Attachment C.pdf

ATTACHMENT C

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

CLARA AND [CONTRACTOR NAME] FOR FISCAL YEAR 2025

Last Reviewed by County Counsel on 6/28/2024

AGREEMENT FOR SUBSTANCE USE TREATMENT AND PREVENTION SERVICES

BETWEEN THE COUNTY OF SANTA CLARA AND [CONTRACTOR NAME] FOR

FISCAL YEAR 2025

County Department Behavioral Health Services Department

County Contract Representative Sherri Terao, Ed.D, Director

Contractor Insert Name of Contractor Agency

Contractor Representative Insert Name of Contractor Agency Representative [Contact listed below in notices]

Contract Term July 1, 2024-June 30, 2025

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

Table of Contents

Article 1. DEFINITIONS 3

Article 2. GENERAL PROVISIONS 3

Article 3. SERVICES AND ACCESS PROVISIONS 9

Article 4. AUTHORIZATION AND DOCUMENTATION PROVISIONS 17

Article 5. CHART AUDITING AND REASONS FOR RECOUPMENT 24

Article 6. CLIENT PROTECTIONS 27

Article 7. PROGRAM INTEGRITY 29

Article 8. QUALITY IMPROVEMENT PROGRAM 36

Article 9. FINANCIAL TERMS 41

Article 10. ADDITIONAL FINAL RULE PROVISIONS 43

Article 11. DATA, PRIVACY AND SECURITY REQUIREMENTS 48

Article 12. CLIENT RIGHTS 50

Article 13. RIGHT TO MONITOR 50

Article 14. SITE INSPECTION 52

Attached and Incorporated:

Exhibit (FY24) A1 [Program Name] SCOPE OF WORK

Exhibit (FY24) A2 [Program Name] SCOPE OF WORK

Exhibit (FY24) A4 [Program Name] SCOPE OF WORK

Exhibit (FY24) B – Summary Substance Use Treatment Services ([Adult/Adolescent]

RES/WM/OP/IOP/NTP/STEP)

Exhibit (FY24) B – Estimated Budget and Provider Rate Table for ([Adult/Adolescent] OP/IOP/NTP) [if applicable]

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

Exhibit (FY24) B – Estimated Budget and Provider Rate Table for ([Adult/Adolescent] RES/WM) [if applicable]

Exhibit (FY24) B – Estimated Budget and Provider Rate Table for ([Adult/Adolescent] RES/WM) [if applicable]

Exhibit C – Insurance Requirements for Professional Services Contracts

Exhibit D – Standard County Provisions

Exhibit E – County of Santa Clara Federally Required Contract Provisions

Exhibit F – Contractor Certification of Compliance with COVID-19 Vaccine Requirements

Exhibit G - Facility Use Addendum [if applicable]

This Agreement for substance use disorder services (Agreement) is entered by and between the County of Santa Clara, a political subdivision of the State of California (“County”), and [Name of Contractor Agency], a California non-profit/for-profit corporation licensed to provide substance use disorder services, whose principal address is [Contractor Address] (“Contractor") (collectively, “Parties”).

RECITALS

WHEREAS, County is under contract with the State of California to provide or arrange for the provision of certain mandated services, including substance use disorder (SUD) services, for Medi-Cal beneficiaries served by the County; and

WHEREAS, County has determined that it will arrange for a contractor to provide Substance Use

Disorder Services to eligible beneficiaries; and

WHEREAS, Contractor has represented, through a proposal in response to County’s request for proposals or through another means acceptable to the County, that it is able and willing to provide such services; and

NOW, THEREFORE, BHSD and Contractor agree that Contractor will provide services pursuant to this

Agreement and in accordance with the purpose and goals of the County’s Department of Health Care

Services (DHCS)-approved Drug Medi-Cal Organized Delivery System (DMC-ODS) implementation plan and Mental Health Service Act (MHSA) as follows:

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

TERMS

Article 1. DEFINITIONS

1. BEHAVIORAL HEALTH INFORMATION NOTICE (BHIN)

“Behavioral Health Information Notice” or “BHIN” means guidance from DHCS to inform counties and contractors of changes in policy or procedures at the federal or state levels. These were previously referred to as a Mental Health and Substance Use Disorder Services Information

Notice (MHSUDS IN). BHINs and MHSUDS INs are available on the DHCS website.

2. BENEFICIARY OR CLIENT

“Beneficiary” or “client” means a Santa Clara County Medi-Cal beneficiary or Unsponsored Santa

Clara County resident who is eligible to receive Specialty Mental Health services. “Unsponsored” refers to an individual who does not have any private or government-sponsored health coverage.

