction will be at Grantee's or its Subcontractor's sole expense. Whether Grantee's action corrects the noncompliance shall be solely the decision of the System Agency. B. As part of the services, Grantee must provide to HHSC upon request a copy of those portions of Grantee's and its Subcontractors'internal audit reports relating to the services and Deliverables provided to the State under the Contract. HttSC tirante a Uniform'Iems and C onditiem Page I3oY21 v.2.161 Elective 03,260019 XIIi DocuSign Envelope ID:2DAB07B4-A920-4608-81A4-CCFFDBODF809 Attachment C 7.4 SAO AUDIT A. The state auditor may conduct an audit or investigation of any entity receiving funds from the state directly under the Contract or indirectly through a subcontract under the Contract. The acceptance of funds directly under the Contract or indirectly through a subcontract under the Contract acts as acceptance of the authority of the state auditor, under the direction of the legislative audit committee,to conduct an audit or investigation in connection with those funds.Under the direction of the legislative audit committee,an entity that is the subject of an audit or investigation by the state auditor must provide the state auditor with access to any information the state auditor considers relevant to the investigation or audit. B. Grantee shall comply with any rules and procedures of the state auditor in the implementation and enforcement of Section 2262.154 of the Texas Government Code. 7.5 CONFIDENTIALITY Grantee shall maintain as confidential,and shall not disclose to third parties without System Agency's prior written consent,any System Agency information including but not limited to System Agency's business activities, practices, systems, conditions and services. This section will survive tennination or expiration of this Contract. ARTICLE VIiI.CONTRACT REMEDIES AND EARLY TERM!NATION 8.1 CONTRACT REMEDIES To ensure Grantee's full performance of the Contract and compliance with applicable law,the System Agency reserves the right to hold Grantee accountable for breach of contract or substandard performance and may take remedial or corrective actions,including,but not limited to: i. suspending all or part of the Contract; ii. requiring the Grantee to take specific actions in order to remain in compliance with the Contract; iii. recouping payments made by the System Agency to the Grantee found to be in error, iv. suspending,limiting, or placing conditions on the Grantee's continued performance of the Project; v. imposing any other remedies,sanctions or penalties authorized under this Contract or permitted by federal or state statute,law,regulation or rule. 8.2 TERMLNATION FOR CONVENIENCE The System Agency may terminate the Contract at any time when, in its sole discretion, the System Agency determines that termination is in the best interests of the State of Texas. The termination «ill be effective on the date specified in HHSC's notice of termination. The System Agency's right to terminate the Contract for convenience is cumulative of all rights and remedies which exist now or in the future. 8.3 TERMINATION FOR CAUSE Except as otherwise provided by the U.S. Bankruptcy Code, or any successor law, the System Agency may terminate the Contract,in whole or in part,upon either of the following conditions: HHS(.Jrant c Ututenn TC/M5 said C onditiens Page 14 nr 2 t v.2.16.1 Effective o3/26/2019 xiv DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDB0DF809 Attachment C i. Material Breach The System Agency will have the right to terminate the Contract in whole or in part if the System Agency determines, in its sole discretion, that Grantee has materially breached the Contract or has failed to adhere to any laws, ordinances, rules, regulations or orders of any public authority having jurisdiction and such violation prevents or substantially impairs performance of Grantee's duties under the Contract. Grantee's misrepresentation in any aspect of Grantee's Solicitation Response,if any,or Grantee's addition to the Excluded Parties List System(EPLS) will also constitute a material breach of the Contract. ii. Failure to Maintain Financial Viability The System Agency may tenninate the Contract if,in its sole discretion,the System Agency has a good faith belief'that Grantee no longer maintains the financial viability required to complete the services and Deliverables, or otherwise fully perform its responsibilities under the Contract. ARTICLE IX.MISCELLANEOUS PROVISIONS 9.1 AMENDMENT The Contract may only be amended by an Amendment executed by both Parties. 9.2 INSURANCE A. Unless otherwise specified in this Contract, Grantee shall acquire and maintain, for the duration of'this Contract, insurance coverage necessary to ensure proper fulfillment of this Contract and potential liabilities thereunder with financially sound and reputable insurers licensed by the Texas Department of insurance, in the type and amount customarily carried within the industry as determined by the System Agency. Grantee shall provide evidence of insurance as required under this Contract,including a schedule of coverage or underwriter's schedules establishing to the satisfaction of the System Agency the nature and extent of coverage granted by each such policy, upon request by the System Agency. In the event that any policy is determined by the System Agency to be deficient to comply with the terms of this Contract.Grantee shall secure such additional policies or coverage as the System Agency may reasonably request or that are required by law or regulation. If coverage expires during the term of this Contract, Grantee must produce renewal certificates for each type of coverage. B. These and all other insurance requirements under the Contract apply to both Grantee and its Subcontractors, if any. Grantee is responsible for ensuring its Subcontractors' compliance with all requirements. 9.3 LEGAL OBLIGATIONS Grantee shall comply with all applicable federal, state, and local laws, ordinances, and regulations, including all federal and state accessibility laws relating to direct and indirect use of information and communication technology. Grantee shall be deemed to have knowledge of all applicable laws and regulations and be deemed to understand them. 1111SC Ca-wilco Unitont]"ferns and Conditions Page 15 or'21 v.2.16.1 Effective 03/26/2019 XV DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 Attachment C 9.4 PERMITTING AND LICENSURE At Grantee's sole expense, Grantee shall procure and maintain for the duration of this Contract any state,county,city,or federal license,authorization,insurance,waiver,permit, qualification or certification required by statute,ordinance,law,or regulation to be held by Grantee to provide the goods or services required by this Contract. Grantee shall be responsible for payment of all taxes, assessments, fees, premiums, permits, and licenses required by law. Grantee shall he responsible for payment of any such government obligations not paid by its Subcontractors during performance of this Contract. 9.5 INDEMNITY A. GRANTEE SHALL DEFEND, INDEMNIFY AND HOLD HARMLESS THE STATE OF TEXAS AND SYSTEM AGENCY, ANI)/OR THEIR OFFICERS, AGENTS, EMPLOYEES, REPRESENTATIVES, CONTRACTORS, ASSIGNEES, AND/OR DESIGNEES FROM ANY AND ALL LIABILITY, ACTIONS, CLAIMS, DEMANDS, OR SUITS, AND ALL RELATED COSTS, ATTORNEY FEES, AND EXPENSES ARISING OUT OF OR RESULTING FROM ANY ACTS OR OMISSIONS OF GRANTEE OR ITS AGENTS, EMPLOYEES, SUBCONTRACTORS,ORDER FULFILLERS,OR SUPPLIERS OF SUBCONTRACTORS IN THE EXECUTION OR PERFORMANCE OF THE CONTRACT AND ANY PURCHASE ORDERS ISSUED UNDER THE CONTRACT. THE DEFENSE SHALL BE COORDINATED BY GRANTEE WITH THE OFFICE OF THE TEXAS ATTORNEY GENERAL WHEN TEXAS STATE AGENCIES ARE NAMED DEFENDANTS IN ANY LAWSUIT AND GRANTEE MAY NOT AGREE TO ANY SETTLEMENT WITHOUT FIRST OBTAINING THE CONCURRENCE FROM THE OFFICE OF THE TEXAS ATTORNEY GENERAL GRANTEE AND SYSTEM AGENCY AGREE TO FURNISH TIMELY WRITTEN NOTICE TO EACH OTHER OF ANY SUCH CLAIM. B. THIS PARAGRAPH IS NOT INTENDED TO AND SHALL NOT BE CONSTRUED TO REQUIRE GRANTEE TO INDEMNIFY OR HOLD HARMLESS THE STATE OR TIIE SYSTEM AGENCY FOR ANY CLAIMS OR LIABILITIES RESULTING FROM THE NEGLEGENT ACTS OR OMISSIONS OF THE SYSTEM AGENCY OR ITS EMPLOYEES. C. For the avoidance of doubt, System Agency shall not indemnify. Grantee or any other entity under the Contract. 9.6 ASSIGNMENTS A. Grantee may not assign all or any portion of its rights under, interests in, or duties required under this Contract without prior written consent of the System Agency, which may be withheld or granted at the sole discretion of the System Agency.Except where otherwise agreed in writing by the System Agency,assignment will not release Grantee from its obligations under the Contract. B. Grantee understands and agrees the System Agency may in one or more transactions assign,pledge, or transfer the Contract. This assignment will only be made to another State agency or a non-state agency that is contracted to perform agency support. HHSC tirsntac Uniform Tann and C o diti.wu INN 16 of 21 v.2.16.1 Ef axive 03126/1019 XVi DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C 9.7 INDEPENDENT CONTRACTOR Grantee and Grantee's employees, representatives, agents, Subcontractors, suppliers, and third-party service providers shall serve as independent contractors in providing the services under the Contract.Neither Grantee nor System Agency is an agent of the other and neither may make any commitments on the other party's behalf. Should Grantee subcontract any of the services required in the Contract,Grantee expressly understands and acknowledges that in entering such subcontract(s), System Agency is in no manner liable to any Subcontractor(s) of Grantee. In no event shall this provision relieve Grantee of the responsibility for ensuring that the services performed under all subcontracts are rendered in compliance with the Contract. Grantee shall have no claim against System Agency for vacation pay,sick leave,retirement benefits,social security,worker's compensation,health or disability benefits.unemployment insurance benefits,or employee benefits of any kind. The Contract shall not create any joint venture, partnership, agency, or employment relationship between Grantee and System Agency. 9.8 TECHNICAL GUIDANCE LETTERS In the sole discretion of the System Agency,and in conformance with federal and state law, the System Agency may issue instructions, clarifications, or interpretations as may be required during work performance in the form of a Technical Guidance Letter(TGL). A TGi, must he in writing, and may be delivered by regular mail, electronic mail, or facsimile transmission. Any TGI.issued by the System Agency will he incorporated into the Contract by reference for all purposes when it is issued. 9.9 DISPUTE RESOLUTION A. The dispute resolution process provided for in Chapter 2260 of the Texas Government Code must be used to attempt to resolve any dispute arising under the Contract. B. If a contract dispute arises that cannot be resolved to the satisfaction of the Parties,either Party may notify the other Party in writing of the dispute. If the Parties arc unable to satisfactorily resolve the dispute within fourteen(14)days of the written notification,the Parties must use the dispute resolution process provided for in Chapter 2260 of the Texas Government Code to attempt to resolve the dispute.This provision will not apply to any matter with respect to which either Party may make a decision within its respective sole discretion. 9.10 GOVERNING LAW AND VENUE The Contract shall be governed by and construed in accordance with the laws of the State of Texas,without regard to the conflicts of law provisions.The venue of any suit arising under the Contract is fixed in any court of competent jurisdiction of Travis County.Texas.unless the specific venue is otherwise identified in a statute which directly names or otherwise identifies its applicability to the System Agency. 9.11 SEVERABILITY If any provision contained in this Contract is held to be unenforceable by a court of law or equity.this Contract shall be construed as if such provision did not exist and the non- }RISC:Liraittcc on-}RISC'irantcc Uniform Tcrms and,nditAons Page 17of21 v.2.16.1 Effective 03/16/2019 xvl l DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment C enforceability of such provision shall not be held to render any other provision or provisions of this Contract unenforceable. 9.12 SURVIVABILITY Expiration or termination of the Contract for any reason does not release Grantee from any liability or obligation set forth in the Contract that is expressly stated to survive any such expiration or termination,that by its nature would be intended to be applicable following any such expiration or termination, or that is necessary to fulfill the essential purpose of the Contract,including without limitation the provisions regarding wan-attty, indemnification, confidentiality,and rights and remedies upon termination. 9.13 FORCE MAJEURE Neither Grantee nor System Agency shall be liable to the other for any delay in,or failure of performance, of any requirement included in the Contract caused by force majeure. The existence of such causes of delay or failure shall extend the period of performance until after the causes of delay or failure have been removed provided the non-performing party exercises all reasonable due diligence to perform. Force majeure is defined as acts of God, war,tires,explosions, hurricanes,floods,failure of transportation,or other causes that are beyond the reasonable control of either party and that by exercise of due foresight such party could not reasonably have been expected to avoid, and which, by the exercise of all reasonable due diligence,such party is unable to overcome. 9.14 No WAIVER OF PROVISIONS The failure of the System Agency to object to or to take affirmative action with respect to any conduct of the Grantee which is in violation or breach of the terms of the Contract shall not be construed as a waiver of the violation or breach,or of any future violation or breach. 9.15 Pt nl.Icrry A. Except as provided in the paragraph below, Grantee must not use the name of, or directly or indirectly refer to, the System Agency, the State of Texas, or any other State agency in any media release,public announcement,or public disclosure relating to the Contract or its subject matter, including in any promotional or marketing materials,customer lists,or business presentations. 13. Grantee may publish, at its sole expense, results of Grantee performance under the Contract with the System Agency's prior review and approval, which the System Agency may exercise at its sole discretion. Any publication(written,visual,or sound) will acknowledge the support received from the System Agency and any Federal agency, as appropriate. C. Contractor is prohibited from using the Work for any Contractor or third party marketing, advertising, or promotional activities, without the prior written consent of System Agency. The foregoing prohibition includes, without limitation, the placement of banners,pop-up ads, or other advertisements promoting Contractor's or a third party's products,services,workshops,trainings,or other commercial offerings on any website portal or internet-based service or software application hosted or managed by Contractor as part of the Work. IIHSC Urantcc Uniform Tums and Conditions Page 18 of 21 v.2.16.1 Effective 03/26/2019 XVIII DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C 9.16 PROHIBITION ON NON-COMPETE RESTRICTIONS Grantee shall not require any employees or Subcontractors to agree to any conditions, such as non-compete clauses or other contractual arrangements that would limit or restrict such persons or entities from employment or contracting with the State of Texas. 9.17 No WAIVER OF SOVEREIGN IMMUNITY Nothing in the Contract will be construed as a waiver of the System Agency's or the State's sovereign immunity.this Contract shall not constitute or be construed as a waiver of any of the privileges, rights, defenses, remedies, or immunities available to the System Agency or the State of Texas.The failure to enforce,or any delay in the enforcement,of any privileges,rights,defenses,remedies,or immunities available to the System Agency or the State of Texas under the Contract or under applicable law shall not constitute a waiver of such privileges, rights, defenses, remedies, or immunities or be considered as a basis for estoppel. System Agency does not waive any privileges, rights, defenses, or immunities available to System Agency by entering into the Contract or by its conduct prior to or subsequent to entering into the Contract. 9.18 ENTIRE CONTRACT AND MODIFICATION The Contract constitutes the entire agreement of the Parties and is intended as a complete and exclusive statement of the promises,representations,negotiations,discussions,and other agreements that may have been made in connection with the subject matter hereof, Any additional or conflicting terms in any future document incorporated into the Contract will be harmonized with this Contract to the extent possible. 9.19 CourrERIARTS This Contract may be executed in any number of counterparts, each of which will be an original.and all such counterparts will together constitute but one and the same Contract. 9.20 PROPER AUTHORITY Each Party represents and warrants that the person executing this Contract on its behalf has full power and authority to enter into this Contract. 9.21 E-VRRiFY PRocatA%t Grantee certifies that it utilizes and will continue to utilize the U.S. 1)epanment of Homeland Security's E-Verify system to determine the eligibility of: i. all persons employed to perform duties within Texas during the term of the Contract; and ii. all persons, (including subcontractors) assigned by the Grantee to perform work pursuant to the Contract within the United States of America. 9.22 CIVIL RIGHTS A. Grantee agrees to comply with state and federal anti-discrimination laws,including: i. Title VI of the Civil Rights Act of 1964(42 U.S.C.§2000d el seq.); ii. Section 504 of the Rehabilitation Act of 1973(29 U.S.C.§794); iii. Americans with Disabilities Act of 1990(42 U.S.C. §12101 el seq.); iv. Age Discrimination Act of 1975(42 U.S.C. §§6101-6107); HIISC<ir.*nu Uniform'rams and Con ditwns Piiga 19of21 v.2.16.1 Effective 03/26/1019 XiX DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment C v. Title IX of the Education Amendments of 1972(20 U.S.C. §§1681-1688); vi. Food and Nutrition Act of 2008(7 U.S.C. §2011 et seg.);and vii. The System Agency's administrative rules,as set forth in the Texas Administrative Code,to the extent applicable to this Contract. B. Grantee agrees to comply with all amendments to the above-referenced laws, and all requirements imposed by the regulations issued pursuant to these laws. These laws provide in part that no persons in the United States may,on the grounds of race,color. national origin, sex, age, disability, political beliefs, or religion, be excluded from participation in or denied any aid,care,service or other benefits provided by Federal or State funding,or otherwise be subjected to discrimination. C. Grantee agrees to comply with Title VI of the Civil Rights Act of 1964, and its implementing regulations at 45 C.F.R. Part 80 or 7 C.F.R. Part 15, prohibiting a contractor from adopting and implementing policies and procedures that exclude or have the effect of excluding or limiting the participation of clients in its programs, benefits, or activities on the basis of national origin. State and federal civil rights laws require contractors to provide alternative methods for ensuring access to services for applicants and recipients who cannot express themselves fluently in English. Grantee agrees to take reasonable steps to provide services and information,both orally and in writing, in appropriate languages other than English, in order to ensure that persons with limited English proficiency are effectively informed and can have meaningful access to programs,benefits,and activities. D. Grantee agrees to post applicable civil rights posters in areas open to the public informing clients of their civil rights and including contact information for the HHS Civil Rights Office. The posters are available on the HHS website at: http:Hhhscx.hhsc.texas.gov/system-support-services/civil-rights/publications E. Grantee agrees to comply with Executive Order 13279, and its implementing regulations at 45 C.P.R. Part 87 or 7 C.F.R. Part 16. These provide in part that any organization that participates in programs funded by direct financial assistance from the United States Department of Agriculture or the United States Department of Health and Human Services shall not discriminate against a program beneficiary or prospective program beneficiary on the basis of religion or religious belief. F. Upon request, Grantee shall provide HHSC's Civil Rights Office with copies of the Grantee's civil rights policies and procedures. G. Grantee must notify HIISC's Civil Rights Office of any civil rights complaints received relating to its performance under this Contract This notice must be delivered no more than ten (10) calendar days after receipt of'a complaint. Notice provided pursuant to this section must be directed to: HHSC Civil Rights Office 701 W. 51'Street,Mail Code W206 Austin,Texas 78751 Phone Toll Free:(888)388-6332 Phone:(512)438-4313 TTY Toll Free:(877)432-7232 Fax:(512)438-5885. It11SC tirantee Uniform Tema and Conditions Page 20of21 v.2.16.1 Effective 03/2612019 XX DocuSign Envelope ID:2DAB0784-A920-4608-B1A4-CCFFDBODF809 Attachment C 9.23 SYSTEM AGENCY DATA As between the Parties,all data and information acquired, accessed, or made available to Contractor by or through System Agency or System Agency contractors, including all electronic data generated, processed,transmitted, or stored by Contractor in the course of providing data processing services in connection with Contractor's performance hereunder, (the"System Agency Data"), is owned solely by System Agency. Contractor has no right or license to use,analyze,aggregate,transmit,create derivatives of,copy,disclose,or process the System Agency Data except as required for Contractor to fulfill its obligations under the Contract or as authorized in advance in writing by System Agency. For the avoidance of doubt,Contractor is expressly prohibited from using,and from permitting any third party to use,System Agency Data for marketing,research,or other non-governmental or commercial purposes,without the prior written consent of System Agency. itiSC(innate Uniform Tums and Cantlitians Ptge 21 or2l v.2.16.1 Effective 03,2612019 XXi DocuSign Envelope ID.2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment D • v ••• TEXAS v Health and Human Services Health and Human Services (HHS) Additional Provisions Version 1.0 Effective: November 7, 2019 DocuSign Envelope ID:2DAB07B4-A920-4608-B 1A4-CCFFDBODF809 Attachment D Table of Contents 1. HHSC APPROVAL OF STAFFING 1 2. TURNOVER PLAN 1 3. NOTICE OF CRIMINAL ACTIVITY AND DISCIPLINARY ACTIONS 1 4. NOTICE OF IRS OR TWC INSOLVENCY 2 5. DISASTER SERVICES 2 6. NOTICE OF A LICENSE ACTION 2 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment D ADDITIONAL PROVISIONS The terms and conditions of these Additional Provisions are incorporated into and made a part of the Contract. Capitalized items used in these Additional Provisons and not otherwise defined have the meanings assigned to them in HHSC Uniform Terms and Conditions. 1. HHSC APPROVAL OF STAFFING A. Contractor shall not employ or contract with or permit the employment of unfit or unqualified persons or persons not skilled in the tasks assigned to them. The Contractor shall at all times employ sufficient labor to carry out functions and services in the manner and time prescribed by the Contract. The Contractor shall be responsible to HHSC for the acts and omissions of the Contractor's employees, agents (including, but not limited to, lobbyists) and Subcontractors and the Contractor shall enforce strict discipline among the Contractor's employees, agents (including, but not limited to, lobbyists) and Subcontractors performing the services under the Contract. B. Any person employed by the Contractor shall, at the written request of HHSC, and within HHSC's sole discretion, be removed immediately by the Contractor from work relating to the Contract. 2. TURNOVER PLAN HHSC, in its sole discretion,may require Contractor to develop and submit a Turnover Plan at any time during the term of the Contract. Contractor must submit the Turnover Plan to HHSC for review and approval. The Turnover Plan must describe Contractor's policies and procedures that will ensure: i. The least disruption in the delivery of the Work during Turnover to HHSC or its designee; and ii. Full cooperation with HHSC or its designee in transferring the Work and the obligations of the Contract. 3. NOTICE OF CRIMINAL ACTIVITY AND DISCIPLINARY ACTIONS A. Contractor shall immediately report in writing to its assigned HHSC contract manager when Contractor learns of or has any reason to believe it or any person with ownership or controlling interest in Contractor,or their agent, employee, subcontractor or volunteer who is providing services under this Contract has: i. Engaged in any activity that could constitute a criminal offense equal to or greater than a Class A misdemeanor or grounds for disciplinary action by a state or federal regulatory authority; or ii. Been placed on community supervision,received deferred adjudication, or been indicted for or convicted of a criminal offense relating to involvement in any financial matter, federal or state program or felony sex crime. Ilealth and human Services Additional Provisions V.1.0—November 7,2019 Page 1 of 3 DocuSign Envelope ID 2DABO7B4-A920-4608-81A4-CCFFDBODF809 Attachment D B. Contractor shall not permit any person who engaged, or was alleged to have engaged, in any activity subject to reporting under this section to perform direct client services or have direct contact with clients, unless otherwise directed in writing by the System Agency. 4. NOTICE OF IRS OR TWC INSOLVENCY Contractor shall notify in writing its assigned HHSC contract manager of any insolvency, incapacity or outstanding unpaid obligations of Contractor owed to the Internal Revenue Service or the State of Texas, or any agency or political subdivision of the State of Texas within five days of the date of Contractor's becoming aware of such. 5. DISASTER SERVICES In the event of a local, state, or federal emergency, including natural, man-made, criminal, terrorist, and/or bioterrorism events, declared as a state disaster by the Governor, or a federal disaster declared by the appropriate federal official, Contractor may be called upon to assist the System Agency in providing the following services: i. Community evacuation; ii. Health and medical assistance; iii. Assessment of health and medical needs; iv. Health surveillance; v. Medical care personnel; vi. Health and medical equipment and supplies; vii. Patient evacuation; viii. In-hospital care and hospital facility status; ix. Food, drug and medical device safety; x. Worker health and safety; xi. Mental health and substance abuse; xii. Public health information; xiii. Vector control and veterinary services; and xiv. Victim identification and mortuary services. 6. NOTICE OF A LICENSE ACTION Contractor shall notify its assigned HHSC contract manager of any action impacting Contractor's license to provide services under this Contract within five days of becoming aware of the action and include the following: i. Reason for such action; ii. Name and contact information of the local, state or federal department or agency or entity; iii. Date of the license action; and iv. License or case reference number. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK Health and Human Services Additional Provisions V.I.0—November 7,2019 Page 2 of 3 DocuSign Envelope ID 2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment E TEXAS HEALTH AND HUMAN SERVICES CONTRACT AFFIRMATIONS (Version 1.6;November 7,2019) The term "System Agency" used in these affirmations means HHS or any of the agencies of the State of Texas that are overseen by HHSC under authority granted under Texas law and the officers, employees, authorized representatives, and designees of those agencies. These agencies include: HHSC and the Department of State Health Services. By entering into this Contract, Contractor affirms, without exception, understands, and agrees to comply with the following items through the life of the Contract: I. Contractor represents and warrants that these Contract Affirmations apply to Contractor and all of Contractor's principals,officers,directors,shareholders,partners,owners,agents, employees, subcontractors, independent contractors, and any other representatives who may provide services under, who have a financial interest in,or otherwise are interested in this Contract and any related Solicitation. 