3. DHCS

“DHCS” means the California Department of Health Care Services.

4. DIRECTOR

“Director” means the Director of the County Behavioral Health Department, unless otherwise specified.

5. PROVIDER MANUAL

Provider Manual means the operations manual developed by the County and modified from time to time that identifies the methods of administration of this Agreement, including but not limited to credentialing procedures, quality management activities, utilization management programs (“UM Programs”), referral procedures, claims filing, guidance for inpatient psychiatric facilities, information on emergency services, and acute psychiatric inpatient services, and adjudication policies and procedures and accounting of Covered Services rendered hereunder.

Article 2. GENERAL PROVISIONS

1. TERM

This Agreement shall govern the period beginning July 1, 2024 and ending on June 30, 2025, inclusive, unless terminated earlier pursuant to Article 2, Paragraph 8 of this Agreement.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

2. SCOPE OF WORK

Contractor shall provide the services set forth in Exhibit A, “SCOPE OF WORK”.

3. COMPENSATION

A. This Agreement shall be subject to any restrictions, limitations, and/or conditions imposed by

County or state or federal funding sources that may in any way affect the fiscal provisions of, or funding for this Agreement. This Agreement is also contingent upon sufficient funds being made available by County, state, or federal funding sources for the term of the Agreement. If the federal or state governments reduce financial participation in the Medi-Cal program, County agrees to meet with Contractor to discuss renegotiating the services required by this

Agreement.

B. Funding is provided by fiscal year. For purposes of this Agreement, the fiscal year begins July

1 and ends the following June 30. Any unspent fiscal year appropriation does not roll over and is not available for services provided in subsequent years.

C. The Maximum Financial Obligation (MFO) of the County under this Agreement shall not exceed the MFO for the services as defined in this Agreement, including all applicable exhibits, is as stated in the Exhibit B Summary Page per fiscal year, which is not a guaranteed sum but shall be paid only for services rendered and received.

4. NOTICE TO PARTIES

A. Unless otherwise specified, all notices to be given by either Party shall be in writing, by U.S.

mail and electronic mail, and addressed as follows:

1) Notices to County:

One copy to:

County of Santa Clara, Board of Supervisors

70 West Hedding Street

San Jose, California 95110

One copy to:

Behavioral Health Services Department

Sherri Terao, Ed.D, Director

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

828 South Bascom Avenue, Suite 200

San Jose, California 95128

2) Notices to Contractor:

Legal Entity Name

CCP Contact Name

Street Address

City, CA ZIP

B. Contractor shall notify County in writing of any change in organizational name, Head of

Organization or principal business at least 15 business days in advance of the change by completing the network change request form as described in the Provider Manual. DHCS shall certify Contractor to participate in the DMC-ODS program. Contractor cannot reduce or relocate without first receiving approval by DHCS. A DMC certification application shall be submitted to the DHCS Provider Enrollment Division (PED) 60 days prior to the desired effective date of the reduction of covered services or relocation. Contractor shall be subject to continuing certification requirements at least once every five years. Said notice shall become part of this Agreement upon acknowledgment in writing by the County, and no further amendment of the Agreement shall be necessary provided that such change of address does not conflict with any other provisions of this Agreement. Contractor must immediately notify County of a change in ownership, organizational status, licensure, or ability of Contractor to provide the quantity or quality of the contracted services in a timely fashion.

C. Contractor must follow the process outlined in the Provider Manual and immediately provide written notice to County of a change in ownership, organizational status, licensure, or ability of Contractor to provide the quantity or quality of the contracted services in a timely fashion. This notification requires completion of the network change request form as described in the Provider Manual.

D. Contractor shall provide County a list of their current contracted programs, by location, and update the list on an annual basis. The list of programs and locations shall include the physical location that staff are serving beneficiaries or distant location from which telehealth

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA services are coordinated. The list shall include the site(s) name, physical address, site

National Provider Identifier (NPI) Number, head of organization name and contact number, and the number of staff located at each site which must correspond to a program listed in

Exhibit A(s).

5. INDEPENDENT CONTRACTOR

A. Contractor understands and agrees that the services performed hereunder by its officer, agents, employees, or contracting persons or entities are performed in an independent capacity and not in the capacity of officers, agents, or employees of the County for any purpose, including workers’ compensation, tax withholding, and employee benefits.

Contractor shall determine the method and manner of performing its duties under this

Agreement, and County may monitor the work performed by Contractor.

B. Contractor shall provide all personnel, supplies, and operating expenses of any kind required for the performance of this Agreement.

6. SUBCONTRACTS

A. Contractor shall obtain prior written approval from the Director before subcontracting any of its obligations to provide services under this Agreement. Approval is at the discretion of the Director but shall not be unreasonably withheld. Contractor shall ensure that all subcontracts are subject to the applicable terms and conditions of this Agreement, including, without limitation, the licensing, certification, privacy, data security and confidentiality requirements set forth herein, and include the applicable provisions of 42

C.F.R. § 438.230.

B. Contractor shall remain legally responsible for the performance of all terms and conditions of this Agreement, including, without limitation, all SUD services provided by third parties under subcontracts, whether approved by the County or not.

7. MODIFICATION AND AMENDMENT

A. Except as specifically provided, this Agreement may only be modified or amended in writing signed by both Parties.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

B. Contractor shall provide written notice to the County BHSD provider liaison and submit a

Program Modification request when the total amount billed and the estimated amount of work in progress total 75 percent of the MFO.

C. Program modification requests are required to make any changes to the terms as agreed to in the Exhibits attached to this Agreement or the maximum financial obligation of the entire contract. through a process County will specify at the beginning of the fiscal year. County will provide notification to Contractor of that process. Changes to the maximum financial obligation will also require executing a formal amendment to this Agreement.

D. For changes related to staffing during the term of this Agreement, Contractor shall submit by email to the BHSD assigned program monitor that is listed on the impacted Exhibit A that has a revised Staffing Exhibit. Changes to staffing will not require executing a formal amendment to this Agreement.

8. TERMINATION

A. This Agreement may be terminated at any time by the mutual written concurrence of both

Parties.

B. In addition to any other remedies it may have, the County may terminate this Agreement for cause in the event the Contractor fails to perform its obligations under this Agreement in a timely and proper manner or violates any local, state or federal law, regulation, or standard applicable to its performance under the Agreement, provided the Contractor fails to cure the breach within five days of receiving written notice of the County’s intent to terminate.

The waiver of any breach or violation of any requirement of this Agreement shall not be deemed to be a waiver of any such breach in the future, or of the breach of any other requirement of this Agreement. County reserves the right to terminate immediately, without a period to cure such breach, if Contractor fails to comply with the requirements of

Article 8, subsection 9 of this AGREEMENT (“REPORTING UNUSUAL OCCURRENCES”).

C. Either Party may terminate this Agreement without cause by providing at least 90 calendar days’ advance written notice of the effective date of termination.

D. In the event this Agreement is terminated, Contractor shall be entitled to compensation for all SUD services satisfactorily provided pursuant to the terms and conditions of this

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

Agreement through and including the effective date of termination. This provision shall not limit or reduce any damages owed to the County due to a breach of this Agreement by

Contractor. Contractor shall participate in and make arrangements for the orderly transition of clients. Within ten (10) business days from the date on the notice of termination, CONTRACTOR must provide to the BHSD a list of clients who received or substance use treatment services or who were seen on a regular basis by Contractor. The information included on the list will be: name of client, recent phone number, address and/or contact information, and all relevant clinical information necessary to transition the client to another provider.

9. INTERPRETATION; VENUE

A. The headings used herein are for reference only. The terms of the Agreement are set out in the text under the headings.

B. This Agreement has been executed and delivered in, and shall be construed and enforced in accordance with, the laws of the State of California. Proper venue for legal action regarding this Agreement shall be in the County of Santa Clara.

10. ENTIRE AGREEMENT

This Agreement, including all schedules, addenda, exhibits and attachments, contains the entire understanding of the Parties in regard to Contractor’s provision of the services specified in

Exhibit A (“Scope of Work”) and supersedes all prior representations in regard to the same subject matter, whether written or oral.

11. SEVERABILITY

If any provision of this Agreement, or any portion thereof, is found by any court of competent jurisdiction to be unenforceable or invalid for any reason, such provision shall be severable and shall not in any way impair the enforceability of any other provision of this Agreement.

12. AUTHORITY TO CONTRACT

County and Contractor warrant that they are legally permitted and otherwise have the authority to enter into this Agreement, the signatories to this Agreement are authorized to execute this

Agreement on behalf of their respective entities, and that any action necessary to bind each

Party has been taken prior to execution of this Agreement.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

13. CONFORMITY WITH STATE AND FEDERAL LAWS AND REGULATIONS

A. Contractor shall provide services in conformance with all applicable state and federal statues, regulations and subregulatory guidance, as from time to time amended, including but not limited to:

I. California Code of Regulations, Title 9;

II. California Code of Regulations, Title 22;

III. California Welfare and Institutions Code, Division 5;

IV. United States Code of Federal Regulations, Title 42, including but not limited to Parts

2, 438 and 455;

V. United States Code of Federal Regulations, Title 45;

VI. United States Code, Title 42 (The Public Health and Welfare), as applicable;

VII. Balanced Budget Act of 1997;

VIII. Health Insurance Portability and Accountability Act (HIPAA); and

IX. Applicable Medi-Cal laws and regulations, including applicable sub-regulatory guidance, such as BHINs, MHSUDS INs, and provisions of County’s state or federal contracts governing client services.