2. Complete and Accurate Information Contractor represents and warrants that all statements and information provided to System Agency are current, complete, and accurate. This includes all statements and information in this Contract and any related Solicitation Response. 3. Public Information Act Contractor understands that System Agency will comply with the Texas Public Information Act (Chapter 552 of the Texas Government Code) as interpreted by judicial rulings and opinions of the Attorney General of the State of Texas. Information, documentation, and other material prepared and submitted in connection with this Contract or any related Solicitation may be subject to public disclosure pursuant to the Texas Public Information Act. In accordance with Section 2252.907 of the Texas Government Code, Contractor is required to make any information created or exchanged with the State pursuant to the Contract, and not otherwise excepted from disclosure under the Texas Public Information Act, available in a format that is accessible by the public at no additional charge to the State. 4. Contracting Information Requirements Contractor represents and warrants that it will comply with the requirements of Section 552.372(a) of the Texas Government Code. Except as provided by Section 552.374(c) of the Texas Government Code, the requirements of Subchapter J (Additional Provisions Related to Contracting Information), Chapter 552 of the Government Code, may apply to the Contract and the Contractor agrees that the Contract can be terminated if the Contractor knowingly or intentionally fails to comply with a requirement of that subchapter. DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 5. Assignment A. Contractor shall not assign its rights under the contract or delegate the performance of its duties under the contract without prior written approval from HHSC.Any attempted assignment in violation of this provision is void and without effect. 13. Contractor understands and agrees the System Agency may in one or more transactions assign, pledge, or transfer the Contract. This assignment will only be made to another State agency or a non-state agency that is contracted to perform agency support. Upon receipt of System Agency's notice of assignment, pledge, or transfer, Contractor shall cooperate with System Agency in giving effect to such assignment, pledge, or transfer, at no cost to System Agency or to the recipient entity. 6. Terms and Conditions Attached to Response Contractor accepts the Solicitation terms and conditions unless specifically noted by exceptions advanced in the form and manner directed in the Solicitation, if any, under which this Contract was awarded. Contractor agrees that all exceptions to the Solicitation, as well as terms and conditions advanced by Contractor that differ in any manner from System Agency's terms and conditions, if any, are rejected unless expressly accepted by System Agency in writing. 7. System Agency Right to Use Contractor agrees that System Agency has the right to use, produce, and distribute copies of and to disclose to System Agency employees, agents, and contractors and other governmental entities all or part of this Contract or any related Solicitation Response as System Agency deems necessary to complete the procurement process or comply with state or federal laws. 8. Release from Liability Contractor generally releases from liability and waives all claims against any party providing information about the Contractor at the request of System Agency. 9. Dealings with Public Servants Contractor has not given, has not offered to give, and does not intend to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with this Contract or any related Solicitation, or related Solicitation Response. 10. Financial Participation Prohibited Under Section 2155.004, Texas Government Code (relating to financial participation in preparing solicitations), Contractor certifies that the individual or business entity named in this Contract and any related Solicitation Response is not ineligible to receive this Contract DocuSign Envelope ID:2DABO7B4-A920-4608-B1 A4-CCFFDBODF809 and acknowledges that this Contract may be terminated and payment withheld if' this certification is inaccurate. 11. Prior Disaster Relief Contract Violation Under Sections 2155.006 and 2261.053 of the Texas Government Code (relating to convictions and penalties regarding Hurricane Rita, Hurricane Katrina, and other disasters), the Contractor certifies that the individual or business entity named in this Contract and any related Solicitation Response is not ineligible to receive this Contract and acknowledges that this Contract may be terminated and payment withheld if this certification is inaccurate. 12. Child Support Obligation Under Section 231.006(d) of the Texas Family Code regarding child support, Contractor certifies that the individual or business entity named in this Contract and any related Solicitation Response is not ineligible to receive the specified payment and acknowledges that the Contract may be terminated and payment may be withheld if this certification is inaccurate. 13. Suspension and Debarment Contractor certifies that it and its principals are not suspended or debarred from doing business with the state or federal government as listed on the State of Texas Debarred Vendor List maintained by the Texas Comptroller of Public Accounts and the System for Award Management (SAM) maintained by the General Services Administration. This certification is made pursuant to the regulations implementing Executive Order 12549 and Executive Order 12689, Debarment and Suspension, 2 C.F.R. Part 376, and any relevant regulations promulgated by the Department or Agency funding this project. This provision shall be included in its entirety in Contractor's subcontracts, if any, if payment in whole or in part is from federal funds. 14. Excluded Parties Contractor certifies that it is not listed in the prohibited vendors list authorized by Executive Order 13224, "Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism, "published by the United States Department of the Treasury, Office of Foreign Assets Control. 15. Foreign Terrorists Organizations Contractor represents and warrants that it is not engaged in business with Iran, Sudan, or a foreign terrorist organization, as prohibited by Section 2252.152 of the Texas Government Code. 16. Executive Head of a State Agency DocuSign Envelope ID 2DAB07B4-A920-4608-81A4-CCFFDBODF809 In accordance with Section 669.003 of the Texas Government Code,relating to contracting with the executive head of a state agency,Contractor certifies that it is not(1)the executive head of an HHS agency, (2)a person who at any time during the four years before the date of this Contract was the executive head of an HHS agency, or(3) a person who employs a current or former executive head of an HHS agency. 17. Human Trafficking Prohibition Under Section 2155.0061 of the Texas Government Code, Contractor certifies that the individual or business entity named in this Contract is not ineligible to receive this contract and acknowledges that this Contract may be terminated and payment withheld if this certification is inaccurate. 18. Franchise Tax Status Contractor represents and warrants that it is not currently delinquent in the payment of any franchise taxes owed the State of Texas under Chapter 171 of the Texas Tax Code. 19. Debts and Delinquencies Contractor agrees that any payments due under this Contract shall be applied towards any debt or delinquency that is owed to the State of Texas. 20. Lobbying Prohibition Contractor represents and warrants that payments to Contractor and Contractor's receipt of appropriated or other funds under this Contract or any related Solicitation are not prohibited by Sections 556.005, 556.0055,or 556.008 of the Texas Government Code(relating to use of appropriated money or state funds to employ or pay lobbyists, lobbying expenses, or influence legislation). 21. Buy Texas Contractor agrees to comply with Section 2155.4441 of the Texas Government Code, requiring the purchase of products and materials produced in the State of Texas in performing service contracts. 22. Disaster Recovery Plan Contractor agrees that upon request of System Agency, Contractor shall provide copies of its most recent business continuity and disaster recovery plans. 23. Technology Access Contractor expressly acknowledges that state funds may not be expended in connection with the purchase of an automated information system unless that system meets certain statutory requirements relating to accessibility by persons with visual impairments. Accordingly, Contractor represents and warrants to System Agency that the technology provided to System Agency for purchase (if applicable under this Contract or any related DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Solicitation) is capable, either by virtue of features included within the technology or because it is readily adaptable by use with other technology,of: • providing equivalent access for effective use by both visual and non-visual means; • presenting information, including prompts used for interactive communications, in formats intended for non-visual use; and • being integrated into networks for obtaining, retrieving, and disseminating information used by individuals who are not blind or visually impaired. For purposes of this Section, the phrase "equivalent access" means a substantially similar ability to communicate with or make use of the technology, either directly by features incorporated within the technology or by other reasonable means such as assistive devices or services which would constitute reasonable accommodations under the Americans With Disabilities Act or similar state or federal laws. Examples of methods by which equivalent access may be provided include, but are not limited to, keyboard alternatives to mouse commands and other means of navigating graphical displays, and customizable display appearance. In accordance with Section 2157.005 of the Texas Government Code, the Technology Access Clause contract provision remains in effect for any contract entered into before September 1,2006. 24. Computer Equipment Recycling Program If this Contract is for the purchase or lease of computer equipment,then Contractor certifies that it is in compliance with Subchapter Y, Chapter 361 of the Texas Health and Safety Code related to the Computer Equipment Recycling Program and the Texas Commission on Environmental Quality rules in 30 TAC Chapter 328. 25. Television Equipment Recycling If this Contract is for the purchase or lease of covered television equipment,then Contractor certifies that it is compliance with Subchapter Z, Chapter 361 of the Texas Health and Safety Code related to the Television Equipment Recycling Program. 26. Cybersecurity Training A. Contractor represents and warrants that it will comply with the requirements of Section 2054.5192 of the Texas Government Code relating to cybersecurity training and required verification of completion of the training program. B. Contractor represents and warrants that if Contractor or Subcontractors, officers, or employees of Contractor have access to any state computer system or database, the Contractor, Subcontractors, officers, and employees of Contractor shall complete cybersecurity training pursuant to and in accordance with Government Code, Section 2054.5192. 27. Restricted Employment for Certain State Personnel DocuSign Envelope ID 2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Contractor acknowledges that, pursuant to Section 572.069 of the Texas Government Code, a former state officer or employee of a state agency who during the period of state service or employment participated on behalf of a state agency in a procurement or contract negotiation involving Contractor may not accept employment from Contractor before the second anniversary of the date the Contract is signed or the procurement is terminated or withdrawn. 28. Disclosure of Prior State Employment If this Contract is for consulting services under Chapter 2254 of the Texas Government Code, in accordance with Section 2254.033 of the Texas Government Code, Contractor certifies that it does not employ an individual who was employed by System Agency or another agency at any time during the two years preceding the submission of any related Solicitation Response related to this Contract or,in the alternative,Contractor has disclosed in any related Solicitation Response the following: (i) the nature of the previous employment with System Agency or the other agency; (ii)the date the employment was terminated; and (iii)the annual rate of compensation at the time of the employment was terminated. 29. No Conflicts of Interest A. Contractor represents and warrants that it has no actual or potential conflicts of interest in providing the requested goods or services to System Agency under this Contract or any related Solicitation and that Contractor's provision of the requested goods and/or services under this Contract and any related Solicitation will not constitute an actual or potential conflict of interest or reasonably create an appearance of impropriety. B. Contractor agrees that, if after execution of the Contract, Contractor discovers or is made aware of a Conflict of Interest, Contractor will immediately and fully disclose such interest in writing to HHSC. In addition, Contractor will promptly and fully disclose any relationship that might be perceived or represented as a conflict after its discovery by Contractor or by HHSC as a potential conflict. HHSC reserves the right to make a final determination regarding the existence of Conflicts of Interest, and Contractor agrees to abide by HHSC's decision. 30. Fraud,Waste,and Abuse Contractor understands that System Agency does not tolerate any type of fraud. The agency's policy is to promote consistent, legal, and ethical organizational behavior by assigning responsibilities and providing guidelines to enforce controls. Violations of law, agency policies, or standards of ethical conduct will be investigated, and appropriate actions will be taken. All employees or contractors who suspect fraud, waste or abuse (including employee misconduct that would constitute fraud,waste,or abuse)are required to immediately report the questionable activity to both the Health and Human Services Commission's Office of the Inspector General at 1-800-436-6184 and the State Auditor's Office. Contractor agrees to comply with all applicable laws,rules,regulations,and System Agency policies regarding fraud including, but not limited to, HHS Circular C-027. DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 31. Antitrust The undersigned affirms under penalty of perjury of the laws of the State of Texas that: A. in connection with this Contract and any related Solicitation Response, neither I nor any representative of the Contractor has violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus. & Comm. Code Chapter 15; B. in connection with this Contract and any related Solicitation Response, neither I nor any representative of the Contractor has violated any federal antitrust law; and C. neither I nor any representative of the Contractor has directly or indirectly communicated any of the contents of this Contract and any related Solicitation Response to a competitor of the Contractor or any other company, corporation, firm, partnership or individual engaged in the same line of business as the Contractor. 32. Legal and Regulatory Actions Contractor represents and warrants that it is not aware of and has received no notice of any court or governmental agency proceeding, investigation, or other action pending or threatened against Contractor or any of the individuals or entities included in numbered paragraph I of these Contract Affirmations within the five(5) calendar years immediately preceding execution of this Contract or the submission of any related Solicitation Response that would or could impair Contractor's performance under this Contract, relate to the contracted or similar goods or services, or otherwise be relevant to System Agency's consideration of entering into this Contract. If Contractor is unable to make the preceding representation and warranty, then Contractor instead represents and warrants that it has provided to System Agency a complete, detailed disclosure of any such court or governmental agency proceeding, investigation,or other action that would or could impair Contractor's performance under this Contract, relate to the contracted or similar goods or services, or otherwise be relevant to System Agency's consideration of entering into this Contract. In addition,Contractor acknowledges this is a continuing disclosure requirement. Contractor represents and warrants that Contractor shall notify System Agency in writing within five (5) business days of any changes to the representations or warranties in this clause and understands that failure to so timely update System Agency shall constitute breach of contract and may result in immediate contract termination. 33. No Felony Criminal Convictions Contractor represents that neither Contractor nor any of its employees, agents, or representatives, including any subcontractors and employees, agents, or representative of such subcontractors, have been convicted of a felony criminal offense or that if such a conviction has occurred Contractor has fully advised System Agency in writing of the facts and circumstances surrounding the convictions. 34. Unfair Business Practices Contractor represents and warrants that it has not been the subject of allegations of Deceptive Trade Practices violations under Chapter 17 of the Texas Business and Commerce Code, or allegations of any unfair business practice in any administrative hearing or court suit and that Contractor has not been found to be liable for such practices DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 in such proceedings. Contractor certifies that it has no officers who have served as officers of other entities who have been the subject of allegations of Deceptive Trade Practices violations or allegations of any unfair business practices in an administrative hearing or court suit and that such officers have not been found to be liable for such practices in such proceedings. 35. Entities that Boycott Israel Pursuant to Section 2271.002 of the Texas Government Code, Contractor certifies that either: (i) it meets an exemption criteria under Section 2271.002; or (ii) it does not boycott Israel and will not boycott Israel during the term of the contract resulting from this Solicitation. If Contractor refuses to make that certification, Contractor shall state here any facts that make it exempt from the boycott certification: 36. E-Verify Program Contractor certifies that for contracts for services, Contractor shall utilize the U.S. Department of Homeland Security's E-Verify system during the term of this Contract to determine the eligibility of: (i) all persons employed by Contractor to perform duties within Texas; and (ii) all persons, including subcontractors, assigned by Contractor to perform work pursuant to this Contract within the United States of America. 37. Professional or Consulting Contract If this Contract is an employment contract, a professional services contract under Chapter 2254 of the Texas Government Code,or a consulting services contract under Chapter 2254 of the Texas Government Code,Contractor represents and warrants that neither Contractor nor any of Contractor's employees including,but not limited to,those authorized to provide services under the contract, were former employees of an HHS Agency during the twelve (12)month period immediately prior to the date of the execution of the contract. 38. Former Agency Employees Contractor represents and warrants,during the twelve(12)month period immediately prior to the date of the execution of this Contract,none of its employees including,but not limited to those who will provide services under the Contract,was an employee of an HHS Agency. Pursuant to Section 2252.901, Texas Government Code(relating to prohibitions regarding contracts with and involving former and retired state agency employees), Contractor will not allow any former employee of the System Agency to perform services under this Contract during the twelve (12) month period immediately following the employee's last date of employment at the System Agency. DocuSign Envelope ID.2DABO7B4-A920-4608-B1A4-CCFFDBODF809 39. Disclosure of Prior State Employment If this Contract is for consulting services, A. In accordance with Section 2254.033 of the Texas Government Code, a Contractor providing consulting services who has been employed by, or employs an individual who has been employed by, HHSC or another State of Texas agency at any time during the two years preceding the submission of Contractor's offer to provide services must disclose the following information in its offer to provide services. Contractor hereby certifies that this information was provided and remains true, correct, and complete: (i) Name of individual(s)(Respondent or employee(s)); (ii) Status; (iii)The nature of the previous employment with HHSC or the other State of Texas agency; (iv)The date the employment was terminated and the reason for the termination; and (v) The annual rate of compensation for the employment at the time of its termination. B. If no information was provided in response to Section A above, Contractor certifies that neither Contractor nor any individual employed by Contractor was employed by HHSC or any other State of Texas agency at any time during the two years preceding the submission of Contractor's offer to provide services. 40. Abortion Funding Limitation Contractor understands, acknowledges, and agrees that, pursuant to Article IX, Section 6.25 of the General Appropriations Act(the Act),to the extent allowed by federal and state law,money appropriated by the Texas Legislature may not be distributed to any individual or entity that, during the period for which funds are appropriated under the Act: (i) performs an abortion procedure that is not reimbursable under the state's Medicaid program; (ii) is commonly owned,managed,or controlled by an entity that performs an abortion procedure that is not reimbursable under the state's Medicaid program; or (iii)is a franchise or affiliate of an entity that performs an abortion procedure that is not reimbursable under the state's Medicaid program. The provision does not apply to a hospital licensed under Chapter 241, Health and Safety Code,or an office exempt under Section 245.004(2), Health and Safety Code. Contractor represents and warrants that it is not ineligible, nor will it be ineligible during the term of this Contract,to receive appropriated funding pursuant to Article IX, Section 6.25. 41. Funding Eligibility Contractor understands, acknowledges, and agrees that, pursuant to Chapter 2272 of the Texas Government Code, except as exempted under that Chapter, HHSC cannot contract with an abortion provider or an affiliate of an abortion provider. Contractor certifies that it is not ineligible to contract with HHSC under the terms of Chapter 2272 of the Texas DocuSign Envelope ID:2DABO7B4-A920-4608-81 A4-CCFFDBODF809 Government Code. If Contractor refuses to make that certification, Contractor shall state here any facts that make it exempt from the certification: 42. False Representation Contractor understands, acknowledges, and agrees that any false representation or any failure to comply with a representation, warranty, or certification made by Contractor is subject to all civil and criminal consequences provided at law or in equity including, but not limited to, immediate termination of this Contract. 43. False Statements Contractor represents and warrants that all statements and information prepared and submitted by Contractor in this Contract and any related Solicitation Response are current, complete, true, and accurate. Contractor acknowledges any false statement or material misrepresentation made by Contractor during the performance of this Contract or any related Solicitation is a material breach of contract and may void this Contract. Further, Contractor understands, acknowledges, and agrees that any false representation or any failure to comply with a representation, warranty, or certification made by Contractor is subject to all civil and criminal consequences provided at law or in equity including, but not limited to, immediate termination of this Contract. 44. Permits and License Contractor represents and warrants that it will comply with all applicable laws and maintain all permits and licenses required by applicable city, county, state, and federal rules, regulations, statutes, codes, and other laws that pertain to this Contract. 45. Drug-Free Workplace Contractor represents and warrants that it shall comply with the applicable provisions of the Drug-Free Work Place Act of 1988 (41 U.S.C. §701 et seq.) and maintain a drug-free work environment. 46. Equal Employment Opportunity Contractor represents and warrants its compliance with all applicable duly enacted state and federal laws governing equal employment opportunities. 47. Federal Occupational Safety and Health Law Contractor represents and warrants that all articles and services shall meet or exceed the safety standards established and promulgated under the Federal Occupational Safety and Health Act of 1970, as amended (29 U.S.C. Chapter 15). DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 48. Signature Authority Contractor represents and warrants that the individual signing this Contract is authorized to sign on behalf of Contractor and to bind the Contractor. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Contract Affirmations Signature. Authorized representative on behalf of Contractor must complete and sign the following: city of Port Arthur Legal Name of Contractor Assumed Business Name of Contractor, if applicable(D.B.A. or `doing business as') Texas County(s) for Assumed Business Name (D.B.A. or `doing business as') Attach Assumed Name Certificate(s) for each County �—DocuSigbed by: AOI , burIOU, August 31. 2020 SignatterewfAuthorized Representative Date Signed Ron Burton 08/31/2020 Printed Name of Authorized Representative Title of Authorized Representative First,Middle Name or Initial,and Last Name PigsaitgiTeet Address ''bde7640 Mailing Address, if different City, State, Zip Code ?hone Number Fax Number ron.burton@portarthurtx.gov 137134909 Email Address DUNS Number 74-6001885 17460018850-011 Federal Employer Identification Number Texas Payee ID No. — 11 digits 1-74-6001885-0 17460018850-11 Texas Franchise Tax Number Texas Secretary of State Filing Number DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Ju11l.ILQWV111V 11111 167VUVV7,7 L)/11111)1 I t. Attachment F DATA USE AGREEMENT BETWEEN THE TEXAS HEALTH AND HUMAN SERVICES SYSTEM AND CONTRACTOR This Data Use Agreement("DUA") is effective as of the date of the Base Contract into which it is incorporated("Effective Date"),by and between the Texas Health and Human Services System,which includes the Texas Health and Human Services Commission and the Department of State Health Services ("1-IHS")and Contractor(the "Base Contract"). ARTICLE 1. PURPOSE;APPLICABILITY; ORDER OF PRECEDENCE The purpose of this DUA is to facilitate access to, creation, receipt, maintenance, use, disclosure or transmission of Confidential Information with Contractor, and describe Contractor's rights and obligations with respect to the Confidential Information and the limited purposes for which the Contractor may create, receive, maintain, use, disclose or have access to Confidential Information. This DUA also describes HHS's remedies in the event of Contractor's noncompliance with its obligations under this DUA. This DUA applies to both HHS business associates, as "business associate" is defined in the Health Insurance Portability and Accountability Act(HIPAA),and contractors who are not business associates, who create, receive, maintain, use,disclose or have access to Confidential Information on behalf of HHS, its programs or clients as described in the Base Contract. As a best practice, HHS requires its contractors to comply with the terms of this DUA to safeguard all types of Confidential Information. As of the Effective Date of this DUA, if any provision of the Base Contract conflicts with this DUA,this DUA controls. ARTICLE 2. DEFINITIONS For the purposes of this DUA,capitalized, underlined terms have the following meanings: "Authorized Purpose"means the specific purpose or purposes described in the Base Contract for Contractor to fulfill its obligations under the Base Contract,or any other purpose expressly authorized by HHS in writing in advance. "Authorized User"means a person: (1) Who is authorized to create, receive, maintain, have access to, process, view, handle, examine, interpret, or analyze Confidential Information pursuant to this DUA; (2) For whom Contractor warrants and represents has a demonstrable need to create, receive, maintain,use,disclose or have access to the Confidential Information; and (3) Who has agreed in writing to be bound by the disclosure and use limitations pertaining to the Confidential Information as required by this DUA. "Breach" means an impermissible use or disclosure of electronic or non-electronic sensitive personal information by an unauthorized person or for an unauthorized purpose that compromises the security or privacy of Confidential Information such that the use or disclosure poses a risk of reputational harm, theft HHS Data Use Agreement v.8.5 October 23,2019 1 of 11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Ul ,l„al1L,al IIIWI,I1G.11u11, lue„L,ly ,,,en, u, ,,,weal identity theft. Any acquisition, access, use, disclosure or loss of Confidential Information other than as permitted by this DUA shall be presumed to be a Breach unless Contractor demonstrates, based on a risk assessment, that there is a low probability that the Confidential Information has been compromised. "Confidential Information"means any communication or record(whether oral,written,electronically stored or transmitted,or in any other form)provided to or made available to Contractor or that Contractor may create, receive, maintain, use,disclose or have access to on behalf of HHS that consists of or includes any or all of the following: (1) Education records as defined in the Family Educational Rights and Privacy Act, 20 U.S.C. §1232g;34 C.F.R. Part 99 (2) Federal Tax Information as defined in Internal Revenue Code §6103 and Internal Revenue Service Publication 1075; (3) Personal Identifying Information (P11) as defined in Texas Business and Commerce Code, Chapter 521; (4) Protected Health Information (PHI) in any form including without limitation, Electronic Protected Health Information or Unsecured Protected Health Information as defined in 45 C.F.R. §160.103; (5) Sensitive Personal Information (SPI) as defined in Texas Business and Commerce Code, Chapter 521; (6) Social Security Administration Data, including, without limitation, Medicaid information means disclosures of information made by the Social Security Administration or the Centers for Medicare and Medicaid Services from a federal system of records for administration of federally funded benefit programs under the Social Security Act,42 U.S.C., Chapter 7; (7) All privileged work product; (8) All information designated as confidential under the constitution and laws of the State of Texas and of the United States, including the Texas Health& Safety Code and the Texas Public Information Act,Texas Government Code,Chapter 552. "Destroy","Destruction",for Confidential Information,means: (1) Paper, film, or other hard copy media have been shredded or destroyed such that the Confidential Information cannot be read or otherwise cannot be reconstructed. Redaction is specifically excluded as a means of data destruction. (2) Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, "Guidelines for Media Sanitization," such that the Confidential Information cannot be retrieved. "Discover, Discovery" means the first day on which a Breach becomes known to Contractor, or, by exercising reasonable diligence would have been known to Contractor. "Legally Authorized Representative" of an individual, including as provided in 45 CFR 435.923 (authorized representative); 45 CFR 164.502(g)(1) (personal representative); Tex. Occ. Code § 151.002(6); Tex. H. & S. Code §166.164 (medical power of attorney); and Texas Estates Code § 22.031 (representative). "Required by Law" means a mandate contained in law that compels an entity to use or disclose Confidential Information that is enforceable in a court of law, including court orders, warrants, subpoenas or investigative demands. "Subcontractor" means a person who contracts with a prime contractor to work, to supply commodities, or to contribute toward completing work for a governmental entity. HHS Data Use Agreement v.8.5 October 23,2019 2of11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4.CCFFDBODF809 YYurKlufl'C iiiea11J e111piuyces, vWUIILCeMJ, Trainees or other persons whose performance of work is under the direct control of a party,whether or not they are paid by that party. ARTICLE 3. CONTRACTOR'S DUTIES REGARDING CONFIDENTIAL INFORMATION Section 3.01 Obligations of Contractor Contractor agrees that: (A) With respect to PHI,Contractor shall: (1) Make PHI available in a designated record set if requested by HHS, if Contractor maintains PHI in a designated record set,as defined in HIPAA. (2) Provide to HHS data aggregation services related to the healthcare operations Contractor performs for HHS pursuant to the Base Contract, if requested by HHS, if Contractor provides data aggregation services as defined in HIPAA. (3) Provide access to PHI to an individual who is requesting his or her own PHI, or such individual's Legally Authorized Representative, in compliance with the requirements of HIPAA. (4) Make PHI available to HHS for amendment, and incorporate any amendments to PHI that HHS directs, in compliance with HIPAA. (5) Document and make available to HHS, an accounting of disclosures in compliance with the requirements of HIPAA. (6) If Contractor receives a request for access, amendment or accounting of PHI by any individual, promptly forward the request to HHS or, if forwarding the request would violate HIPAA, promptly notify HHS of the request and of Contractor's response. HHS will respond to all such requests, unless Contractor is Required by Law to respond or HHS has given prior written consent for Contractor to respond to and account for all such requests. (B) With respect to ALL Confidential Information,Contractor shall: (1) Exercise reasonable care and no less than the same degree of care Contractor uses to protect its own confidential, proprietary and trade secret information to prevent Confidential Information from being used in a manner that is not expressly an Authorized Purpose or as Required by Law. Contractor will access, create, maintain, receive, use, disclose, transmit or Destroy Confidential Information in a secure fashion that protects against any reasonably anticipated threats or hazards to the security or integrity of such information or unauthorized uses. (2) Establish, implement and maintain appropriate procedural, administrative, physical and technical safeguards to preserve and maintain the confidentiality, integrity, and availability of the Confidential Information, in accordance with applicable laws or regulations relating to Confidential Information, to prevent any unauthorized use or disclosure of Confidential Information as long as Contractor has such Confidential Information in its actual or constructive possession. (3) Implement, update as necessary, and document privacy, security and Breach notice policies and procedures and an incident response plan to address a Breach, to comply with the privacy, security and breach notice requirements of this DUA prior to conducting work under the Base Contract. Contractor shall produce, within three business days of a request by HHS, copies of its policies and procedures and records relating to the use or disclosure of Confidential Information. (4) Obtain HHS's prior written consent to disclose or allow access to any portion of the Confidential Information to any person, other than Authorized Users, Workforce or Subcontractors of Contractor who have completed training in confidentiality, privacy, security and the importance of promptly reporting any Breach to Contractor's management and as permitted in Section 3.01(A)(3), above. Contractor shall produce evidence of completed training to HHS upon request. HHS, at its election, may assist Contractor in training and education on specific or unique HHS processes, systems HHS Data Use Agreement v.8.5 October 23,2019 3of11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 aim an icyuueute,ns. nu ul wuuaciui s riuuiurized Users, Workforce and Subcontractors with access to a state computer system or database will complete a cybersecurity training program certified under Texas Government Code Section 2054.519 by the Texas Department of Information Resources. (5) Establish, implement and maintain appropriate sanctions against any member of its Workforce or Subcontractor who fails to comply with this DUA, the Base Contract or applicable law. Contractor shall maintain evidence of sanctions and produce it to HHS upon request. (6) Obtain prior written approval of HHS, to disclose or provide access to any Confidential Information on the basis that such act is Required by Law, so that HHS may have the opportunity to object to the disclosure or access and seek appropriate relief. If HHS objects to such disclosure or access, Contractor shall refrain from disclosing or providing access to the Confidential Information until HHS has exhausted all alternatives for relief. (7) Certify that its Authorized Users each have a demonstrated need to know and have access to Confidential Information solely to the minimum extent necessary to accomplish the Authorized Purpose and that each has agreed in writing to be bound by the disclosure and use limitations pertaining to the Confidential Information contained in this DUA. Contractor and its Subcontractors shall maintain at all times an updated,complete,accurate list of Authorized Users and supply it to HHS upon request. (8) Provide, and shall cause its Subcontractors and agents to provide, to HHS periodic written confirmation of compliance with controls and the terms and conditions of this DUA. (9) Return to HHS or Destroy, at HHS's election and at Contractor's expense, all Confidential Information received from HHS or created or maintained by Contractor or any of Contractor's agents or Subcontractors on HHS's behalf upon the termination or expiration of this DUA, if reasonably feasible and permitted by law. Contractor shall certify in writing to HHS that all such Confidential Information has been Destroyed or returned to HHS, and that Contractor and its agents and Subcontractors have retained no copies thereof. Notwithstanding the foregoing, Contractor acknowledges and agrees that it may not Destroy any Confidential Information if federal or state law, or HHS record retention policy or a litigation hold notice prohibits such Destruction. If such return or Destruction is not reasonably feasible, or is impermissible by law, Contractor shall immediately notify HHS of the reasons such return or Destruction is not feasible and agree to extend the protections of this DUA to the Confidential Information for as long as Contractor maintains such Confidential Information. (10)Complete and return with the Base Contract to HHS, attached as Attachment 2 to this DUA, the HHS Security and Privacy Initial Inquiry(SPI)at https://hhs.texas.gov/laws- regulations/forms/miscellaneous/hhs-information-security-privacy-initial-inquiry-spi. The SPI identifies basic privacy and security controls with which Contractor must comply to protect Confidential Information. Contractor shall comply with periodic security controls compliance assessment and monitoring by HHS as required by state and federal law, based on the type of Confidential Information Contractor creates, receives, maintains, uses, discloses or has access to and the Authorized Purpose and level of risk. Contractor's security controls shall be based on the National Institute of Standards and Technology (NIST) Special Publication 800-53. Contractor shall update its security controls assessment whenever there are significant changes in security controls for HHS Confidential Information and shall provide the updated document to HHS. HHS also reserves the right to request updates as needed to satisfy state and federal monitoring requirements. (11) Comply with the HHS Acceptable Use Policy (AUP) and require each Subcontractor and Workforce member who has direct access to HHS Information Resources, as defined in the AUP, to execute an HHS Acceptable Use Agreement. (12)Only conduct secure transmissions of Confidential Information whether in paper, oral or electronic form. A secure transmission of electronic Confidential Information in motion includes secure File Transfer Protocol (SFTP)or encryption at an appropriate level as required by rule, regulation or law. Confidential Information at rest requires encryption unless there is adequate administrative,technical,and HHS Data Use Agreement v.8.5 October 23,2019 4 of 11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 puystuat scculny as icquucu uy iwc, icgu►auuu or law. All electronic data transfer and communications of Confidential Information shall be through secure systems. Contractor shall provide proof of system, media or device security and/or encryption to HHS no later than 48 hours after HHS's written request in response to a compliance investigation, audit, or the Discovery of a Breach. HHS may also request production of proof of security at other times as necessary to satisfy state and federal monitoring requirements. Deidentification of Confidential Information in accordance with H1PAA de-identification standards is deemed secure. (13) Designate and identify a person or persons, as Privacy Official and Information Security Official,each of whom is authorized to act on behalf of Contractor and is responsible for the development and implementation of the privacy and security requirements in this DUA. Contractor shall provide name and current address, phone number and e-mail address for such designated officials to HHS upon execution of this DUA and prior to any change. Upon written notice from HHS, Contractor shall promptly remove and replace such official(s) if such official(s)is not performing the required functions. (14) Make available to HHS any information HHS requires to fulfill HHS's obligations to provide access to, or copies of, Confidential Information in accordance with applicable laws, regulations or demands of a regulatory authority relating to Confidential Information. Contractor shall provide such information in a time and manner reasonably agreed upon or as designated by the applicable law or regulatory authority. (15)Comply with the following laws and standards if applicable to the type of Confidential Information and Contractor's Authorized Purpose: • Title 1, Part 10,Chapter 202, Subchapter B,Texas Administrative Code; • The Privacy Act of 1974; • OMB Memorandum 17-12; • The Federal Information Security Management Act of 2002(FISMA); • The Health Insurance Portability and Accountability Act of 1996(HIPAA); • Internal Revenue Publication 1075 —Tax Information Security Guidelines for Federal, State and Local Agencies; • National Institute of Standards and Technology (NIST) Special Publication 800-66 Revision 1 — An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act(HIPAA)Security Rule; • NIST Special Publications 800-53 and 800-53A — Recommended Security Controls for Federal Information Systems and Organizations,as currently revised; • NIST Special Publication 800-47 — Security Guide for Interconnecting Information Technology Systems; • NIST Special Publication 800-88,Guidelines for Media Sanitization; • NIST Special Publication 800-111, Guide to Storage of Encryption Technologies for End User Devices containing PHI; • Family Educational Rights and Privacy Act • Texas Business and Commerce Code,Chapter 521; • Any other State or Federal law, regulation, or administrative rule relating to the specific HHS program area that Contractor supports on behalf of HHS. (16) Be permitted to use or disclose Confidential Information for the proper management and administration of Contractor or to carry out Contractor's legal responsibilities, except as otherwise limited by this DUA, the Base Contract, or law applicable to the Confidential Information, if: HHS Data Use Agreement v.8.5 October 23,2019 5of11 DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 lad viscwSuic IS uy L,aw, (b) Contractor obtains reasonable assurances from the person to whom the information is disclosed that the person shall: I. Maintain the confidentiality of the Confidential Information in accordance with this DUA; 2. Use or further disclose the information only as Required by Law or for the Authorized Purpose for which it was disclosed to the person; and 3. Notify Contractor in accordance with Section 4.01 of a Breach of Confidential Information that the person Discovers or should have Discovered with the exercise of reasonable diligence. (C) With respect to ALL Confidential Information,Contractor shall NOT: (I) Attempt to re-identify or further identify Confidential Information that has been deidentified, or attempt to contact any persons whose records are contained in the Confidential Information, except for an Authorized Purpose,without express written authorization from HHS. (2) Engage in prohibited marketing or sale of Confidential Information. (3) Permit, or enter into any agreement with a Subcontractor to, create, receive, maintain, use, disclose, have access to or transmit Confidential Information, on behalf of HHS without requiring that Subcontractor first execute either the Form Subcontractor Agreement,Attachment 1,or Contractor's own Subcontractor agreement that ensures that the Subcontractor shall comply with the same safeguards and restrictions contained in this DUA for Confidential Information. Contractor is directly responsible for its Subcontractors' compliance with,and enforcement of,this DUA. ARTICLE 4. BREACH NOTICE,REPORTING AND CORRECTION REQUIREMENTS Section 4.01. Cooperation and Financial Responsibility. (A) Contractor shall, at Contractor's expense, cooperate fully with HHS in investigating, mitigating to the extent practicable, and issuing notifications as directed by HHS, for any Breach of Confidential Information. (B) Contractor shall make Confidential Information in Contractor's possession available pursuant to the requirements of HIPAA or other applicable law upon a determination of a Breach. (C) Contractor's obligation begins at the Discovery of a Breach and continues as long as related activity continues, until all effects of the Breach are mitigated to HHS's satisfaction (the "incident response period"). Section 4.02. Initial Breach Notice. For federal information obtained from a federal system of records, including Federal Tax Information and Social Security Administration Data (which includes Medicaid and other governmental benefit program Confidential Information),Contractor shall notify HHS of the Breach within the first consecutive clock hour of Discovery. The Base Contract shall specify whether Confidential Information is obtained from a federal system of records. For all other types of Confidential Information Contractor shall notify HHS of the Breach not more than 24 hours after Discovery, or in a timeframe otherwise approved by HHS in writing. Contractor shall initially report to HHS's Privacy and Security Officers via email at: privacy@a,HHSC.state.tx.us and to the HHS division responsible for the Base Contract. HHS Data Use Agreement v.8.5 October 23,2019 6of11 DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 l..uuuacw, S11411 ,cpuit au llllui111d1,101 I is soiiawy available to Contractor about the Breach. Contractor shall provide contact information to HHS for Contractor's single point of contact who will communicate with HHS both on and off business hours during the incident response period. Section 4.03 Third Business Day Notice: No later than 5 p.m. on the third business day after Discovery, or a time within which Discovery reasonably should have been made by Contractor of a Breach of Confidential Information, Contractor shall provide written notification to HHS of all reasonably available information about the Breach, and Contractor's investigation, including, to the extent known to Contractor: a. The date the Breach occurred; b. The date of Contractor's and, if applicable, Subcontractor's Discovery; c. A brief description of the Breach, including how it occurred and who is responsible (or hypotheses, if not yet determined); d. A brief description of Contractor's investigation and the status of the investigation; e. A description of the types and amount of Confidential Information involved; f. Identification of and number of all individuals reasonably believed to be affected, including first and last name of the individual and if applicable, the Legally authorized representative, last known address, age, telephone number, and email address if it is a preferred contact method; g. Contractor's initial risk assessment of the Breach demonstrating whether individual or other notices are required by applicable law or this DUA for HHS approval, including an analysis of whether there is a low probability of compromise of the Confidential Information or whether any legal exceptions to notification apply; h. Contractor's recommendation for HHS's approval as to the steps individuals and/or Contractor on behalf of individuals, should take to protect the individuals from potential harm, including Contractor's provision of notifications, credit protection, claims monitoring, and any specific protections for a Legally Authorized Representative to take on behalf of an individual with special capacity or circumstances; i. The steps Contractor has taken to mitigate the harm or potential harm caused (including without limitation the provision of sufficient resources to mitigate); j. The steps Contractor has taken, or will take, to prevent or reduce the likelihood of recurrence of a similar Breach; k. Identify, describe or estimate of the persons, Workforce, Subcontractor, or individuals and any law enforcement that may be involved in the Breach; I. A reasonable schedule for Contractor to provide regular updates regarding response to the Breach, but no less than every three (3) business days, or as otherwise directed by HHS in writing, including information about risk estimations, reporting, notification, if any, mitigation, corrective action, root cause analysis and when such activities are expected to be completed;and m. Any reasonably available,pertinent information, documents or reports related to a Breach that HHS requests following Discovery. Section 4.04. Investigation,Response and Mitigation. (A) Contractor shall immediately conduct a full and complete investigation, respond to the Breach, commit necessary and appropriate staff and resources to expeditiously respond, and report as required to HHS for incident response purposes and for purposes of HHS's compliance with report and notification requirements,to the satisfaction of HHS. HHS Data Use Agreement v.8.5 October 23,2019 7of11 DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 tD) t..uuuacun auau wimp= ui Nai ucipate in a risk assessment as directed by HHS following a Breach, and provide the final assessment, corrective actions and mitigations to HHS for review and approval. (C) Contractor shall fully cooperate with HHS to respond to inquiries and/or proceedings by state and federal authorities,persons and/or individuals about the Breach. (D) Contractor shall fully cooperate with HHS's efforts to seek appropriate injunctive relief or otherwise prevent or curtail such Breach, or to recover or protect any Confidential Information, including complying with reasonable corrective action or measures, as specified by HHS in a Corrective Action Plan if directed by HHS under the Base Contract. Section 4.05. Breach Notification to Individuals and Reporting to Authorities. (A) HHS may direct Contractor to provide Breach notification to individuals, regulators or third- parties, as specified by HHS following a Breach. (B) Contractor must comply with all applicable legal and regulatory requirements in the time, manner and content of any notification to individuals, regulators or third-parties, or any notice required by other state or federal authorities, including without limitation, notifications required by Texas Business and Commerce Code, Chapter 521.053(b) and HIPAA. Notice letters will be in Contractor's name and on Contractor's letterhead, unless otherwise directed by HHS, and will contain contact information, including the name and title of Contractor's representative, an email address and a toll-free telephone number,for the individual to obtain additional information. (C) Contractor shall provide HHS with draft notifications for HHS approval prior to distribution and copies of distributed and approved communications. (D) Contractor shall have the burden of demonstrating to the satisfaction of HHS that any required notification was timely made. If there are delays outside of Contractor's control, Contractor shall provide written documentation to HHS of the reasons for the delay. (E) If HHS directs Contractor to provide notifications, HHS shall, in the time and manner reasonably requested by Contractor, cooperate and assist with Contractor's information requests in order to make such notifications. ARTICLE 5. GENERAL PROVISIONS Section 5.01 Ownership of Confidential Information Contractor acknowledges and agrees that the Confidential Information is and shall remain the property of HHS. Contractor agrees it acquires no title or rights to the Confidential Information. Section 5.02 HHS Commitment and Obligations HHS will not request Contractor to create, maintain, transmit, use or disclose PHI in any manner that would not be permissible under applicable law if done by HHS. Section 5.03 HHS Right to Inspection At any time upon reasonable notice to Contractor, or if HHS determines that Contractor has violated this DUA, HHS, directly or through its agent, will have the right to inspect the facilities, systems, books and records of Contractor to monitor compliance with this DUA. For purposes of this subsection, HHS's agent(s) include, without limitation, the HHS Office of the Inspector General, the Office of the Attorney General of Texas,the State Auditor's Office, outside consultants,legal counsel or other designee. HHS Data Use Agreement v.8.5 October 23,2019 8of11 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDB0DF809 OCI:LIUt1 J.V4 lel 111; 1C11111111111011 Ul JJIJA:, Survival This DUA will be effective on the date on which Contractor executes the Base Contract and will terminate upon termination of the Base Contract and as set forth herein. If the Base Contract is extended,this DUA is extended to run concurrent with the Base Contract. (A) If HHS determines that Contractor has violated a material term of this DUA; HHS may in its sole discretion: (1) Exercise any of its rights including but not limited to reports, access and inspection under this DUA and/or the Base Contract;or (2) Require Contractor to submit to a corrective action plan, including a plan for monitoring and plan for reporting as HHS may determine necessary to maintain compliance with this DUA;or (3) Provide Contractor with a reasonable period to cure the violation as determined by HHS;or (4) Terminate the DUA and Base Contract immediately and seek relief in a court of competent jurisdiction in Travis County,Texas. Before exercising any of these options, HHS will provide written notice to Contractor describing the violation and the action it intends to take. (B) If neither termination nor cure is feasible, HHS shall report the violation to the applicable regulatory authorities. (C) The duties of Contractor or its Subcontractor under this DUA survive the expiration or termination of this DUA until all the Confidential Information is Destroyed or returned to HHS, as required by this DUA. Section 5.05 Injunctive Relief (A) Contractor acknowledges and agrees that HHS may suffer irreparable injury if Contractor or its Subcontractor fails to comply with any of the terms of this DUA with respect to the Confidential Information or a provision of HIPAA or other laws or regulations applicable to Confidential Information. (B) Contractor further agrees that monetary damages may be inadequate to compensate HHS for Contractor's or its Subcontractor's failure to comply. Accordingly, Contractor agrees that HHS will, in addition to any other remedies available to it at law or in equity, be entitled to seek injunctive relief without posting a bond and without the necessity of demonstrating actual damages,to enforce the terms of