B. In the event any law, regulation, or guidance referred to in subsection (A), above, is amended during the term of this Agreement, the Parties agree to comply with the amended authority as of the effective date of such amendment without amending this Agreement.

14. COMPLIANCE WITH PROVDER MANUAL

A. Contractor shall adhere to the requirements set forth in the Provider Manual. The Provider

Manual is hereby incorporated into this Agreement by reference. If any provision of the

Provider Manual is inconsistent with the terms of this Agreement, the terms of this

Agreement shall govern. The Manual is available on BHSD’s website, Provider portal |

Behavioral Health Services | County of Santa Clara (santaclaracounty.gov). Providers may email BHSDBusinessOffice@hhs.sccgov.org to request a printed copy of the Manual.

B. The Provider Manual may be revised from time to time, and County shall provide notice of amendments, as outlined in Article 2 Section 4, identifying the changes that County has determined are material, not less than thirty (30) business days prior to the amendment https://bhdp.santaclaracounty.gov/home https://bhdp.santaclaracounty.gov/home

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA date. Notice of amendments to the Provider Manual that are necessary to comply with state or federal law or regulations may be less than thirty (30) business days if a shorter time for compliance is required. Contractor has the right to provide feedback regarding any change. The Parties shall meet and confer in good faith regarding the change. If the Parties are unable to agree to the amendment within the foregoing thirty (30) business day period, the Contractor may terminate this Agreement pursuant to Article 2 Section 8.

Article 3. SERVICES AND ACCESS PROVISIONS

1. CERTIFICATION OF ELIGIBILITY

Contractor will, in cooperation with County, comply with 42 C.F.R. § 455.1(a)(2) and BHIN 23-

001, or any subsequent superseding DHCS notices, to obtain a certification of a client’s eligibility for SUD services under Medi-Cal.

2. ACCESS TO SUBSTANCE USE DISORDER SERVICES

A. In collaboration with the County, Contractor will work to ensure that individuals to whom the Contractor provides SUD services meet access criteria and medical necessity requirements, as per DHCS guidance specified in BHIN 24-001, or any subsequent superseding DHCS notices. Specifically, the Contractor will ensure that the clinical record for each client includes information as a whole indicating that client’s presentation and needs are aligned with the criteria applicable to their age at the time of service provision as specified below.

B. Contractor shall have written admission criteria for determining the client’s eligibility and suitability for treatment and services. All clients admitted shall meet the admission criteria and this shall be documented in the client’s record.

C. Programs shall ensure that their policies, procedures, practices, and rules and regulations do not discriminate against the above special populations. Whenever the needs of the client cannot be reasonably accommodated, efforts shall be made to make referral(s) to appropriate programs.

D. Contractor should recognize and educate staff and collaborative partners that Parole and

Probation status is not a barrier to SUD services.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

E. Contractor will ensure that the clinical record for each client includes information as a whole indicating that client’s presentation and needs are aligned with the criteria applicable to their age at the time-of-service provision as outlined in this Agreement.

F. The initial assessment shall be performed face-to-face, by telehealth or by telephone by an

Licensed Practitioner of the Healing Arts (LPHA) or registered or certified counselor and may be done in the community or the home, except for residential treatment services and narcotic treatment programs (NTPs). If the assessment of the client is completed by a registered or certified counselor, then an LPHA shall evaluate that assessment with the counselor and the LPHA shall make the final diagnosis. The consultation between the LPHA and the registered or certified counselor can be conducted in person, by video conferencing, or by telephone.

G. The Contractor shall notify the County through the Provider Network Change (PNC) process if they will be closing a level of care for the following month. The Provider Manual outlines additional details on process.