this DUA. Section 5.06 Indemnification Contractor shall indemnify, defend and hold harmless HHS and its respective Executive Commissioner, employees, Subcontractors, agents (including other state agencies acting on behalf of HHS) or other members of HHS' Workforce (each of the foregoing hereinafter referred to as "Indemnified Party")against all actual and direct losses suffered by the Indemnified Party and all liability to third parties arising from or in connection with any breach of this DUA or from any acts or omissions related to this DUA by Contractor or its employees, directors, officers, Subcontractors, or agents or other members of Contractor's Workforce. The duty to indemnify, defend and hold harmless is independent of the duty to insure. Upon demand, Contractor shall reimburse HHS for any and all losses, liabilities, lost profits, fines, penalties, costs or expenses (including costs of required notices, investigation, and mitigation of a Breach, fines or penalties imposed on an Indemnified Party by a regulatory authority, and reasonable attorneys' fees) which may be imposed upon any Indemnified Party to the extent caused by and which results from the Contractor's failure to meet any of its obligations under this DUA. Contractor's obligation to defend, indemnify and hold harmless any Indemnified Party will survive the expiration or termination of this DUA. HHS Data Use Agreement v.8.5 October 23,2019 9of11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 JeClluu JAY/ lnntliluve (A) In addition to any insurance required in the Base Contract, at HHS's option, HHS may require Contractor to maintain, at its expense, the special and/or custom first- and third-party insurance coverages, including without limitation data breach, cyber liability, crime theft and notification expense coverages, with policy limits sufficient to cover any liability arising under this DUA,naming the State of Texas,acting through HHS,as an additional named insured and loss payee, with primary and noncontributory status. (B) Contractor shall provide HHS with written proof that required insurance coverage is in effect,at the request of HHS. Section 5.08 Entirety of the Contract This DUA is incorporated by reference into the Base Contract and, together with the Base Contract, constitutes the entire agreement between the parties. No change, waiver, or discharge of obligations arising under those documents will be valid unless in writing and executed by the party against whom such change, waiver,or discharge is sought to be enforced. Section 5.09 Automatic Amendment and Interpretation Upon the effective date of any amendment or issuance of additional regulations to any law applicable to Confidential Information, this DUA will automatically be amended so that the obligations imposed on HHS and/or Contractor remain in compliance with such requirements. Any ambiguity in this DUA will be resolved in favor of a meaning that permits HHS and Contractor to comply with laws applicable to Confidential Information. Section 5.10 Notices; Requests for Approval All notices and requests for approval related to this DUA must be directed to the HHS Chief Privacy Officer at privacy@hhsc.state.tx.us. HHS Data Use Agreement v.8.5 October 23,2019 10 of 11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 ATTACHMENT 1. SUBCONTRACTOR AGREEMENT FORM HHS CONTRACT NUMBER The DUA between HHS and Contractor establishes the permitted and required uses and disclosures of Confidential Information by Contractor. Contractor has subcontracted with N/A (Subcontractor) for performance of duties on behalf of CONTRACTOR which are subject to the DUA. Subcontractor acknowledges,understands and agrees to be bound by the same terms and conditions applicable to Contractor under the DUA, incorporated by reference in this Agreement, with respect to HHS Confidential Information. Contractor and Subcontractor agree that HHS is a third-party beneficiary to applicable provisions of the subcontract. HHS has the right, but not the obligation,to review or approve the terms and conditions of the subcontract by virtue of this Subcontractor Agreement Form. Contractor and Subcontractor assure HHS that any Breach as defined by the DUA that Subcontractor Discovers shall be reported to HHS by Contractor in the time, manner and content required by the DUA. If Contractor knows or should have known in the exercise of reasonable diligence of a pattern \,. of activity or practice by Subcontractor that constitutes a material breach or violation of the DUA or the Subcontractor's obligations,Contractor shall: 1. Take reasonable steps to cure the violation or end the violation,as applicable; 2. If the steps are unsuccessful, terminate the contract or arrangement with Subcontractor, if feasible; 3. Notify HHS immediately upon Discovery of the pattern of activity or practice of Subcontractor that constitutes a material breach or violation of the DUA and keep HHS reasonably and regularly informed about steps Contractor is taking to cure or end the violation or terminate Subcontractor's contract or arrangement. This Subcontractor Agreement Form is executed by the parties in their capacities i CONTRACTOR SUBCONTRACTOR d i c BY: HY: t NAME: NAME: d TITLE: TITLE: DATE b ,202 . DATE: elow. 1-IHS Data Use Agreement v.8.5 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 .«achment F • TEXAS Texas HHS System-Data Use Agreement-Attachment 2 vl*vSECURITY AND PRIVACY INQUIRY(SPI) ; Health and Human Services If you are a bidder for a new procurement/contract,in order to participate in the bidding process,you must have corrected any"No" responses(except A9a)prior to the contract award date.If you are an applicant for an open enrollment,you must have corrected any"No"answers(except A95 and All)prior to performing any work on behalf of any Texas HHS agency. For any questions answered"No"(except A9a and All),an Action Plan for Compliance with a Timeline must be documented in the designated area below the question.The timeline for compliance with HIPAA-related requirements for safeguarding Protected Health Information is 30 calendar days from the date this form is signed. Compliance with requirements related to other types of Confidential Information must be confirmed within 90 calendar days from the date the form is signed. SECTION A:APPLICANT/BIDDER INFORMATION(To be completed by Applicant/Bidder) 1. Does the applicant/bidder access,create,disclose,receive,transmit,maintain,or store Texas Q Yes HHS Confidential Information in electronic systems(e.g.,laptop, personal use computer, 0 No mobile device,database,server,etc.)? IF NO,STOP. THE SPI FORM IS NOT REQUIRED. 2. Entity or Applicant/Bidder Legal Name Legal Name: City Of Port Arthur Legal Entity Tax Identification Number (TIN)(Last Four Numbers Only): 11 • Procurement/Contract#: Address:449 Austin Avenue City:Port Arthur State:TX ZIP: 77640 Telephone#:(409)983-8832 Email Address: judith.smith@portarthurtx.gov 3. Number of Employees,at all locations,in Total Employees:43 Applicant/Bidder's Workforce "Workforce"means all employees,volunteers.trainees,and other Persons whose conduct is under the direct control of Applicant/Bidder,whether or not they are paid by Applicant/ Bidder.If Applicant/Bidder is a sole proprietor,the workforce may be only one employee. 4. Number of Subcontractors Total Subcontractors: 1 (if Applicant/Bidder will not use subcontractors,enter"0") 5. Name of Information Technology Security Official A.Security Official: and Name of Privacy Official for Applicant/Bidder Legal Name: Fay Young,IT Manager (Privacy and Security Official may be the same person.) Address:444 Lakeshore Drive City:Port Arthur State:TX ZIP: 77640 Telephone#: (409)983-8164 Email Address: fay.young@portarthurtx.gov B.Privacy Official: Legal Name:Fay Young Address:444 Lakeshore Drive City: Port Arthur State: Texas ZIP: 77640 Telephone#: (409)983-8164 Email Address: fay.young@portarthurtx.gov SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 1 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DAB07B4-A920-4608-61A4-CCFFDBODF809 6. Type(s)of Texas HHS Confidential Information the HIPAA CJIS IRS FTI CMS SSA I P11 Applicant/Bidder will create,receive,maintain,use, 0 El 0 El El El disclose or have access to:(Check all that apply) Other(Please List) •Health Insurance Portability and Accountability Act(HIPAA)data •Crimion!Justice Information Services(GIS)data •Internal Revenue Service Federal Tax Information(IRS FT!)data •Centers for Medicare&Medicaid Services(CMS) •Social Security Administration(SSA) •Personalty Identifiable fnformnt,on(P11) 7. Number of Storage Devices for Texas HHS Confidential Information(as defined in the Total# Texas HHS System Data Use Agreement(DUA)) (Sum a-d) Cloud Services involve using a network of remote servers hosted on the Internet to store, 8 manage,and process data,rather than a local server or a personal computer. A Data Center is a centralized repository,either physical or virtual,for the storage, management,and dissemination of data and information organized around a particular body of knowledge or pertaining to a particular business. a. Devices.Number of personal user computers,devices or drives,including mobile 2 devices and mobile drives. b.Servers.Number of Servers that are not in a data center or using Cloud Services. 0 c.Cloud Services.Number of Cloud Services in use. 5 d.Data Centers.Number of Data Centers in use. 1 8. Number of unduplicated individuals for whom Applicant/Bidder reasonably expects to Select Option handle Texas HHS Confidential Information during one year: (a-d) a. 499 individuals or less O a. b. 500 to 999 individuals 0 b. c. 1,000 to 99,999 individuals 0 c- d. 100,000 individuals or more 0 d. 9. HIPAA Business Associate Agreement a. Will Applicant/Bidder use,disclose,create, receive,transmit or maintain protected ®Yes health information on behalf of a HIPAA-covered Texas HHS agency for a HIPAA- 0 No covered function? b. Does Applicant/Bidder have a Privacy Notice prominently displayed on a Webpage or a 0 Yes Public Office of Applicant/Bidder's business open to or that serves the public?(This is a 0 No HIPAA requirement. Answer"N/A" if not applicable, such as for agencies not covered 0 N/A by HIPAA.) Action Plan far Compliance with a Timeline: Compliance Date: 10.Subcontractors.If the Applicant/Bidder responded"0"to Question 4(indicating no subcontractors),check"N/A"for both'a.'and'b.' a. Does Applicant/Bidder require subcontractors to execute the DUA Attachment 1 0 Yes Subcontractor Agreement Form? 0 No 0 N/A Action Plan for Compliance with a Timeline: Compliance Date: • SPI Version 2 1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 2 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 b.Will Applicant/Bidder agree to require subcontractors who will access Confidential 0 Yes Information to comply with the terms of the DUA, not disclose any Confidential 0 No Information to them until they have agreed in writing to the same safeguards and to 0 N/A discontinue their access to the Confidential Information if they fail to comply? Action Plan for Compliance with a Timeline: Compliance Date: 11.Does Applicant/Bidder have any Optional Insurance currently in place? Yes Optional Insurance provides coverage for:(1)Network Security and Privacy;(2)Data Breach;(3)Cyber Liability(lost data,lost use or delay/suspension in business,denial of service with e-business,the Internet, © No networks and informational assets,such as privacy,intellectualroe0 N/A p p rty,virus transmission,extortion, sabotage or web activities);(4)Electronic Media Liability;(5)Crime/Theft;(6)Advertising Injury and Personal Injury liability;and(7)Crisis Management and Notification Expense Coverage. SPI Version 2.1(0612018) Texas HHS System-Data Use Agreement-Attachment 2: Page 3 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 SECTION B:PRIVACY RISK ANALYSIS AND ASSESSMENT(To be completed by Applicant/Bidder) For any questions answered"No,"an Action Plan for Compliance with a Timeline must be documented in the designated area below the question. The timeline for compliance with HIPAA-related requirements for safeguarding Protected Health Information is 30 calendar days from the date this form is signed. Compliance with requirements related to other types of Confidential Information must be confirmed within 90 calendar days from the date the form is signed. 1.Written Policies&Procedures.Does Applicant/Bidder have current written privacy and Yes or No security policies and procedures that,at a minimum: a. Does Applicant/Bidder have current written privacy and security policies and O Yes procedures that identify Authorized Users and Authorized Purposes(as defined in the ©No DUA)relating to creation,receipt,maintenance,use,disclosure,access or transmission of Texas HHS Confidential Information? Action Plan for Compliance with a Timeline; Compliance Date: i 1 b. Does Applicant/Bidder have current written privacy and security policies and Q Yes procedures that require Applicant/Bidder and its Workforce to comply with the Q No applicable provisions of HIPAA and other laws referenced in the DUA,relating to creation,receipt,maintenance,use,disclosure,access or transmission of Texas HHS Confidential Information on behalf of a Texas HHS agency? Action Plan for Compliance with a Timeline: Compliance Date: c. Does Applicant/Bidder have current written privacy and security policies and procedures to Yes that limit use or disclosure of Texas HHS Confidential Information to the minimum that is necessary to fulfill the Authorized Purposes? Q No Action Plan for Compliance with a Timeline: Compliance Date: d.Does Applicant/Bidder have current written privacy and security policies and procedures ()Yes that respond to an actual or suspected breach of Texas HHS Confidential Information,to include at a minimum(if any responses are"No"check"No"for all three): ONo i. Immediate breach notification to the Texas HHS agency,regulatory authorities,and other required Individuals or Authorities,in accordance with Article 4 of the DUA; ii. Following a documented breach response plan,in accordance with the DUA and applicable law;& iii.Notifying Individuals and Reporting Authorities whose Texas HHS Confidential Information has been breached,as directed by the Texas HHS agency? SPI Version Z1(0812018) Texas HHS System-Data Use Agreement-Attachment 2: Page 4 of 18 SECURITY AND PRIVACY INQUIRY(SPI) g DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Action Plan for Compliance with a Timeline: Coinoliance Date; e. Does Applicant/Bidder have current written privacy and security policies and procedures Q Yes that conduct annual workforce training and monitoring for and correction of any training delinquencies? No Action Plan for Compliance with a Timeline: Compliance Date: f. Does Applicant/Bidder have current written privacy and security policies and • ©. Yes procedures that permit or deny individual rights of access,and amendment or correction,when appropriate? Q No Action Plan for Compliance with a Timeline: Compliance Date: g. Does Applicant/Bidder have current written privacy and security policies and procedures Q Yes that permit only Authorized Users with up-to-date privacy and security training,and Q No with a reasonable and demonstrable need to use,disclose,create,receive,maintain, access or transmit the Texas HHS Confidential Information,to carry out an obligation under the DUA for an Authorized Purpose,unless otherwise approved in writing by a Texas HHS agency? Action Plan for Compliance with a Timeline: Compliance Date: h. Does Applicant/Bidder have current written privacy and security policies and procedures ®Yes that establish,implement and maintain proof of appropriate sanctions against any Workforce or Subcontractors who fail to comply with an Authorized Purpose or who is No not an Authorized User,and used or disclosed Texas HHS Confidential Information in violation of the DUA,the Base Contract or applicable law? Action Plan for Compliance with a Timeline: Compliance Date: i. Does Applicant/Bidder have current written privacy and security policies and 0 Yes procedures that require updates to policies,procedures and plans following major changes with use or disclosure of Texas HHS Confidential Information within 60 No days of identification of a need for update? Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 5 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 j. Does Applicant/Bidder have current written privacy and security policies and 0 Yes procedures that restrict permissions or attempts to re-identify or further identify 0 No de-identified Texas HHS Confidential Information,or attempt to contact any Individuals whose records are contained in the Texas HHS Confidential Information,except for an Authorized Purpose,without express written authorization from a Texas HHS agency or as expressly permitted by the Base Contract? Action Plan for Compliance with a Timeline: Compliance Date: k. If Applicant/Bidder intends to use,disclose,create,maintain,store or transmit Texas HHS 0 Yes Confidential Information outside of the United States,will Applicant/Bidder obtain the Q No express prior written permission from the Texas HHS agency and comply with the Texas HHS agency conditions for safeguarding offshore Texas HHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date 1. Does Applicant/Bidder have current written privacy and security policies and procedures ®Yes that require cooperation with Texas HHS agencies'or federal regulatory inspections, ©No audits or investigations related to compliance with the DUA or applicable law? Action Plan for Compliance with a Timeline; Compliance Date: m. Does Applicant/Bidder have current written privacy and security policies and ®Yes procedures that require appropriate standards and methods to destroy or dispose of o No Texas HHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date: n. Does Applicant/Bidder have current written privacy and security policies and procedures Q Yes that prohibit disclosure of Applicant/Bidder's work product done on behalf of Texas HHS No pursuant to the DUA,or to publish Texas HHS Confidential Information without express prior approval of the Texas HHS agency? Action Plan for Compliance with a Timeline: Compliance Date: 2. Does Applicant/Bidder have a current Workforce training program? 0 Yes Training of Workforce must occur at least once every year,and within 30 days of date of hiring a new O No Workforce member who will handle Texas HHS Confidential Information.Training must include:(1)privacy and security policies,procedures,plans and applicable requirements for handling Texas HHS Confidential Information,(2)a requirement to complete training before access is given to Texas HHS Confidential Information,and(3)written proof of training and a procedure for monitoring timely completion of training. SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 6 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Action Plan for Compliance with a Timeline: Compliance Date: 3. Does Applicant/Bidder have Privacy Safeguards to protect Texas HHS Confidential ®Yes Information in oral,paper and/or electronic form? 0 No "Privacy Safeguards"means protection of Texas NHS Confidential Information by establishing,implementing and maintaining required Administrative,Physical and Technical policies,procedures,processes and controls, required by the DUA,HIPAA(45 CFR 164.530),Social Security Administration.Medicaid and laws,rules or regulations,as applicable.Administrative safeguards include administrative protections,policies and procedures for matters such as training,provision of access,termination,and review of safeguards,incident management,disaster recovery plans,and contract provisions.Technical safeguards include technical protections,policies and procedures,such as passwords,logging,emergencies,how paper is faxed or mailed, and electronic protections such as encryption of data.Physical safeguards include physical protections, policies and procedures,such as locks,keys,physical access,physical storage and trash. Action Plan for Compliance with a Timeline: Compliance Date: 4. Does Applicant/Bidder and all subcontractors(if applicable)maintain a current list of Q Yes Authorized Users who have access to Texas HHS Confidential Information,whether oral, 0 No written or electronic? Action Plan for Compliance with a Timeline: Comoliance Date: 5. Does Applicant/Bidder and all subcontractors(if applicable)monitor for and remove ®Yes terminated employees or those no longer authorized to handle Texas HHS 0 No Confidential Information from the list of Authorized Users? Action Plan for Compliance with a Timeline: i Compliance Date: SPI Version 2.1(0612018) Texas HH5 System-Data Use Agreement-Attachment 2: Page 7 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 SECTION C:SECURITY RISK ANALYSIS AND ASSESSMENT(to be completed by Applicant/Bidder) This section is about your electronic system.If your business DOES NOT store,access,or No Electronic transmit Texas HHS Confidential Information in electronic systems(e.g.,laptop,personal Systems use computer,mobile device,database,server,etc.)select the box to the right,and "YES"will be entered for all questions in this section. For any questions answered"No,"an Action Plan for Compliance with a Timeline must be documented in the designated area below the question. The timeline for compliance with HIPAA-related items is 30 calendar days, PH-related items is 90 calendar days. 1. Does the Applicant/Bidder ensure that services which access,create,disclose,receive, Oyes transmit,maintain,or store Texas HHS Confidential Information are maintained IN the (�No United States(no offshoring)unless ALL of the following requirements are met? a. The data is encrypted with FIPS 140-2 validated encryption b. The offshore provider does not have access to the encryption keys c. The Applicant/Bidder maintains the encryption key within the United States d. The Application/Bidder has obtained the express prior written permission of the Texas HHS agency For more information regarding FIPS 140-2 encryption products,please refer to: httpll/csrc.nat.govfpublicahons/figs Action Plan for Compliance with a Timeline: Compliance Date: 2. Does Applicant/Bidder utilize an IT security-knowledgeable person or company to maintain '®Yes or oversee the configurations of Applicant/Bidder's computing systems and devices? 0 No Action Plan for Compliance with a Timeline: Compliance Date: 3. Does Applicant/Bidder monitor and manage access to Texas HHS Confidential Information Q Yes (e.g.,a formal process exists for granting access and validating the need for users to access ®No Texas HHS Confidential Information,and access is limited to Authorized Users)? Action Plan for Compliance with a Timeline: Compliance Date, 4. Does Applicant/Bidder a) have a system for changing default passwords, b) require user C)Yes password changes at least every 90 calendar days, and c) prohibit the creation of weak 0 No passwords (e.g., require a minimum of 8 characters with a combination of uppercase, lowercase, special characters, and numerals, where possible) for all computer systems that access or store Texas HHS Confidential Information. If yes,upon request must provide evidence such as a screen shot or a system report. Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 8 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 5. Does each member of Applicant/Bidder's Workforce who will use,disclose,create,receive, ®Yes transmit or maintain Texas HHS Confidential Information have a unique user name ©No (account)and private password? Action Plan for Compliance with a Timeline: Compliance Date: 6. Does Applicant/Bidder lock the password after a certain number of failed attempts and C)Yes after 15 minutes of user inactivity in all computing devices that access or store Texas 0 No NHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date: 7. Does Applicant/Bidder secure,manage and encrypt remote access(including wireless ; ()Yes access)to computer systems containing Texas HHS Confidential Information?(e.g.,a formal o No process exists for granting access and validating the need for users to remotely access Texas HHS Confidential Information,and remote access is limited to Authorized Users). Encryption is required for all Texas HHS Confidential Information. Additionally,FIPS 140-2 validated encryption is required for Health insurance Portability and Accountability Act(H!PAA)dote,Criminal Justice Information Services(GIS)data, Internal Revenue Service Federal Tax Information(IRS FR)data,and Centers for Medicare&Medicaid Ser,nctt(CMS)data. For more information regarding FIPS 140-2 encryption products,please refer to: http://csrc.n,st.gov/pubhcationsifips Action Plan for Compliance with a Timeline: Compliance Date: 8. Does Applicant/Bidder implement computer security configurations or settings for all 0 Yes computers and systems that access or store Texas HHS Confidential Information? 0 No (e.g.,non-essential features or services have been removed or disabled to reduce the threat of breach and to limit exploitation opportunities for hackers or intruders,etc.) Action Plan for Compliance with a Timeline: Compliance Date: 9. Does Applicant/Bidder secure physical access to computer,paper,or other systems C)Yes containing Texas HHS Confidential Information from unauthorized personnel and theft 0 No (e.g.,door locks,cable locks,laptops are stored in the trunk of the car instead of the passenger area,etc.)? Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 9 of 18 SECURITY AND PRIVACY INQUIRY(SPII DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 10.Does Applicant/Bidder use encryption products to protect Texas HHS Confidential 0 Yes Information that is transmitted over a public network(e.g.,the Internet,WiFi,etc.)? o No If yes,upon request must provide evidence such as a screen shot or a system report. Encryption is required for all HHS Confidential Information.Additionally,NPS 140.2 validated encryption is required for Health Insurance Portability and Accountability Act(HIPAA)data,Criminal Justice Information Services(CJIS)data,Internal Revenue Service Federal Tox information(IRS FT!)data,and Centers for Medicare&Medicaid Services(CMS)data. For more information regarding FIPS 140-2 encryption products,please refer to: h t tp.//cs rc.n is t.Ro v/p u b Ii ca tr o n s/frp s Action Plan for Compliance with a Timeline: Compliance Date: 11.Does Applicant/Bidder use encryption products to protect Texas HHS Confidential ()Yes Information stored on end user devices(e.g.,laptops,USBs,tablets,smartphones,external 0 No hard drives,desktops,etc.)? If yes,upon request must provide evidence such as a screen shot or a system report. Encryption is required for all Texas HHS Confidential Information. Additionally,FIPS 140.2 validated encryption is required for Health insurance Portability and Accountability Act(HIPAA)data,Criminal Justice Information Services(CPS)data, Internal Revenue Service Federal Tax Information(IRS FTI)data,and Centers for Medicare&Medicaid Services(CMS)data. For more information regarding FIPS 140-2 encryption products,please refer to: h t ep://c s rr.n ist.a o v/p u b l is o ti on s/fig s Action Plan for Compliance with a Timeline: Compliance Date: 12.Does Applicant/Bidder require Workforce members to formally acknowledge rules outlining Q Yes their responsibilities for protecting Texas HHS Confidential Information and associated No systems containing HHS Confidential Information before their access is provided? Action Plan for Compliance with a Timeline: Compliance Date' 13.Is Applicant/Bidder willing to perform or submit to a criminal background check on Q Yes Authorized Users? o No Action Plan for Compliance with a Timeline: Compliance Date: 14.Does Applicant/Bidder prohibit the access,creation,disclosure,reception,transmission, 0 Yes maintenance,and storage of Texas HHS Confidential Information with a subcontractor O No (e.g.,cloud services,social media,etc.)unless Texas HHS has approved the subcontractor agreement which must include compliance and liability clauses with the same requirements as the Applicant/Bidder? Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 21(06/2018) Texas HHS System-Data Use Agreement•Attachment 2: Page 10 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 15.Does Applicant/Bidder keep current on security updates/patches(including firmware, • Q. Yes software and applications)for computing systems that use,disclose,access,create, • Q No • transmit,maintain or store Texas HHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date: 16.Do Applicant/Bidder's computing systems that use, disclose,access,create,transmit, ()Yes maintain or store Texas HHS Confidential Information contain up-to-date anti- • Q No malware and antivirus protection? Action Plan for Compliance with a Timeline: I Compliance Date: 17.Does the Applicant/Bidder review system security logs on computing systems that access 0 Yes or store Texas HHS Confidential Information for abnormal activity or security concerns on o No a regular basis? Action Plan for Compliance with a Timeline: Compliance Date: 18.Notwithstanding records retention requirements,does Applicant/Bidder's disposal Q Yes processes for Texas HHS Confidential Information ensure that Texas HHS Confidential o No Information is destroyed so that it is unreadable or undecipherable? Action Plan for Compliance with a Timeline: Compliance Date: 19.Does the Applicant/Bidder ensure that all public facing websites and mobile 0 Yes applications containing Texas HHS Confidential Information meet security testing o No standards set forth within the Texas Government Code(TGC),Section 2054.516; including requirements for implementing vulnerability and penetration testing and addressing identified vulnerabilities? For more information regarding TGC.Section 2051.516 DATA SECURITY PLAN FOR ONLINE AND MOBILE APPLICATIONS,please refer to:https://legiscan.com/TX/text/H88/2017 Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 11 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 SECTION D:SIGNATURE AND SUBMISSION(to be completed by Applicant/Bidder) Please sign the form digitally,if possible. If you can't,provide a handwritten signature. 1.I certify that all of the information provided in this form is truthful and correct to the best of my knowledge. If I learn that any such information was not correct,I agree to notify Texas HHS of this immediately. '2.Signature '3.Title 4.Date: Judith A. Smith020.$131 5030-0500 rth To submit the completed,signed form: • Email the form as an attachment to the appropriate Texas HI-IS Contract Manager(s). Section E:To Be Completed by Texas HHS Agency Staff: `Agency(s): Requesting Deoartment(s): HHSC:D DFPS:J DSHS:❑ Legal Entity Tax Identification Number(TIN)(Last four Only): PO/Contract(s)H. Contract Manager: [Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: ,Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: Contract Manager Email Address: Contract Manager Telephone U: Contract Manager: Contract Manager Email Address: Contract Manager Telephone U: SPI Version 2.1(06/2018) Texas HHS System-Data Use Agreement-Attachment 2: Page 12 of 18 SECURITY AND PRIVACY INQUIRY(SPI) DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment G Insurance Requirements Grantee must maintain insurance, bonds or both, with financially sound and reputable independent insurers, in the type and amount listed in this Attachment G. Failure to maintain insurance coverage or acceptable alternative methods of insurance shall be deemed a breach of Contract. 1. General Insurance Requirements 1.1. Grantee must carry insurance in the types and amounts indicated in this Attachment G for the duration of the Contract.The insurance must be evidenced by delivery to System Agency of certificates of insurance executed by the insurer or its authorized agent stating coverages, limits,expiration dates and compliance with all applicable required provisions. Upon request, System Agency,and/or its agents,must be entitled to receive without expense,copies of the policies and all endorsements. 1.2. Grantee must update all expired policies prior to submission for monthly payment. Failure to update policies shall be reason for withholding of payment until renewal is provided to System Agency. 1.3. Grantee must provide and maintain all insurance coverage with the minimum amounts described throughout the life of the Contract. 1.4. Failure to maintain insurance coverage,as required, is grounds for suspension of work for cause. 1.5. Grantee must deliver to System Agency true and complete copies of certificates and corresponding policy endorsements upon award. 1.6. Failure of System Agency to demand such certificates or other evidence of Grantee's full compliance with these insurance requirements or failure of System Agency to identify a deficiency in compliance from the evidence provided shall not be construed as a waiver of Grantee's obligation to maintain such insurance. 1.7. The insurance and insurance limits required herein shall not be deemed as a limitation on Grantee's liability under the indemnities granted to System Agency in the Contract. 1.8. The insurance coverage and limits established below shall not be interpreted as any representation or warranty that the insurance coverage and limits necessarily will be adequate to protect Grantee. 1.9. Coverage must be written on an occurrence basis by companies authorized and admitted to do business in the State of Texas and rated A or better by A.M. Best Company or similar rating company or otherwise acceptable to System Agency. 2. Policies must include the following clauses, as applicable: 1 DocuSign Envelope ID.2DAB07B4-A920-4608-81 A4-CCFFDBODF809 Attachment G 2.1. This insurance must not be canceled,materially changed,or non-renewed except after thirty (30)days written notice has been given to System Agency. 2.2. It is agreed that Grantee's insurance must be deemed primary with respect to any insurance or self-insurance carried by System Agency for liability arising out of operations under the Contract with System Agency.Texas Health and Human Services Commission, its officials, directors, employees,representatives,and volunteers are added as additional insureds as respects operations and activities of,or on behalf of the named insured performed under Contract with System Agency. The additional insured status must cover completed operations as well.This is not applicable to workers' compensation policies. 2.3. A waiver of subrogation in favor of Texas Health and Human Services Commission must be provided in all policies. 2.4. Without limiting any of the other obligations or liabilities of Grantee,Grantee must require each SubGrantee performing work under the Contract,at SubGrantee's own expense,to maintain during the term of the Contract,the same stipulated minimum insurance including the required provisions and additional policy conditions as shown above. 2.5. As an alternative,Grantee may include its SubGrantee's as additional insureds on its own coverage as prescribed under these requirements.Grantee's certificate of insurance must note in such event that SubGrantee's are included as additional insureds and that Grantee agrees to provide workers' compensation for SubGrantees and their employees.Grantee must obtain and monitor the certificates of insurance from each SubGrantee in order to assure compliance with the insurance requirements.Grantee must retain the certificates of insurance for the duration of the Contract plus seven(7)years and must have the responsibility of enforcing these insurance requirements among its SubGrantees.Owner must be entitled, upon request and without expense,to receive copies of these certificates. 2 DocuSign Envelope ID 2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment G 3. Specific Insurance Coverage Required. 3.1. Workers' Compensation. Insurance with limits as required by the Texas Workers' Compensation Act,with the policy endorsed to provide a waiver of subrogation in favor of Health and Human Services Commission,employer's liability insurance of not less than: a. $1,000,000 each accident; b. $1,000,000 disease each employee;and c. $1,000,000 disease policy limit. d. Workers' compensation insurance coverage must be provided for all workers at all tier levels and meet the statutory requirements of Texas Labor Code. 3.2. Commercial General Liability Insurance. Including premises, operations, independent contractor's liability,products and completed operations and contractual liability,covering, but not limited to,the liability assumed under the indemnification provisions of this Contract, fully insuring Grantee's liability for bodily injury (including death)and property damage with a minimum limit of: a. $1,000,000 per occurrence; b. $2,000,000 general aggregate; c. $5,000 Medical Expense each person; d. $1,000,000 Personal Injury and Advertising Liability; e. $2,000,000 products and completed operations aggregate; f. $50,000 Damage to Premises Rented to You;and g. Coverage must be on an"occurrence"basis. h. The policy must include endorsement CG2503 Amendment of Aggregate Limits of Insurance(per Project)or its equivalent. i. The term"You"as reference in Subsection above,means the Grantee. 3.3. Comprehensive Automobile Liability Insurance,covering owned,hired,and non-owned vehicles,with a minimum combined single limit for bodily injury(including death)and property damage of$1,000,000 per accident.No aggregate shall be permitted for this type of coverage. 3.4. Umbrella Liability Insurance. Grantee must obtain,pay for and maintain umbrella liability insurance during the Contract term, insuring Grantee for an amount of not less than amount $1,000,000 that provides coverage at least as broad as and applies in excess and follows form of the primary liability coverages required hereinabove. The policy must provide"drop down"coverage where underlying primary insurance coverage limits are insufficient or exhausted. 3.5. Cyber/Privacy Liability Insurance Policy. Grantee must provide Cyber/Privacy Liability Insurance to cover risk of loss to electronic data.The policy must include coverage for electronic vandalism to electronic data, including coverage for a third party's willful electronic alteration of data, introduction of viruses which impact electronic data, unauthorized use of electronic data,or denial of service to web site or email destinations. 3 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Attachment G Cyber Liability insurance$1,000,000 Claim/$1,000,000 Aggregate. 3.6. Professional Liability Insurance.Grantee must obtain,pay for and maintain professional liability errors and omissions insurance during the Contract term,insuring Grantee for an amount of not less than $1,000,000. 4 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Attachment H- Indirect Cost Rate Letter The Entity Declined Indirect Costs DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809++-^hmerit I-Program Policy Manual s ¢1. •' ``� 7 r �� �b t 4 yIi a- ;`.� A : �. ! i . wt.[ , �• ray . , TEXAS - ' }- Health and Human - �. ` ' ' v Services o' '; *-, '• , Primary Health Care (PHC) Services Program Policy Manual Office of Primary and Specialty Health March 2020 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Table of Contents Table of Contents 2 Contact Us 4 Purpose of the Manual 5 Program Authorization and Services 6 Primary Health Care Services Program Background 6 Statute 6 Rules 6 Funding Sources 7 Definitions 8 Section I: Administrative Policy 13 Section I, Chapter 1: Administrative Policies 14 Client Access 14 Important Information for Former Military Service Members 14 Section I, Chapter 2: Abuse and Neglect Reporting 15 Child Abuse Reporting, Compliance and Monitoring 15 Human Trafficking 16 Domestic and Intimate Partner Violence 16 Section I, Chapter 3: Confidentiality 17 Minors and Confidentiality 17 Non-Discrimination and Limited English Proficiency (LEP) 17 Termination of Services 18 Resolution of Complaints 18 Research (Human Subject Clearance) 18 Section I, Chapter 4: Client Records Management 19 Section I, Chapter 5: Personnel Policy and Procedures 20 Section I, Chapter 6: Facilities and Equipment 21 Hazardous Materials 21 Fire Safety 21 Medical Equipment 21 Radiology Equipment and Standards 21 Smoking Ban 22 Disaster Response Plan 22 Section I, Chapter 7: Emergency Responsiveness 23 Clinical Emergencies 23 Emergency Preparedness 23 Section I, Chapter 8: Quality Management 24 Section II Eligibility and Fees 26 Section II, Chapter 1: Eligibility and Assessment of Co-pay/Fees 27 Client Eligibility Screening Process 27 Procedures and Terminology When Determining PHC Eligibility 27 Section III Clinical Guidelines 34 Section III, Chapter 1: General Consent 35 Consent for Dental Procedures 35 Consent for Sterilization Procedures: 35 DocuSign Envelope ID:2DAB0764-A920-4608-B1A4-CCFFDBODF809 Texas Medical Disclosure Panel Consent 35 Consent for Services Provided to Minors 36 Consent for HIV Tests 36 Section III, Chapter 2: Clinical Policy 37 Scope of Services: Six Priority Primary Health Care Services 37 Telehealth and Telemedicine 38 Client Health Records and Documentation of Encounters 39 Initial Medical History and Risk Assessment 40 Physical Assessment 41 Healthy Lifestyle Intervention 43 Diet and Nutrition 43 Laboratory Tests 43 Expedited Partner Therapy 44 Radiology Procedures 45 Family Planning Services 45 Dental Clinical Policy 47 Referral and Follow-Up 47 Section III, Chapter 3: Prescriptive Authority Agreements, Clinical Protocols, Standing Delegation Orders, and Client Education 49 Prescriptive Authority Agreements 49 Protocols 50 Standing Delegation Orders (SDO) 50 Client Education 51 Section IV Reimbursement, Data Collection and Reporting 52 Section IV, Chapter 1: Reimbursement 53 Categorical Reimbursement 53 Monthly Billing and Reporting 53 Submission of Vouchers 54 Non-Reimbursable Expenditures 54 Reimbursable Expenditures 54 Altering of Forms 55 Section IV, Chapter 2: Data Collection and Reporting 56 OPSH Forms and Resources 59 Summary of Revisions to the Primary Health Care Program Policy Manual Effective March 2020 60 3 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Contact Us Mailing Address PHC Services Program MC 1938 P.O. Box 149347 Austin, TX 78714-9347 Helpline 800-222-3986 Ext. 5922 8 a.m. to 5 p.m. Central Time Monday through Friday Austin Area Local Phone 512-776-5922 Fax Number 512-776-7417 Email PrimaryHealthCarehhsc.state.tx.us Websites Primary Health Care Services Program SharePoint Contractor Portal 4 DocuSign Envelope ID:2DAB07B4-A920-4608-B 1 A4-CCFFDBODF809 Purpose of the Manual The Texas Health and Human Services Commission (HHSC) Primary Health Care (PHC) Policy Manual is a guide for contractors who deliver primary health care services in Texas. The policy manual has been structured to provide contractor staff with information needed to comply with program legislation and rules. Federal and state laws related to reporting abuse, operation of health facilities, professional practice, insurance coverage, and similar topics also impact primary health care services. Contractors are required to be aware of and comply with existing laws. Primary Health Care Services Program contractors must also follow the DSHS Standards for Public Health Clinic Services. 5 DocuSign Envelope ID:20AB07B4-A920-4608-B1A4-CCFFDBODF809 Program Authorization and Services Primary Health Care Services Program Background In the early 1980s, economic recession and cost containment measures on the part of employers and government agencies led to a decrease in the availability and accessibility of health care services for many Texans. A legislative task force identified the provision of primary health care to the medically indigent as a major priority. The task force recommended the following: • A range of primary health care services shall be made available to the medically indigent residing in Texas. • The Texas Health and Human Services Commission (HHSC) shall provide or contract to provide primary health care services to the medically indigent. • These services should complement existing services and/or should be provided where there is a scarcity of services. • Health education should be an integral component of all primary care services delivered to the medically indigent population. • Preventive services should be marketed and made accessible to reduce the use of more expensive emergency room services. Statute These recommendations became the basis of the indigent health care legislative package enacted by the 69th Texas Legislature in 1985. The Primary Health Care Services Act, H.B. 1844, was part of this legislation and is the statutory authority for the Primary Health Care Services Program (PHC) administered by HHSC. The Act delineates the specific target population, eligibility, reporting, and coordination requirements for PHC. Rules The state rules for PHC services in Texas can be found in the Texas Administrative Code (TAC), Title 25, Part 1, Chapter 39, Subchapter A. PHC program rules require that, at a minimum, a contractor must provide the following six priority primary health care services: 1. Diagnosis and treatment 2. Emergency medical services 3. Family planning services 4. Preventive health services 5. Health education, and 6. Laboratory, x-ray, nuclear medicine, or other appropriate diagnostic services. PHC provides primary health care services through contracted providers for individuals who are at or below 200% of the Federal Poverty Level (FPL) and are unable to access the same care through other funding sources or programs. 6 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Contractors must assure that services provided to clients are accessible in terms of cost, scheduling and distance, and are provided in a way that is sensitive to the individual's culture. Funding Sources PHC program services are funded by State General Revenue. HHSC PHC funds are allocated through a competitive application process, after which, selected applicants negotiate contracts with HHSC to provide services. Organizations of all types provide Primary Health Care program services, such as local health departments, medical schools, hospitals, private non-profit agencies, community-based clinics, federally qualified health centers (FQHCs), and rural health clinics. Providers must enroll with the Texas Medicaid and Healthcare Partnership (TMHP) in order to provide HHSC Primary Health Care program services. State and federal law prohibits the use of contracted funds awarded by HHSC to pay the direct or indirect costs (including overhead, rent, phones and utilities) of abortion procedures. 7 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Definitions The following words and terms, when used in this manual, have the following meanings: Barrier to Care A factor that hinders a person from receiving health care (e.g., proximity or distance, lack of transportation, documentation requirements, co-payment amount, etc.) Client An individual who has been screened, determined to be eligible for services, and has successfully completed the eligibility process. "Client" and "patient" may be used interchangeably throughout this manual. Contraception The means of pregnancy prevention, including permanent and temporary methods. Contractor The entity contracted by the Texas Health and Human Services Commission to provide services. The contractor is the responsible entity, even if there is a subcontractor involved who actually provides the services. Co-payment (co-pay) Monies collected directly from clients for services. The amount collected each month should be deducted from the monthly Purchase Voucher (Form 4116) and is considered program income. Dental Services Diagnostic, preventive, and therapeutic dental services that are provided to eligible individuals and are performed in a dental office or clinic. Diagnosis The recognition of disease status determined by evaluating the history of the client, the disease process, and the signs and symptoms present. Determining the diagnosis may require microscopic (e.g., culture), chemical (e.g., blood tests), and/or radiological examinations (x-rays). Diagnosis and Treatment This includes diagnosis and treatment of common acute and chronic disease that affect the general health of the client. Services include first contact with a client for 8 DocuSign Envelope ID:2DABO7B4-A920-4608-B 1 A4-CCFFDBODF809 an undiagnosed health concern as well as continuing care of varied medical conditions not limited by cause or organ system. Services must not be limited to only one service (i.e., family planning, breast and cervical cancer screening, or podiatry). Diagnostic Services Activities related to the diagnosis made by a physician or nurse practitioner, which may also be performed by nurses or other health professionals. Diagnostic Studies or Diagnostic Tests Tests ordered by the client's health care practitioner(s) to evaluate an individual's health status for diagnostic purposes. Eligibility Date Date the contractor determines an individual to be eligible for the program. The eligibility expiration date will be twelve (12) months after the eligibility date. Emergency Services Urgent care services provided for an unexpected health condition requiring immediate attention. Clinical emergency situations include conditions such as anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, respiratory difficulties, and in response to environmental emergencies (including natural and man-made disaster situations). Family Composition/Household A person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person. Family Planning Services Services that assist women and men in planning their families, whether it is to achieve, postpone, or prevent pregnancy. Family planning services should include the following: pregnancy test (if indicated), health history, physical examinations, basic infertility services, lab tests, STD services (including HIV/AIDS), other preconception health services (e.g. screening for obesity, smoking, and mental health), counseling/education, and contraceptive supplies. Federal Poverty Level (FPL) The set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Public assistance programs, such as Medicaid, define eligibility income limits as some percentage of FPL. 9 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Fiscal Year State fiscal year from September 1 - August 31 of each year. Health Education The process of educating or teaching individuals about lifestyles and daily activities that promote physical, mental, and social well-being. This process may be provided to an individual or to a group of individuals. Health and Human Services Commission (HHSC) State agency with administration and oversight responsibilities for designated Health and Human Services agencies. Health Screening The provision of tests (e.g., blood glucose, serum cholesterol, fecal occult blood) as a means of determining the need for intervention and perhaps more comprehensive evaluation. Laboratory (informally, lab) Facility that measures or examines materials derived from the human body for the purpose of providing information on diagnosis, monitoring prevention or treatment of disease. Laboratory, X-Ray, or other Appropriate Diagnostic Services Studies or tests ordered by the client's health care practitioner(s) (e.g., physicians, dentists, mid-level providers) to evaluate an individual's health status for diagnostic purposes. Managing Conservator A person designated by a court to have daily legal responsibility for a child. Medicaid Title XIX of the Social Security Act reimburses contractors for health care services delivered to low-income clients who meet eligibility guidelines. Minor In Texas, a minor is a person under 18 years of age who has never been married and never been declared an adult by a court (emancipated). See Texas Family Code Sections 101.003, 31.001-31.007, 32.003-004, 32.202. In this manual, "minor" and "child" may be used interchangeably. 10 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Patient An individual who is eligible to receive medical care, treatment, or services. "Client" and "patient" may be used interchangeably in this manual. Payer Source Programs, benefits, or insurances that pay for a service provided. Preventive Health Care Services Medical care that focuses on disease prevention and health maintenance, including early diagnosis of disease, discovery and identification of people at risk of developing specific medical issues, counseling, and other necessary intervention to avert a health problem. Included are screening tests, immunizations, risk assessments, health histories and baseline physicals for early detection of disease and restoration to a previous state of health, and prevention of further deterioration and/or disability. Program Income Monies collected directly by the contractor/subcontractor/provider for services provided under the contract award (i.e., third-party reimbursements, such as Title XIX, private insurance, and patient co-pay fees). Program income also includes client donations. Provider An individual clinician or group of clinicians who provide services. Re-certification The process of re-screening and determining eligibility for the next year. Referral The process of directing or redirecting (as a medical case or a patient) to an appropriate specialist or agency for definitive treatment, or direct to a source for help or information. Telehealth service A health service, other than a telemedicine medical service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology. Telemedicine medical service A health care service delivered to a patient at a different physical location than the physician or health professional using telecommunications or information 11 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 technology, by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state, and acting within the scope of the physician's or health professional's license. Texas Resident An individual who resides within the geographic boundaries of the state. Treatment Any specific procedure used for the cure or the improvement of a disease or pathological condition. Unduplicated Client Clients are counted only one time during the program's fiscal year, regardless of the number of visits, encounters, or services they receive (e.g., one client seen four times during the year is counted as one unduplicated client). 12 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Section I: Administrative Policy This section assists the contractor in conducting administrative activities such as assuring client access to services and managing client records. 13 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Section I, Chapter 1 : Administrative Policies Client Access The contractor must ensure that clients are provided services in a timely and non- discriminatory manner. The contractor must: • Have a policy in place that delineates the timely provision of services. • Have policies in place to identify and eliminate possible barriers to client care. • Comply with all applicable civil rights laws and regulations including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA) of 1990, the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973, and ensure services are accessible to persons with Limited English Proficiency (LEP) and speech or sensory impairments. • Have a policy in place that requires qualified staff to assess and prioritize client needs. • Provide referral resources for individuals that cannot be served or cannot receive a specific needed service. • Manage funds to ensure that established clients continue to receive services throughout the budget year, even after allocated funds are expended. • Ensure that family planning services are provided to clients in a timely manner, preferably within 30 days of the request for services. Clients who request contraception but cannot be immediately provided a clinical appointment must be offered a nonprescription method. • Ensure clinic/reception room wait times are reasonable so as not to represent a barrier to care. Important Information for Former Military Service Members Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Forces, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. For more information, please visit the Texas Veterans Portal at httos://veterans.portal.texas.gov. 14 DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 Section I, Chapter 2: Abuse and Neglect Reporting Texas Health and Human Services agencies may only provide funds to contractors/providers who show good faith efforts to comply with all child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code. To report abuse or neglect, call the Texas Abuse Hotline at 1-800-252-5400, or use the secure Texas Abuse Hotline Website. For cases that pose an imminent threat or danger to an individual, call 9-1-1, or any local or state law enforcement agency. Child Abuse Reporting, Compliance and Monitoring Contractors are required to develop policies and procedures that comply with the child abuse reporting guidelines and requirements set forth in Chapter 261. Contractors must develop an internal policy specific to: • How child abuse reporting requirements will be implemented throughout their agency; • How staff will be trained; and • How internal monitoring will be done to ensure timely reporting. During Quality Assurance (QA) monitoring, the following procedures will be utilized to evaluate compliance: • The contractor's process to ensure that staff is reporting child abuse as required by Chapter 261. To verify compliance, contract monitors will review that the contractor: o Has an internal policy which details how the contractor will determine, document, report, and track instances of abuse, sexual or non-sexual, for all individuals under the age of 17 in compliance with the Texas Family Code, Chapter 261; o Followed their internal policy; and o Has documented staff training on child abuse reporting requirements and procedures. • The contractor's internal policy must clearly describe the reporting process for child abuse. Additional information for abuse reporting: Texas Department of Family and Protective Services. 15 DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 Human Trafficking HHSC mandates that contractors comply with state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that contractors comply with all applicable federal laws, contractors must comply with the federal anti- trafficking laws, including the Trafficking Victims Protection Act of 2000 (22 USC 87101, et seq.). Contractors must have a written policy on human trafficking which includes the provision of annual staff training. References for human trafficking policy development: • Texas Human Trafficking Resource Center website • Human trafficking into and within the United States: A review of the literature on human trafficking in the US • Polaris Project website • Rescue and Restore Campaign Domestic and Intimate Partner Violence Intimate partner violence (IPV) describes physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy. Contractors must have a written policy related to assessment and prevention of domestic and intimate partner violence, including the provision of annual staff training. Additional information on intimate partner violence can be found on the CDC website. 16 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBDDF809 Section I, Chapter 3: Confidentiality All contracting agencies must be in compliance with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPPA) established standards for protection of client privacy. Contractors must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. All employees, volunteers, sub-contractors, and board members and/or advisory board members must sign a confidentiality statement during orientation. The client's preferred method of follow-up to clinic services (cell phone, email, work phone, and/or text) and preferred language must be documented in the client's record. Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting. Minors and Confidentiality Except as permitted by law, a provider is legally required to maintain the confidentiality of care provided to a minor. Confidential care does not apply when the law requires parental notification or consent, or when the law requires the provider to report health information such as in the cases of contagious disease or abuse. The definition of privacy is the ability of the individual to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider not to disclose protected information. While confidentiality is implicit in maintaining a patient's privacy, confidentiality between provider and patient is not an absolute right. The HIPAA privacy rule requires a covered entity to treat a "personal representative" the same as the individual with respect to uses and disclosures of the individual's protected health information. In most cases, parents are the personal representatives for their minor children, and they can exercise individual rights, such as access to medical records, on behalf of their minor children (Code of Federal Regulations - 45 CFRg164.502(g)). For more information, see: Adolescent Health - A Guide for Providers. Non-Discrimination and Limited English Proficiency (LEP) As outlined in the HHSC Uniform Terms and Conditions - Grant Version 2.16, HHSC contractors must comply with state and federal anti-discrimination laws, including but not limited to: 17 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 • Title VI of the Civil Rights Act of 1964 (42 U.S.C. g2000d et seq.), • Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794), • Americans with Disabilities Act of 1990 (42 U.S.C. X12101 et seq.), • Age Discrimination Act of 1975 (42 U.S.C. 6101-6107), • Title IX of the Education Amendments of 1972 (20 U.S.C. E§1681 et seq.), • Administrative rules for HHS agencies, as set forth in the Texas Administrative Code (TAC). More information about non-discrimination laws and regulations can be found on the HHSC Civil Rights Office page. Termination of Services A qualifying individual must never be denied services due to an inability to pay. Contractors have the right to terminate services to a client if the client is disruptive, unruly, threatening, or uncooperative to the extent that the client seriously impairs the contractor's ability to effectively and safely provide services or if the client's behavior jeopardizes his or her own safety, clinic staff, or others. An individual has the right to appeal the denial, modification, suspension, or termination of services. (See Appeals, in the PHC rules Title 25, Part 1, Chapter 39.10, Subchapter A). Any policy related to termination of services must be included in the contractor's policy manual. Resolution of Complaints Contractors must ensure that clients have the opportunity to express concerns about care received and to further ensure that those complaints are handled in a consistent manner. Contractors' policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received. If an aggrieved client requests a hearing, a contractor shall not terminate services to the client until a final decision is rendered by HHSC. Any client complaint must be documented in the client's record. Research (Human Subject Clearance) Contractors considering clinical or sociological research using Primary Health Care Services Program funded clients as subjects must obtain prior approval from their own internal Institutional Review Board (IRB) and HHSC. The contractor must have a policy in place that indicates that prior approval will be obtained from the HHSC PHC Program, as well as the IRB, prior to instituting any research activities. The contractor must also ensure that all staff is made aware of this policy through staff training. Documentation of training on this topic must be maintained. 18 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Section I, Chapter 4: Client Records Management HHSC contractors must have an organized and secure client record system. The contractor must ensure that the record is organized, readily accessible, and available to the client upon request with a signed release of information. The records must be kept confidential and secure, as follows: • Safeguarded against loss and used by unauthorized persons; • Secured by lock when not in use or inaccessible to unauthorized persons; and • Maintained in a secure environment in the facility, as well as during transfer between clinics and in between home and office visits. The written consent of the client is required for the release of personally identifiable information, except as it may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years of age or younger, the client's parent, managing conservator, or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. HIV information should be handled according to law. When information is requested, contractors should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistically, or in a form that does not identify individuals. Upon request, clients transferring to other providers must be provided with a copy or a summary of their record to expedite continuity of care. Electronic records are acceptable as medical records. Contractors, providers, sub-recipients, and subcontractors must maintain for the time specified by HHSC all records pertaining to client services, contracts, and payments. Contractors must follow contract provisions, maintain medical records for at least seven years after the close of the contract, and follow the retention standards of the appropriate licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law. 19 DocuSign Envelope ID:2DABO7B4-A920-4608-B 1 A4-CCFFDBODF809 Section I, Chapter 5: Personnel Policy and Procedures Contractors must develop and maintain personnel policies and procedures to ensure that clinical staff are hired, trained, and evaluated appropriately to their job position. Contracted staff must also be trained and evaluated according to their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include: • Job descriptions, including those for contracted personnel; • A written orientation plan for new staff to include skills evaluation and/or competencies appropriate for the position; and • Performance evaluation process for all staff. Contractors must show evidence that employees meet all required qualifications and are provided annual training. Job evaluations should include observation of staff/client interactions during clinical, counseling and educational services. Contractors shall establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict of interest statement during orientation. All medical care must be provided under the supervision, direction, and responsibility of a qualified medical director. All dental services must be provided under the supervision, direction, and responsibility of a qualified licensed dentist. The PHC Medical Director for the clinic must be a licensed Texas physician and the PHC Dental Director for the clinic must be a U.S. licensed dentist. Contractors must have a documented plan for organized staff development. There must be an assessment of: • Training needs • Quality assurance indicators • Changing regulations/requirements Staff development must include orientation and in-service training for all personnel and volunteers (non-profit entities must provide orientation for board members and government entities must provide orientation for their advisory committees). Employee orientation and continuing education must be documented in agency personnel files. 20 DocuSign Envelope ID:2DABO7B4-A920-4608-131 A4-CCFFDBODF809 Section I, Chapter 6: Facilities and Equipment HHSC contractors are required to maintain a safe environment at all times. Contractors must have written policies and procedures that address hazardous waste, fire safety, and medical equipment. Hazardous Materials Contractors must have written policies and procedures that address: • The handling, storage, and disposing of hazardous materials and waste according to applicable laws and regulations; • The handling, storage, and disposing of chemical and infectious waste including sharp objects; and • An orientation and education program for personnel who manage or have contact with hazardous materials and waste. Fire Safety Contractors must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients. Medical Equipment Contractors must have a written policy and maintain documentation of the maintenance, testing, and inspection of medical equipment including an Automated External Defibrillator (AED). Documentation must include: • Assessments of the clinical and physical risks of equipment through inspection, testing and maintenance; • Reports of any equipment management problems, failures and use errors; • An orientation and education program for personnel who use medical equipment; and • Manufacturer recommendations for care and use of medical equipment. Radiology Equipment and Standards All facilities providing radiology services, including dental x-rays, must: • Possess a current Certificate of Registration from the Texas Department of State Health Services, Radiation Control Program; • Have operating and safety procedures as required by Title 25 Texas Administrative Code, Chapter 289, Texas Regulations for Control of Radiation; • Post Notice to Employees, Texas Regulations for Control of Radiation. 21 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 For information on x-ray machine registration, see the Texas Department of State Health Services, Radiation Control Program. Smoking Ban Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must also comply with this policy. Disaster Response Plan Contractors must have written and oral plans that address how staff must respond to emergency situations (e.g., fires, flooding, power outage, bomb threats, etc.). The disaster plan must identify the procedures and processes that will be initiated during a disaster and the staff position(s) responsible for each activity. A disaster response plan must be in writing, formally communicated to staff, and kept in the workplace available to employees for review. For an employer with ten or fewer employees, the plan may be communicated orally to employees. For additional resources on facilities and equipment, see the Occupational Safety and Health Administration website. 22 DocuSign Envelope ID:2DABO7B4-A920-4608-B 1 A4-CCFFDBODF809 Section I, Chapter 7: Emergency Responsiveness Clinical Emergencies Contractors must be adequately prepared to handle clinical emergency situations, as follows: • There must be a written plan for the management of on-site medical emergencies, emergencies requiring ambulance services and hospital admission. • Each site must have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present during all hours of clinic operations. • There must be written protocols to address vaso-vagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, and respiratory difficulties. • Each site must maintain emergency resuscitative drugs, supplies, and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present. • Documentation must be maintained in personnel files that staff has been trained regarding these written plans or protocols. Emergency Preparedness There must be a written safety plan that includes maintenance of fire safety equipment, an emergency evacuation plan, end a disaster response plan. 23 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section I, Chapter 8: Quality Management Contractors must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor PHC services. Contractors must have a QM program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care. Contractors should integrate Quality Management (QM) concepts and methodologies into the structure of the organization and day-to-day operations. Contractors are expected to develop quality processes based on four core Quality Management principles that focus on: • The client • Systems and processes • Measurement, and • Teamwork The QM program must be developed and implemented in such a way that provides for ongoing evaluation of services. Contractors should have a comprehensive plan for the internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability. Contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subcontracting entities. The QM Committee, whose membership consists of key leadership of the organization, including the Executive Director/CEO and the Medical and Dental Director and other appropriate staff where applicable, annually reviews and approves the quality work plan for the organization. The QM Committee must meet at least quarterly to: • Receive reports of monitoring activities; • Make decisions based on the analysis of data collected; • Determine quality improvement actions to be implemented; and • Reassess outcomes and goal achievement. Minutes of the discussion and actions taken by the committee and a list of the attendees must be maintained. The comprehensive quality work plan at a minimum must: 24 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 • Include clinical and administrative standards by which services will be monitored; • Include process for credentialing and peer review of clinicians; • Identify individuals responsible for implementing monitoring, evaluating and reporting; • Establish timelines for quality monitoring activities; • Identify tools/forms to be utilized; and • Outline reporting to the Quality Management Committee. Although each organization's quality assurance program is unique, the following activities must be undertaken by all agencies providing client services: • On-going eligibility, billing, and clinical record reviews to assure compliance with program requirements and clinical standards of care; • Tracking and reporting of adverse outcomes; • Client satisfaction surveys; • Annual review of facilities to maintain a safe environment, including an emergency safety plan; • Annual review of prescriptive authority agreements (PAAs), policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current; and • Performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, and immunization status to ensure they are current. HHSC contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subcontracting entities including: • Annual license verification (primary source verification) • Clinical record review • Eligibility and billing review • On-site facility review • Annual client satisfaction evaluation process, and • Child abuse training and reporting - subcontractor staff Data from these activities must be presented to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented. 25 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Section II Eligibility and Fees This section provides policy requirements for eligibility, client services community activities, and clinical guidelines. 26 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section II, Chapter 1: Eligibility and Assessment of Co-pay/Fees Contractors must develop a policy to determine PHC eligibility. The contractor must ensure documentation provides a clear understanding of the eligibility screening process. Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of one of following eligibility tools: • Office of Primary and Specialty Health (OPSH) Application for Program Benefits, Form 3029 • A comparable paper or electronic eligibility tool, previously approved by the PHC Program may be used, as long as it contains the required HHSC information for eligibility determination and the applicant's signature. The following forms are optional, but may be used to aid in completing the PHC eligibility process: • OPSH Request for Information, Form 3056 • OPSH Employment Verification, Form 3049 • OPSH Statement of Self-Employment Income, Form 3051 Client Eligibility Screening Process For an individual to receive PHC program services, three (3) criteria must be met: • Gross family income at or below 200% of the Federal Poverty Level (FPL) • Texas resident; and • Not eligible for other programs/benefits providing the same services. • Residency is self-declared. Contractors may require residency verification, but such verification should not jeopardize delivery of services. Contractors must require income verification for countable income. In cases when submitting the income verification jeopardizes the client's right to confidentiality or imposes a barrier to receipt of services, the contractor must waive this requirement. Reasons for waiving verification of income must be noted in the client record. Procedures and Terminology When Determining PHC Eligibility Household The household consists of a person living alone, or a group of two or more persons related by birth, marriage (including common law), or adoption, who reside together and are legally responsible for the support of the other person. If an unmarried applicant lives with a partner, ONLY count the partner's income and children as part of the household group IF the applicant and his/her partner have 27 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 mutual children together. Unborn children should also be included. Treat applicants who are 18 years of age as adults. No children aged 18 and older or other adults living in the home should be counted as part of the household group. Legal responsibility for support exists between: • Persons who are legally married (including common-law marriage); • A legal parent and a minor child (including unborn children); or, • A managing conservator and a minor child. A managing conservator is a person designated by a court to have daily legal responsibility for a child. Income All income received must be included. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), as defined in OPSH Definition of Income. Contractors must have a written PHC income verification policy. Income Deductions Dependent care expenses shall be deducted from total income in determining eligibility. Allowable deductions are actual expenses up to $200.00 per child per month for children under age 2; $175.00 per child per month for each dependent age 2; and $175.00 per adult with disabilities per month. Legally obligated child support payments made by a member of the household group shall also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount by using one of the conversion factors listed below. Monthly Income Conversions If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the period of time the income is expected to cover. Income received weekly, every two weeks or twice a month must be converted as follows: • Weekly income is multiplied by 4.33; • Income received every two weeks is multiplied by 2.17; • Income received twice monthly is multiplied by 2. Presumptive Eligibility PHC emphasizes the importance of prevention and early intervention. The goal of PHC is for clients to be part of the health care system and not rely on episodic, acute care. An applicant's medical needs shall be met quickly and appropriately, using available resources in the community. Presumptive eligibility is the short-term availability and access to health care services (up to 90 days) when the client screens potentially eligible for services but 28 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 lacks verification to achieve full eligibility. For clients who are determined to be fully eligible during the presumptive period, the eligibility expiration date will include the days of presumptive eligibility (expiration date is 365 days beginning the first date of eligibility determination). When full eligibility is granted during or at the end of the 90 days, the eligibility period end date is 12 months from the presumptive eligibility. On a case-by-case basis, the contractor may waive the requirement to submit the eligibility documentation and approve full eligibility, if the contractor determines submitting the documentation will create a barrier to care and no other documentation is available. Adjunctive Eligibility An applicant is considered adjunctively (automatically) eligible for PHC program services at an initial or renewal eligibility screening, if the individual is currently enrolled in Children's Health Insurance Program (CHIP) Perinatal, Medicaid for Pregnant Women, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP) and/or Healthy Texas Women Program (HTW). The applicant must be able to provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include: PROGRAM DOCUMENTATION CHIP Perinatal CHIP Perinatal benefits card. Medicaid for Pregnant Women Your Texas Benefits card (Medicaid card)* WIC verification of certification letter, WIC printed WIC-Approved shopping list, or recent WIC purchase receipt with remaining balance. SNAP SNAP eligibility letter. Your Texas Benefits card with `Healthy HTW Texas Women' printed in the upper right corner. * NOTE: Presentation of the Your Texas Benefits card does not completely verify current eligibility in the Healthy Texas Women Program or the Medicaid for Pregnant Women program. To verify eligibility, contractors must call TMHP at 1-800-925-9126 or access TexMedConnect on the TMHP website at www.tmhp.com. For a client's current eligibility status, you must enter 2 of the following 4 data elements for the Client: • Patient Control Number • Date of Birth • Social Security Number • Last Name 29 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 If the applicant's current enrollment status cannot be verified during the eligibility screening process, adjunctive eligibility would not be granted. The contractor would then determine eligibility according to usual protocols. Potential Eligibility and Referral to Other Possible Qualifying Programs In general, individuals are not eligible for the PHC Program if they are enrolled in another third-party payer such as private health insurance, Medicaid or Medicare, TRICARE, Worker's Compensation, Veteran's Administration Benefits, or other federal, state, or local public health care coverage that provides the same services. An individual may still be potentially eligible for the PHC program even if they are also possibly eligible for another program that covers the same services that are provided by the PHC program. The contractor should proceed with the eligibility process for the PHC program but inform the individual of their possible eligibility for the other program and suggest that they also apply for services for that program. The contractor must document in the individual's case record that they were informed and were referred to the other program. Supplemental Benefits In some cases, individuals receiving benefits from other sources such as Medicaid or Medicare may be eligible for partial PHC coverage. This "supplemental' or "wraparound" coverage is limited to services provided by PHC but not covered by other sources. Whenever federal, state, private, or other benefits are available for payment of clients receiving PHC covered-services, no PHC funds shall be used to pay for such care. An example of supplemental benefits would be providing health education services to a Medicaid-eligible individual, since Medicaid does not provide health education services. The contractor must communicate to the client that supplemental services are of limited scope. Insurance Individuals with insurance may be eligible for services provided by PHC when the applicant's confidentiality is a concern or if the applicant's insurance deductible is 5% or greater than their income. Most insurance deductibles are given as an annual amount. PHC household incomes are figured as a monthly amount. To compare an annual deductible with a monthly income, multiply the monthly income by 12 and then determine 5% of that amount. See example below for a monthly household income of $1,000: 1. Determine the total household's monthly income; 2. Determine the total household's annual income by multiplying the monthly income by 12 (months); 3. Determine 5% of the total annual income by multiplying it by 0.05 (5%). Total Monthly Household Total Annual Household 5% of Total Annual Income Income Household Income 30 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 1. Determine the total household's monthly income; 2. Determine the total household's annual income by multiplying the monthly income by 12 (months); 3. Determine 5% of the total annual income by multiplying it by 0.05 (5%). $1,000 x 12 (months) = $12,000 X 0.05 = $600 In this case, if the applicant's annual insurance deductible is any amount over $600, then they are eligible under this criterion for PHC. Another way to make the comparison is to divide the annual insurance deductible into a monthly amount. See example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000: 1. Determine the household's monthly insurance deductible by dividing the annual deductible by 12 (months); 2. Determine 5% of the total monthly household income by multiplying it by 0.05 (5%). Household Household Total Monthly 5% of Total Annual Insurance Monthly Household Monthly Deductible Insurance Income Household Deductible Income $6,000 _ 12 = $500 $1,000 X 0.05 = $50 In this case, if the applicant's monthly insurance deductible is any amount over $50, then they are eligible under this criterion for PHC. The completed eligibility form must be maintained in the client medical record, indicating the client's poverty level and the co-pay amount the person will be charged. Payer of Last Resort As previously mentioned, individuals seeking PHC-covered services may be dually- eligible for other HHSC funded programs within an agency that provides the same services, such as HHSC Family Planning, Breast and Cervical Cancer Screening Services, or Title V Prenatal, Child or Dental program(s). In such cases, it is up to the contractor to determine the best use of funds within their agency. PHC is the payer of last resort for a client who is enrolled in any other non-HHSC program that provides payment for the cost of the same primary care services at the time he or she presents for those services. Calculation of Applicant's Federal Poverty Level (FPL) Percentage If a contractor collects a co-payment, the contractor must determine the applicant's exact household FPL percentage. The contractor must not charge a co-payment for PHC clients whose household income is at or below 100% of the FPL. 31 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBDDF809 The maximum monthly income amounts by household size are based on the Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning of each calendar year. The steps to determine the applicant's actual household FPL percentage are: 1. Determine the applicant's total monthly income amount; 2. Determine the applicant's household size; 3. Divide the applicant's total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size; 4. Multiply by 100. See example below for a family of 3, with a monthly income amount of $2093.00: Maximum Total Monthly Monthly Actual Income Income Household I (Household FPL 0/0 Size of 3) $2,093 - $1,778 = 1.18 x 100 = 118% FPL Client Fees/Co-Payments PHC contractors may (but are not required to) assess a co-payment (co-pay) for services from PHC clients. The Co-pay Guidelines are as follows: • No PHC client shall be denied services based on an inability to pay. • Clients with a household FPL at or below 100%, should not be charged a co- pay. • Contractors may charge a co-pay amount ranging from $10 up to a maximum of $30 per encounter for clients above 100% of the FPL. • Individuals who are assessed a co-pay should be presented with the bill at the time of service. • Clients who declare an inability to pay a co-pay shall not be denied services, have an account with an outstanding balance turned over to a collection agency, or reported delinquent to a credit reporting agency. • Client co-pays must be reported as program income on the monthly Purchase Voucher (Form 4116) and the quarterly Financial Status Report (FSR or Form 269a). • The OPSH Monthly Federal Poverty Guidelines is for contractor use to determine a PHC household's FPL and is updated annually when the revised Federal Poverty Income Guidelines becomes available. • Contractors must have policies and procedures regarding fee collection, which must be approved by the contractor's Board of Directors. • Client co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC PHC services. 32 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Other Fees Clients shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc. Contractors are allowed to bill clients for services outside the scope of PHC allowable services, if the service is provided at the client's request, and the client is made aware of her responsibility for paying for the charges. Continuation of Services Contractors who have expanded their awarded PHC funds are required to continue to serve their existing PHC clients through the end of the client's eligibility. If other funding sources are used to provide PHC services, the funds must be reported as non-HHSC funds on the monthly Purchase Voucher (Form 4116) and the quarterly Financial Status Report (FSR or Form 269a). Date Eligibility Begins An individual/household is eligible for services beginning with the date the contractor determines the individual/household is eligible for the program and signs the completed application. This includes the date an individual/household is determined eligible for Presumptive Eligibility. Contractors have the option to notify PHC applicants of their eligibility status using the optional letters provided by the PHC program: • OPSH Health Presumptive Eligibility Notice, Form 3045 • OPSH Notice of Ineligibility, Form 3047 • OPSH Notice of Eligibility, Form 3048 Annual Re-Certification Annual eligibility determination and recertification is required for all clients who receive PHC services. Client eligibility must be re-determined every 12 months, using the most recent version of the HHSC Office of Primary and Specialty Health Application for Program Benefits, Form 3029. Contractors must have a system in place to track client eligibility and renewal status on an annual basis. 33 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section III Clinical Guidelines This section describes the requirements and recommendations for contractors pertaining to the delivery of direct clinical services to clients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population. 34 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section III, Chapter 1: General Consent Contractors must obtain the client's written, informed, voluntary and general consent prior to performing any clinical services. The general consent form explains the types of services provided and how client information may be shared with other entities for reimbursement or reporting purposes. If there is a period of three years or more during which a client does not receive services, a new general consent must be signed prior to reinitiating delivery of services. Consent information must be effectively communicated to every client in a manner that is understandable. This communication must allow the client to participate, make sound decisions regarding their own medical care, and address any disabilities that impair communication in compliance with Limited English Proficiency regulations. Only the client may consent, except when the client is legally unable to consent (i.e., a minor or an individual with development disability), to which a parent, legal guardian or caregiver must consent on his or her behalf. Consent must never be obtained in a manner that could be perceived as coercive. HHSC contractors should consult a qualified attorney to determine the appropriateness of the consent forms used by their health care agency. Consent for Dental Procedures Written, informed consent for dental procedures must be obtained in compliance with 22 TAC X108.7 regarding minimum standards of care for dentists. Consent for Sterilization Procedures: There are two consent forms required for sterilization procedures: • The Sterilization Consent Form (English / Spanish / Instructions), and • The Texas Medical Disclosure Panel Consent Form Texas Medical Disclosure Panel Consent The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to: 1) Determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients; and 2) Establish the general form and substance of such disclosure. TMDP has developed a List A (informed consent requiring full and specific disclosure) for certain procedures, which can be found in the 25 TAC X601.2. 35 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Contractors that directly perform tubal sterilization and/or vasectomy (both List A procedures), must also complete the TMDP Disclosure and Consent Form. For all other procedures not included on List A, the physician must disclose, through a procedure specific consent, all risks that a reasonable client would need to know. This includes all risks that are inherent to the procedure (one which exists in and is inseparable from the procedure itself) and that are material (could influence a reasonable person in making a decision whether or not to consent to the procedure). Consent for Services Provided to Minors Generally, a parent must consent to treatment for minors. A minor is defined as a person under 18 years of age who has never been married and has never been declared an adult by a court (emancipated). However, there are certain circumstances under which a minor may consent for their own treatment. Requirements for parental consent for the provision of family planning services to minors vary according to the funding source subsidizing the services. The department and providers may provide family planning services, including prescription drugs, without the consent of the minor's parent, managing conservator, or guardian only as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations. Resources and References: • Adolescent Health - A Guide for Providers. • Chapter 151 of the Texas Family Code: Rights and Duties in Parent-Child Relationship • Chapter 32 of the Texas Family Code: Consent to Treatment of Child by Non- Parent or Child Consent for HIV Tests For HIV testing, contractors must comply with Texas Health and Safety Code: • §81.105, regarding Informed Consent; and • §81.106, regarding General Consent 36 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Section III, Chapter 2: Clinical Policy Scope of Services: Six Priority Primary Health Care Services 1. Diagnosis and Treatment This includes diagnosis and treatment of common acute and chronic diseases that affect the general health of the client. Services include first contact with a client for an undiagnosed health concern as well as continuing care of varied medical conditions not limited by cause or organ system. Services must not be limited to only one service (e.g., family planning, breast and cervical cancer screening, or podiatry). a. Physician services Services must be medically necessary and provided by a physician in the doctor's office, clinic, or facility other than a hospital setting. b. Physician assistant (PA) services These services must be medically necessary and provided by a PA under the direction of a physician and may be billed by and paid to the supervising physician. c. Advanced practice nurse (APN) services An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically, a nurse practitioner, a clinical nurse specialist, a certified nurse midwife (CNM), and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nurse Examiners. APN services must be medically necessary, provided within the scope of practice of an APN, and covered in the Texas Medicaid Program under the direction of a physician. 2. Emergency medical services Services must be for urgent care for an unexpected health condition requiring immediate attention as determined by the appropriate medical staff. These must also be services that can be treated in a primary care clinic or setting. 3. Family planning services These are preventive health and medical services that assist an individual in controlling fertility and achieving optimal reproductive and general health. Services include: • Health check-up and physical exam • Birth control methods (pills, IUD, condoms, injection, ring, etc.) • Natural family planning • Lab tests for: o Sexually Transmitted Infections (STI) o Pregnancy testing • Counseling regarding: o Abstinence o Pre-conception counseling (planning for a healthy pregnancy) o Nutrition o Infertility 37 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 4. Preventive health services Services that may be included are: • Immunizations o These services are provided in appropriate setting for diseases that are preventable by vaccines. • Cancer screening services o Services must be medically necessary and by clinical recommendation. Services include: o Clinical breast examinations, o Mammograms, o Pelvic examinations, and o Cervical cancer screening. • Screenings for chronic conditions o These services may include screenings for hypertension, diabetes and other chronic conditions as indicated. • Health screening • Screening to determine the need for intervention and possibly a more comprehensive evaluation. Health screenings may include taking a personal and family health history and performing a physical examination, laboratory tests or radiological examination, and may be followed by counseling, education, referral or further testing. Some examples of these services include blood pressure, blood sugar, and cholesterol screening. 5. Health education Planned learning experiences based on sound theories that provide individuals, groups, and communities the opportunity to increase knowledge and skills needed to make healthy decisions. 6. Diagnostic laboratory and radiological services Services must be medically necessary. These are technical laboratory and radiological services ordered and provided by, or under the direction of a physician in an office or a facility other than a hospital inpatient setting. Providers are strongly encouraged to visit the U.S. Preventive Services Task Force web site for additional guidance on preventive services. Telehealth and Telemedicine Providers may deliver services via telehealth and telemedicine medical services, if appropriate. Providers who offer telehealth and telemedicine medical services must have written policies and procedures for doing so that include the following: • Clinical oversight by the medical director or designated physician responsible for medical leadership; • Contraindication considerations for telemedicine use; • Qualified staff members to ensure the safety of the individual being served by telemedicine at the remote site; 38 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 • Safeguards to ensure confidentiality and privacy in accordance with state and federal laws; • Services are provided by credentialed, licensed clinicians providing clinical care within the scope of their licenses; • Demonstrated competency by all staff members who are involved in the operation of the system and provision of the services prior to initiating the protocol; • Priority in scheduling the system for clinical care of individuals; • Quality oversight and monitoring of satisfaction of the individuals served; and • Management of information and documentation for telemedicine services that ensures timely access to accurate information between the two sites. Client Health Records and Documentation of Encounters Providers must ensure that a patient health record is established for every individual who receives clinical services. All patient health records must be: • Complete, legible and accurate documentation of all client encounters, including those by phone, email or text message; • Written in ink without erasures or deletions; or documented in the electronic medical record (EMR) or electronic health record (EHR); • Signed by the provider making the entry, including the name of the provider, the provider's title, and the date for each entry; o Electronic signatures are allowable to document the encounter and/or provider review of care. o Stamped signatures are not allowable. • Readily accessible to assure continuity of care and availability to clients; and • Systematically organized to allow easy documentation and prompt retrieval of information. All client health records must include: • Client identification and personal data, including financial eligibility; • The client's preferred language and method of communication; • Client contact information, including the best way and alternate ways to reach the client to ensure continuity of care, confidentiality, and compliance with HIPAA regulations; • A complete medication list, including prescription, nonprescription medications, and dietary supplements, updated at each encounter; • A complete listing of all allergies and adverse reactions to medications, food, and environmental substances (e.g., latex). If the patient has no known allergies, this should be listed. • This information should be prominently displayed in the patient's record and updated at each encounter. 39 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 • A plan of care, updated as appropriate, that is consistent with diagnoses and assessments, which in turn are consistent with clinical findings; • Documentation of recommended follow-up care, scheduled return visit dates, and follow-up for missed appointments; • Documentation of informed consent or refusal of services; • Documentation of client education and counseling with attention to risks identified through the health risk assessment; and • At every visit, the record must be updated as appropriate, documenting the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and treatment plan. Initial Medical History and Risk Assessment In addition to the elements required for the Client Health Record listed above, a comprehensive medical history must be obtained during the initial or early subsequent clinical visit (appropriately adapted to the age and gender of the client): • Reason for the visit and current health status; • History of present illness, if indicated; • Past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood and blood products, and mental health history; • Age appropriate immunizations o Immunization status/assessment [see Centers for Disease Control and Prevention (CDC) immunization schedules by age]; o Rubella status - based on a history of rubella vaccination or documented rubella serology. Non-pregnant female clients of childbearing age with unknown or inadequate rubella immunity must be provided vaccination on-site or referred appropriately; o PHC providers can voluntarily participate in the DSHS Adult Safety Net (ASN) Program or the Texas Vaccines for Children (TVFC). Both programs provide vaccines at no cost. • Review of systems with pertinent positives and negatives documented in the chart; • Current and past tobacco, alcohol and substance use/abuse; • Occupational and environmental hazard exposure; • Environmental safety (e.g., seat belt use, car seat use, bicycle helmets, etc.), nutritional and physical activity assessment, and living arrangements; • Assessment for sexual and intimate partner violence (IPV) (Mandated by Texas Family Code, Chapter 261). For any positive result, the client should be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91; • Pertinent family history; • Pertinent partner history, including injectable drug use, number of partners, STIs and HIV history and risk factors, gender of sexual partners; • Cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of most recent testing; and • A reproductive health history as detailed below. 40 DocuSign Envelope ID:2DAB0784-A920-4608-B1A4-CCFFDBODF809 Reproductive health history in female clients of reproductive age must include: • Menstrual history, including last normal menstrual period; • Pertinent sexual behavior history, including family planning practices (i.e., contraceptive use - past and current), number of partners, gender of sexual partners, last sexual encounter, sexual abuse; • Obstetrical history; • Gynecological and urological conditions; and • STI/STDs, and HIV history, risks, and exposure. Reproductive health history in male clients of reproductive age must include: • Pertinent sexual behavior history, including family planning practices (i.e., contraceptive use - past and current), number of partners, gender of sexual partners, last sexual encounter, and sexual abuse; • Genital and urologic conditions as indicated; • STI/STDs; and • HIV history, risks, and exposure. Physical Assessment A periodic preventive health care visit offers an excellent opportunity for clinicians to address issues of wellness and health risk reduction as well as current findings and client concerns. The periodic preventive health care visit must include an update of the person's health record as described in the Client Health Record section above. It must also include appropriate screening, assessment, health education and counseling, and immunizations based on the client's age, risk factors, preferences, and concerns. All clients must be provided an appropriate physical assessment as indicated by health history and health risk assessment. A physical examination is not essential prior to the provision of most contraceptive methods and should not be a barrier to the client receiving a method of contraception. The initial physical exam may be deferred if the client history and presentation do not reveal potential problems requiring immediate evaluation. The comprehensive physical exam should be performed within six (6) months of the initial visit unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the client record. Program protocols should be developed accordingly and must be consistent with national evidence-based guidelines. The new-client baseline physical examination must include the following components: 41 DocuSign Envelope ID:2DA807B4-A920-4608-B1A4-CCFFDBODF809 Clients age 21 years and older • Height measurement • Body Mass Index (BMI), waist measurement and/or other measurement to assess for underweight, overweight, and obesity • Blood pressure evaluation • Cardiovascular assessment • Other systems as indicated by history and health risk assessment (HRA) (e.g., evaluation of thyroid, lungs, abdomen) Periodic Primary Health Visit Physical Examination • Clients age 21 years and older • Height measurement annually until 5 years post menarche for females or annually until 20 years of age for males • Weight measurement annually (to assess for underweight, overweight, and obesity) • Blood pressure evaluation • Other systems as indicated by history (e.g., evaluation of thyroid, heart, lungs, abdomen) Clients who are birth through 20 years must have the following age- appropriate baseline and periodic health assessment components*: • Health history • Health risk assessment • Preventive health education to include anticipatory guidance, provided to parent(s) or child as appropriate • Physical exam • Immunizations *See Texas Health Steps Provider Information Periodicity Schedules Episodic or Acute Care Visit • History of present illness • Physical assessment focused on presenting problem • Laboratory tests based on presenting problem • Interventions appropriate to current findings Resources • United States Preventive Services Task Force (USPSTF) • American Academy of Family Physicians (AAFP) • Centers for Disease Control and Prevention (CDC) • American Heart Association (AHA) • American Congress of Obstetricians and Gynecologists (ACOG) • American Cancer Society (ACS) 42 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Healthy Lifestyle Intervention All clients should receive a health risk survey at least annually to determine areas where lifestyle modifications might reduce the risk of future disease and improve health outcomes and quality of life. Counseling on Healthy Lifestyle Choices All clients should be advised not to smoke or use tobacco products and to avoid exposure to second-hand smoke as much as possible. Those who use tobacco products should be advised to quit and assessed for their readiness to do so at each encounter. Clients should be counseled on healthy eating patterns and offered access to relevant information. Clients should be advised to engage in physical activity or resistance training tailored to their individual health condition and risks. Diet and Nutrition There is strong evidence that nutrition plays an important role in our risk of disease. No single diet has been shown to be the best, and providers should counsel clients on a variety of healthy eating patterns tailored to their particular health condition and cultural background. Laboratory Tests All clients presenting for an initial, annual, routine follow-up or problem-related visit must be provided appropriate laboratory and diagnostic tests as indicated by history, health risk assessment (HRA), physical examination and/or clinical assessment. The following tests or procedures must be provided: • Colorectal cancer screening in individuals 50 years of age and older; • Cervical cancer screening for females age 21 years and older; • Human Papillomavirus (HPV) screening for female patients who are 21 years or older after an initial ASC-US Pap result*; • HIV screening**; • STI screening, per CDC guidelines; • Pregnancy test must be provided on-site; • Rubella serology, if status not previously established by client history and documented in chart, either on-site or by referral; • Other labs (such as blood glucose, lipid panel, thyroid stimulating hormone, etc.) as indicated by HRA, history and physical, either on-site or by referral. NOTE: Initial tests may be deferred until the initial physical exam is provided. 43 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Agencies must have written plans to address laboratory and other diagnostic tests orders, results and follow-up to include: • Tracking and documentation of tests ordered and performed for each client; • Tracking test results and documentation in clients' records; • Mechanism to notify clients of results in a manner that ensures confidentiality, privacy, and prompt, appropriate follow-up; and • Provider must comply with state and local STI reporting requirements. * HPV screening is only reimbursable for female clients who are 21 years or older after an initial abnormal squamous cells-undetermined significance (ASC-US) pap result. [See current information about HPV and HPV testing. For the management of abnormal Pap tests, see the American Society for Colposcopy and Cervical Pathology (ASCCP) Management Guidelines.] **HIV screening must be provided on-site. Providers should follow CDC recommendations that all clients age 13-64 years be screened at least once for HIV infection and that all persons likely to be at high risk for HIV be rescreened at least annually. CDC further recommends that screening be provided after the patient is notified that testing will be performed as part of general medical consent unless the patient declines (opt-out screening). The provision of negative test results by telephone must follow procedures that address patient confidentiality, identification of the client, and prevention counseling. Providers must always provide positive HIV test results to patients in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff knowledgeable about HIV prevention and HIV testing. Clients whose risk screenings assessment reveals high risk behaviors should be provided directly or referred for more extensive risk reduction counseling by a DSHS HIV/STD program trained risk reduction specialist. To find a DSHS HIV/STD program provider, visit the DSHS HIV/STD website. Resources • American Congress of Obstetricians and Gynecologists (ACOG) • Cervical Cancer Screening Guidelines for Average-Risk Women - Centers for Disease Control and Prevention (CDC) • American Cancer Society Guidelines for the Early Detection of Cancer • Morbidity and Mortality Weekly Report (MMWR) Sexually Transmitted Diseases Treatment Guidelines, 2015 and Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020 Expedited Partner Therapy Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of clients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the client to take to his/her partner without the health care provider first examining the partner. 44 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 The Texas Administrative Code, Title 22, §190.8(1)(L)(ii) allows the use of EPT for STI treatment. HHSC endorses the CDC recommendations for EPT. Clinic sites implementing EPT should develop necessary policies, procedures and Standing Delegation Orders (SDOs) to reflect the CDC guidelines. For more information on implementing EPT see the DSHS HIV/STD website. Radiology Procedures PHC clients must be provided appropriate radiologic tests, to include the technical procedure and the interpretation of the x-ray, as indicated by history and clinical assessment related to the current reason for visit. If a provider is unable to provide radiological services on-site, the provider must have a Memorandum of Understanding (MOU) with another provider and make the services available through referral. Family Planning Services Contraceptive Method Counseling Clients who are provided contraceptive method-specific information must receive individualized dialogue that covers: • Results of physical exam and assessments; • Correct use of the contraceptive method(s) selected for personal use by the client as well as possible side effects and complications; • Back up methods, including information about emergency contraception and discontinuation issues; • Scheduled revisits; • Access for urgent and emergency care, including 24-hour emergency telephone number; and • Appropriate referral for additional services as needed. Providers are encouraged to present the most effective methods of contraception first before presenting information on less effective methods. This information should state that long-acting reversible contraception (LARC) methods are safe and effective for most women, including those who have never given birth. A visual depiction of contraceptive methods arranged in order of typical effectiveness can be found on the CDC website. LARCs, i.e., intrauterine devices (IUDs) and implants, have definite benefits related to client contraceptive efficacy, client convenience, and long-term costs. Providers should discuss and offer these methods for consideration to all women, as medically appropriate. As with all methods, the client's preference after receiving unbiased, factual, nondirective education should be respected. A specific contraceptive method that requires additional clinical expertise outside the training of the PHC contracted clinicians (e.g., sterilization) may be provided by referral. 45 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 If a provider offers a method or service by referral, the method or service must be provided to clients at the referral site at no fee or at the same discounted client fee that would be charged if the method or service were provided on-site. The referring site must have a written agreement with the referral site to provide the method or service to clients under this condition. Sterilization procedures, when performed or arranged for by the provider, must be in compliance with consent requirements for sterilization of persons in federally assisted family planning projects. The federally mandated consent form is necessary for both abdominal and trans-cervical sterilization procedures in women and vasectomy in men (see section on consent). NOTE: Abortion is not considered a method of family planning and no state funds appropriated to the department shall be used to pay the direct or indirect costs (including overhead, rent, phones and utilities) of abortion procedures provided by contractors. Personnel at contractors' clinics must be informed that they may be subject to prosecution under federal law if they coerce or endeavor to coerce any person to undergo an abortion or sterilization procedure (Section 205 of Public Law 94-63). Counseling Adolescents Adolescents age 17 and younger must be provided individualized family planning counseling and medical services that meet their specific needs. Appointments should be available to them for counseling and medical services as soon as possible. Contractors must address these issues in counseling adolescents: • All methods of contraception, including abstinence; • Discussion about contraceptive options and safe sex practices that reduce risk of STI/HIV and pregnancy; • Identifying and resisting sexual coercion; and • Discussion about partner, dating, and/or family violence, as well as available resources and/or assistance. Perinatal Clinical Guidelines Prenatal and postpartum services should be provided based on American Congress of Obstetricians and Gynecologists (ACOG) guidelines. State-Mandated Education Information for Parents of Newborns Requirement Chapter 161, Health and Safety Code, Subchapter T requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care to pregnant women during gestation or at delivery to provide the woman and the father of the infant or other adult caregiver for the infant with a resource pamphlet that includes information on postpartum depression, shaken baby syndrome, 46 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 immunizations, newborn screening, pertussis and sudden infant death syndrome. In addition, it must be documented in the client's chart that they received this information and the documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery. Information for Parents of Newborns: • English (Revised Jan. 2016) • Spanish (Revised Feb 2016) Information for Parents of Children Chapter 161, Health and Safety Code, Subchapter T also requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid to provide the woman and the father of the infant or other adult caregiver for the infant with a resource guide that includes information relating to the development, health, and safety of a child from birth until age five. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate child care. • A Parent's Guide to Raising Healthy, Happy Children - available through Texans Care for Children. Dental Clinical Policy Dental services should be provided based on American Dental Association (ADA) guidelines. Referral and Follow-Up Contractors should assist clients to meet identified primary health care needs, either directly or by referral. When services required as part of the HHSC PHC contract are to be provided by referral, the contractor must establish a written agreement with a referral resource for the provision of services and reimbursement of costs and assure that the client is charged no more than the appropriately assessed copay fee. Contractors must have written policies and procedures for follow-up on referrals that are made as a result of abnormal physical examination or laboratory test findings. These policies must be sensitive to clients' concerns for confidentiality and privacy and must be in compliance with state or federal requirements for transfer of health information. Before a contractor can consider a client as "lost to follow-up," the contractor must have at least three separate, documented attempts to contact the client. The provider must comply with state and local STI reporting requirements. 47 DocuSign Envelope ID:2DAB0784-A920-4608-B1A4-CCFFDBODF809 For services determined to be necessary, but which are not provided by the contractor, clients must be referred to other resources for care. For referral purposes, Contractors are expected to have established communications with Federally Qualified Health Centers (FQHCs) or HHSC funded organizations that provide breast cancer and cervical cancer services , if there are any such providers within their service area. Whenever possible, clients should be given a choice of referral resources from which to select. When a client is referred to another resource because of an abnormal finding or for emergency clinical care, the contractor must: • Plan for the provision of pertinent client information to the referral resource (obtaining required client consent with appropriate safeguards to ensure confidentiality - i.e., adhering to HIPAA regulations); • Advise the client about her/his responsibility in complying with the referral; • Follow up to determine if the referral was completed; and • Document the outcome of the referral. Health services available through HHSC Office of Primary and Specialty Health (OPSH) can be found by searching the OPSH Service Locator. Clients who have abnormal clinical breast exam (CBE) or cervical cytology findings may be scheduled to return for repeat exams if this is considered to be an appropriate follow up by the clinician. For clients whose cervical cytology test or CBE result in an abnormal finding that requires referral for services beyond those available through primary health care, contractors are encouraged, whenever possible, to refer to a HHSC Breast and Cervical Cancer Services (BCCS) contractor. In order to promote the most effective use of limited resources, PHC contractors' clinicians should be familiar with nationally recognized guidelines and algorithms describing recommended practices regarding abnormal cervical cytology and CBE results. 48 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section III, Chapter 3: Prescriptive Authority Agreements, Clinical Protocols, Standing Delegation Orders, and Client Education Contractors that provide clinical services must develop and maintain written clinical prescriptive authority agreements (PAAs), protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical, dental and nursing practice and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, contractors need to incorporate the revised policy into their written procedures. Prescriptive Authority Agreements Contractors who delegate the act of prescribing or ordering a drug or device to advanced practice registered nurse(s) and/or physician assistant(s) must have in place a prescriptive authority agreement (PAA), as required by Texas Administrative Code Title 22, Part 9, Chapter 193. The PAA must meet all the requirements delineated in the Texas Medical Practice Act, Chapter 157 including, but not limited to, the following minimum criteria: • Be in writing, signed and dated by the parties to the agreement; • Include the name, address, and professional license numbers of all parties to the agreement; • State the nature of the practice, practice locations, or practice settings; • Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed; • Provide a general plan for addressing consultation and referral; • Provide a plan for addressing patient emergencies; • Describe the general process for communication and sharing of information between the physician and the advanced practice registered nurse or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of patients. If alternate physician supervision is to be utilized, designate one or more alternate physicians who may: • Provide appropriate supervision on a temporary basis in accordance with the requirements established by the prescriptive authority agreement and the requirements of this subchapter; • Participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and • Describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following: 49 DocuSign Envelope ID:2DAB07B4-A920-4608-B 1 A4-CCFFDBODF809 o Chart review, with the number of charts to be reviewed determined by the physician and advanced practice registered nurse or physician assistant; and o Periodic face-to-face meetings between the advanced practice registered nurse or physician assistant and the physician at a location determined by the physician and the advanced practice registered nurse or physician assistant. Protocols Contractors that employ advanced practice nurses or physician assistants must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement if both parties agree to do so. The PAA and/or protocols need not describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease, or symptom. The protocols must be reviewed, agreed upon, signed, and dated by the supervising physician and the physician assistant and/or advanced practice nurse, at least annually, and maintained on-site. Standing Delegation Orders (SDO) When services are provided by unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for a particular individual. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances an RN, LVN, or non- licensed healthcare provider (NLHP) may initiate actions or tasks in the clinical setting and provide authority for use with individuals when a physician or advanced practice provider is not on the premises, and/or prior to being examined or evaluated by a physician or advanced practice provider. Example: SDO for assessment of blood pressure/blood sugar which includes an RN, LVN or NLHP that will perform the task, the steps to complete the task, the normal/abnormal range, and the process of reporting abnormal values. Other applicable SDOs when a physician is not present on-site may include, but are not limited to: • Obtaining a personal and medical history; • Performing an appropriate physical assessment and the recording of physical findings; 50 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 • Initiating/performing laboratory procedures; • Administering or providing drugs ordered by voice communication with the authorizing physician; • Providing pre-signed prescriptions for: o Oral contraceptives; o Diaphragms; o Contraceptive creams and jellies; o Topical anti-infective for vaginal use; o Oral anti-parasitic drugs for treatment of pinworms; o Topical anti-parasitic drugs; or o Antibiotic drugs for treatment of STIs. • Handling medical emergencies - to include on-site management as well as possible transfer of client; • Giving immunizations; or • Performing pregnancy testing. The SDOs must be reviewed, signed, and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually and maintained on site. Client Education In addition to the above, contractors must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. Contractors' plans for client education must be reviewed and signed by the clinic medical director. Resources Requirements addressing scope of practice and delegation of medical and nursing acts can be accessed at the following websites: • Texas Medical Board • Texas Board of Nursing Rules that are most pertinent to this topic are: • Texas Administrative Code, Title 22, Part 9, Chapter 193; • Texas Administrative Code, Title 22, Part 11, Chapters 221 and 224; and • Texas Administrative Code, Title 22, Part 9, Chapter 185 (Physician Assistant Scope of Practice). 51 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 Section IV Reimbursement, Data Collection and Reporting This section provides policy requirements for submitting for reimbursement, data collection and required reports. 52 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section IV, Chapter 1: Reimbursement PHC services contract amounts are ceilings against which contractors may bill for services provided to PHC eligible clients. Once this ceiling has been reached, no further funds will be available for reimbursement. Contractors may only bill for services provided to clients who have been screened for potential Medicaid and other benefit programs and who have been determined PHC eligible. Categorical Reimbursement PHC categorical funding (cost reimbursement) is used to develop and maintain contractor infrastructure for the provision of primary health services. The funding can be used to support clinic facilities, staff salaries, utilities, medical and office supplies, equipment, and travel, as well as direct medical services. All services will be reimbursed on a cost reimbursement basis. Payments will be made for costs incurred and will be supported by reporting to show services provided and limited client-level data. Costs may be assessed against any of the following categories the contractor identifies during their budget development process: • Personnel • Fringe Benefits • Travel • Equipment and Supplies • Contractual • Other, and • Indirect Costs PHC funds are disbursed to contractors through a voucher system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the voucher process. Contractors must still submit vouchers monthly even if the contract reimbursement limit has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all fees paid by the clients (client co-pay). Monthly Billing and Reporting Categorical reimbursement for the cost of providing services shall be billed monthly on the HHSC Purchase Voucher Form 4116 and submitted to the contact(s) outlined in the instructions for the form. Each request will cover services provided, or expenses incurred, in the preceding month as applicable to the contract. Requests should be submitted within 30 days of the end of the preceding month and within 60 days of providing the service. Appropriate financial records must be maintained for review by HHSC through the quality assurance review process and/or fiscal monitoring and/or programmatic desk reviews. 53 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 A monthly PHC Form 225 must be submitted with the monthly voucher, within 30 days following the end of the month covered by the bill. Reimbursement requests submitted without the required program reports will not be approved for payment. Vouchers and/or reports submitted with incorrect or missing information will be rejected and the contractor will be contacted to remedy the problem. Submission of Vouchers If expenses are overstated on one month's voucher, the following month's expenses should be reduced accordingly. All claims for reimbursement for services delivered must be submitted within 45 days of the end of the contract term. If contractors have services that occurred during the contract period left to bill after the August Purchase Voucher has been submitted, contractors can bill those services using a Purchase Voucher and a PHC Form 225 report marked SUPPLEMENTAL and FINAL and submit the forms on or before October 15th. All requests for reimbursement must be submitted by email to HDS.ADShhsc.state.tx.us and PHCReports©hhsc.state.tx.us. The Purchase Voucher must be submitted via email to the email address provided on the form. Requests received more than 45 days following the end of the contract will not be paid. A signed Financial Status Report (Form 269A) must be submitted by email to the email address on the form no later than 45 days after the contract term. The 269A form must be marked as FINAL and include all reimbursements and adjustments in payments for the contract term. Voucher Submission and Reporting after Entire Contract Award is Expended Contractors must continue to submit a HHSC Purchase Voucher and supporting monthly program reports even after contract ceilings have been reached. Any cost over the contract ceiling after deducting program income should be reflected under "Non-HHSC Funding" on the voucher and on the FSR. This submission is required to continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services. Non-Reimbursable Expenditures PHC will not reimburse services for individuals enrolled in another program or clients who do not complete the respective eligibility process, except for clients who meet the presumptive eligibility criteria. Payment for clients that were treated under presumptive eligibility may be eligible for services only during the 90-day period. If clients fail to fully comply with all requirements to apply for Medicaid services, they will not be considered eligible for PHC services after the presumptive time period expires. Reimbursable Expenditures Services may be provided to clients whose screening results indicate they are potentially Medicaid eligible, but the client has not yet completed the application 54 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 process. With the exception of presumptive eligibility, services provided on the initial day of service may be billed to PHC for reimbursement with proper documentation of client's eligibility status. Altering of Forms Contractors are required to use the most current version of their organization's personalized HHSC Purchase Voucher Form 4116 for ease of processing. None of the billing or the reporting forms may be altered in any manner. The vouchers should not be altered to itemize expenses for PHC services provided. Vouchers should be submitted for the total monthly reimbursement amount only. 55 DocuSign Envelope ID 2DAB07B4-A920-4608-91A4-CCFFDBODF809 Section IV, Chapter 2: Data Collection and Reporting The table below outlines the data collection and reporting requirements for HHSC PHC Services Program contractors. PROGRAM INFORMATION Program Name: Primary Health Care (PHC) Contract Type: Categorical Contract Term: September 1 through August 31 Required Form Voucher 1 Type: j Name: HHSC Purchase Voucher Form 4116 (Excel Format) Submission Date: By the last business day of the following month. Final voucher due within 45 days after the end of the contract term. Submit Copy To: HDS.ADS@hhsc.state.tx.us PHCReports@hhsc.state.tx.us Original Signature No Required: Accepted Method Email of Submission: No. of Copies: 1 1 Instructions• Submit 1 Form 4116 vouchers to Health and Developmental Services (HDS) Voucher Form 4116 and PHC-225 must be submitted at the same time to the HDS email box(es). Vouchers will not be Note: processed unless the PHC-225 is received with the voucher Form 4116. All forms must be submitted in their original format, in the same email. No exceptions. Required Form Report 1 - Supporting Type: Name: PHC-225 Monthly Report Form (PDF format) Submission Date: By the last business day of the following month. Final report due within 45 days after the end of the contract term. Submit Copy To: HDS.ADS@hhsc.state.tx,us PHCReborts(a hhsc.state.tx.us Original Signature No Required: Accepted Method Email of Submission: -- JNo. of Copies: 1 56 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 PROGRAM INFORMATION Program Name: Primary Health Care (PHC) Contract Type: Categorical Contract Term: September 1 through August 31 Instructions• Submit 1 Form 4116 vouchers to Health and Developmental Services (HDS) Voucher Form 4116 and PHC-225 must be submitted at the same time to the HDS email box(es). Vouchers will not be Note: processed unless the PHC-225 is received within the voucher Form 4116. All forms must be submitted in their original format, in the same email. No exceptions. Required Form Report 1 Type: Name: Financial Status Report 269A Quarterly, Sept 1-Nov 30, Dec 1-Feb 28, Mar 1-May 31, June 1-Aug 31. Submit 30 days after the end of each quarter. The Submission Date: final quarterly FSR is due 45 days after the end of the contract term. The final quarter report includes all final charges and expenses associated with the program contract. Mark it as "FINAL." Submit Copy To: HDS.AD5c hhsc.state.tx.us PHCReportsPhhsc.state.tx.us Original Signature Yes Required: Accepted Method Email scanned document of Submission: No. of Copies: 1 Instructions• Submit one Form 269A, with an original signature (signed and scanned in email accepted). Note: Required Form Report 2 Type: Name: PHC Annual Report, Form 325 Submission Date: Within 60 days following the end of the contract period. Submit Copy To: HDS.ADS@hhsc.state.tx.us PHCReportsCahhhsc.state.tx.us Original Signature No Required: Accepted Method of Submission: Email 57 DocuSign Envelope ID:2DABO7B4-A920-4608-131A4-CCFFDBODF809 PROGRAM INFORMATION Program Name: Primary Health Care (PHC) Contract Type: Categorical Contract Term: September 1 through August 31 Instructions• Submit PHC Annual Report to Health and Developmental Services (HDS). Note: 58 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 OPSH Forms and Resources The following forms or guidance documents are referenced in this manual and are available via the Provider Portal on the HHS website: • OPSH Application for Program Benefits, Form 3029 • OPSH of Applicant's Rights and Responsibilities, Form 3046 • OPSH Definition of Income • OPSH Optional Co-Pay Table Based on Monthly Federal Poverty Level • OPSH Employment Verification, Form 3049 • OPSH Statement of Self-Employment Income, Form 3051 • OPSH Request for Information, Form 3056 • OPSH Presumptive Eligibility Notice, Form 3045 • OPSH Notice of Ineligibility, Form 3047 • OPSH Notice of Eligibility, Form 3048 • PHC Annual Report Form 325 FY20 • PHC Annual Report Form 325 Instructions 59 DocuSign Envelope ID:2DABO7B4-A920-4608-B1A4-CCFFDBODF809 IS- `Jv: TEXAS Summary of Revisions to V Health and Human the 44/6 Services Primary Health Care Program Policy Manual Effective March 2020 Summary of changes to the HHSC Primary Health Care Program Policy Manual, excluding minor edits such as updates to agency names, dates, and web links; reordered sections for better flow of information; renumbered pages. Heading Summary of Changes • Minor edits to clarify language • Added program contact information Introduction • Moved Scope of Services to Clinical Section • Deleted unused/unnecessary definitions/acronyms • Added definitions of telehealth and telemedicine medical service. Section I: Administrative Policy Section I, Chapter 1: • Client Access - Added paragraph regarding additional Administrative Policies benefits for former military service members • Updated section. DSHS Child Abuse Screening, Section I, Chapter 2: Documenting, and Reporting Policy for Abuse and Neglect Contractors/Providers and the DSHS Reporting Form are Reporting no longer available; report directly to DFPS Texas Abuse Hotline Section I, Chapter 3: • Section reordered for clarity and flow Confidentiality • Reduced text by adding hyperlinks Section I, Chapter 6: • Section reordered for clarity and flow Facilities and Equipment Section I, Chapter 7: Emergency • Added information in new chapter for clarity and flow Responsiveness Section I, Chapter 8: • Added annual review of prescriptive authority agreements Quality Management (PAAs) 60 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Section II Eligibility and Fees • Section reorganized for clarity and flow • Minor revisions to clarify language • Added link to new OPSH Application for Program Benefits Section II, Chapter 1: • Clients with household FPL at or below 1000/0 should not Eligibility and Assessment be charged a co-pay of Co-pay/Fees • Corrected process for verifying current eligibility in HTW or Medicaid for Pregnant Women programs • The maximum amount of co-pay per encounter is $30.00 • Added links to optional eligibility forms Section III Clinical Guidelines Section III, Chapter 1: Reduced text b eneral • h yperlinks regarding consents • Reordered section for better flow of information • Moved Scope of Services to this section • Added section on telehealth and telemedicine Section III, Chapter 2: • Added section on Healthy Lifestyle Clinical Policy • Reduced text by adding hyperlinks for certain lab tests • Reduced text of Perinatal Clinical Guidelines by adding hyperlink • Retitled section on State-Mandated Education • Reduced text of Dental Clinical Policy by adding hyperlink Section III, Chapter 3 • Added section regarding Prescriptive Authority Agreements PAAs, Protocols, SDOs, and Client Education Section IV: Reimbursement, Data Collection, and Reporting • HHS Voucher Form 4116 replaced B-13 voucher; updated reporting information and mailbox addresses. Added new Section IV, Chapter 1: form, Monthly Reimbursement Form (MRF). The MRF, Reimbursement Form 4116, and PHC Form 225 are all together in one Excel workbook called the Monthly Reporting Forms Packet (MRFP). Each contractor will be sent their personalized MRFP after the beginning of each fiscal year. • Each contractor will be sent their personalized FSR after the beginning of each fiscal year. Section IV, Chapter 2: • The Annual Report Form 325 is not personalized. It can be Data Collection and accessed from the HHS PHC Provider Portal webpage Reporting under the Forms section. • Table is revised to reflect changes in forms OPSH Forms and Resources (formally Appendix) 61 DocuSign Envelope ID:2DAB07B4-A920-4608-B1A4-CCFFDBODF809 Appendices • Updated to reflect agency name changes. • Form 3029, OPSH Application for Program Benefits, Appendix A replaces the Individual Form, Household Form, and Individual Eligibility Form - Household Worksheet; the form is no longer part of the Removed policy manual; it will be on the HHS PHC Provider Portal webpage under the Forms section. • Form 3029, OPSH Application for Program Benefits, Appendix B Household replaces the Individual Form, Household Form, and Eligibility Form Removed Household Worksheet; the form is no longer part of the policy manual; it will be on the HHS PHC Provider Portal webpage under the Forms section. Appendix C • The form is no longer part of the policy manual; it was Definition of Income renamed and will be available on the HHS PHC Provider Portal webpage under the Forms section. Appendix D • The form is no longer part of the policy manual; it was Program Fee Scale renamed, updated and will be available on the HHS PHC Provider Portal webpage under the Forms section. Appendix E Checklist of FP & • Deleted Preventive Services Appendix F FDA-approved • Deleted Contraceptive Methods Appendix G • Deleted Dental Diagnosis Codes 62 Docu inti SECURED Certificate Of Completion Envelope Id:2DABO7B4A9204608B1A4CCFFDBODF809 Status:Completed Subject:NEW$311,500.00;HHS000697900024;City of Port Arthur;HHSC/HDS/HDIS/OPSH Source Envelope: Document Pages: 182 Signatures:3 Envelope Originator: Certificate Pages:2 Initials:0 Texas Health and Human Services Commission AutoNav:Enabled 1100 W.49th St. Envelopeld Stamping:Enabled Austin,TX 78756 Time Zone:(UTC-06:00)Central Time(US&Canada) PCS_DocuSign@hhsc.state.tx.us IP Address: 167.137.1.11 Record Tracking Status:Original Holder:Texas Health and Human Services Location:DocuSign 8/24/2020 1:21:16 PM Commission PCS_DocuSign@hhsc.state.tx.us Signer Events Signature Timestamp DAC Completed Sent:8/24/2020 1:24:48 PM Reilly.Webb@hhsc.state.tx.us Viewed:8/24/2020 1:38:44 PM Security Level:Email,Account Authentication Signed:8/24/2020 1:38:49 PM (None) Using IP Address: 167.137.1.10 Electronic Record and Signature Disclosure: Not Offered via DocuSign Ron Burton ,DocuSSned by: Sent:8/24/2020 1:38:53 PM ron.burton@portarthurtx.gov rat bj tY'('bin. Viewed:8/31/2020 9:08:04 AM `-224C7424DBA40C..CihManager Signed:8/31/2020 9:16:47 AM City of Port Arthur Security Level:Email,Account Authentication Signature Adoption:Pre-selected Style (None) Using IP Address:67.48.55.198 Electronic Record and Signature Disclosure: Not Offered via DocuSign Lindsay Rodgers f—oocus.gned by. Sent:8/31/2020 9:17:02 AM Lindsay.Rodgers@hhsc.state.tx.us LU41,$0ui o L n Viewed:8/31/2020 9:56:00 AM Associate Commissioner,Health and Develo mental�z9D47aeFDo74a3. P Signed:8/31/2020 9:56:11 AM Services Texas Health and Human Services Commission Signature Adoption:Pre-selected Style Security Level:Email,Account Authentication Using IP Address:45.19.198.53 (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Carbon Copy Events Status Timestamp Marissa Acosta COPIED Sent:8/24/2020 1:24:48 PM marissa.acosta05@hhsc.state.tx.us Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Lily Ferris COPIED Sent:8/24/2020 1:24:48 PM lily.ferris@hhsc.state.tx.us Viewed:8/24/2020 1:32:06 PM Security Level:Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Judith A.Smith Sent:8/24/2020 1:38:54 PM judith.smith@portarthurtx.gov COPIED Viewed:8/24/20201:41:41 PM Director of Health Services City of Port Arthur Security Level: Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 8/31/2020 9:17:02 AM Certified Delivered Security Checked 8/31/2020 9:56:00 AM Signing Complete Security Checked 8/31/2020 9:56:11 AM Completed Security Checked 8/31/2020 9:56:11 AM Payment Events Status Timestamps