H. a. These requests will be evaluated based on assessment of the Contractors current performance.

I. b. County reserves the right to deny Contractor’s request to close a program to referrals.

J. Contractor shall comply with beneficiaries’ access criteria after initial assessment requirements:

I. Beneficiaries 21 years of age and older, to qualify for DMC-ODS services after the initial assessment, must meet one of the following criteria:

a. Have at least one diagnosis from the most current edition of the Diagnostic and

Statistical Manual (DSM) of Mental Disorders for Substance-Related and

Addictive Disorders, except for Tobacco-Related Disorders and Non-Substance-

Related Disorders, OR

b. Have had at least one diagnosis from the most current edition of the DSM for

Substance-Related and Addictive Disorders, except for Tobacco-Related

Disorders and Non-Substance-Related Disorders, prior to being incarcerated or during incarceration, determined by substance use history.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

II. Beneficiaries under the age of 21, qualify for DMC-ODS medically necessary services after the initial assessment, in the following circumstances:

a. All services that are Medi-Cal-coverable, appropriate, and medically necessary, needed to correct and ameliorate health conditions shall be provided, as per federal Early & Periodic Screening, Diagnostic and Treatment (EPSDT) statutes and regulations.

b. Services need not be curative or completely restorative to ameliorate a health condition, including substance misuse and SUDs, consistent with federal guidance.

c. Services that sustain, support, improve, or make more tolerable substance misuse or an SUD are considered to ameliorate the condition and are thus covered as EPSDT services.

3. ASAM LEVEL OF CARE DETERMINATION

A. Contractor shall use the ASAM Criteria to determine placement into the appropriate level of care (LOC) for all beneficiaries, which is separate and distinct from determining medical necessity. LOC determinations shall ensure that beneficiaries are able to receive care in the least restrictive LOC that is clinically appropriate to treat their condition.

B. A full ASAM Criteria assessment and an SUD diagnosis is not required to deliver prevention and early intervention services for beneficiaries under the age of 21; a brief screening ASAM

Criteria tool is sufficient for these services.

C. For clients who withdraw from treatment prior to completing the ASAM Criteria assessment or prior to establishing a diagnosis from the DSM for Substance-Related and Addictive

Disorders, and later return, the time period for initial assessment starts over.

D. A full ASAM Criteria assessment, or brief screening ASAM Criteria tool for preliminary LOC recommendations, shall not be required to begin receiving DMC-ODS services.

E. A full ASAM Criteria assessment does not need to be repeated unless the client’s condition changes.

F. Requirements for ASAM LOC assessments apply to NTP clients and settings.

4. MEDICAL NECESSITY

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

A. Pursuant to BHIN 24-001, or any subsequent superseding DHCS notices, and consistent with

Welfare & Institutions Code § 14059.5, DMC-ODS services must be medically necessary.

B. For beneficiaries 21 years of age and older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

C. For beneficiaries under the age of 21, a service is “medically necessary” or a “medical necessity” if the service is necessary to correct or ameliorate screened health conditions.

Consistent with federal guidance, services need not be curative or completely restorative to ameliorate a health condition, including substance misuse and SUDs. Services that sustain, support, improve, or make more tolerable substance misuse or an SUD are considered to ameliorate the condition and are thus covered as EPSDT services.

D. Contractor should not refuse or fail to provide medically necessary services to any client unless Contractor is incapable of providing the services necessary or has an approved temporary program closure as outlined in the Provider Manual. Contractor is expected to provide services to clients in the same manner, in accordance with the same standards, and with the same time availability as provided to other clients.

5. ADDITIONAL COVERAGE REQUIREMENTS AND CLARIFICATIONS

A. The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-

Cal, reside in the County, and meet the criteria for DMC-ODS services as per established requirements above.

B. Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when:

I. Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis.

II. Clinically appropriate and covered DMC-ODS services provided to clients over the age of

21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA assessment, those clinically appropriate and covered DMC-ODS services provided are reimbursable.

III. All Medi-Cal claims shall include a current CMS approved International Classification of

Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected

SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or

“Factors influencing health status and contact with health services”.

IV. Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan.

C. While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 22-

019, or any subsequent superseding DHCS notices, treatment plans continue to be required for some services in accordance with federal law.

D. Treatment plans are required by federal law for:

I. Narcotic Treatment Programs (NTPs)

II. Peer Support Services

III. The beneficiary has a co-occurring mental health condition.

E. Medically necessary covered DMC-ODS services delivered by Contractor shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.

F. Contractor shall have the ability to address the symptoms and functional impairment related to co-occurring mental health conditions of clients/beneficiaries who are not so impaired as to substantially interfere with the clients/beneficiary’s treatment, which includes the ability to recognize symptoms and make appropriate referrals and linkages to

Contractors who may treat those symptoms of severe impairment beyond the scope of an individual’s co-occurring capability.

6. DIAGNOSIS DURING INITIAL ASSESSMENT

A. Contractor may use the following options during the assessment phase of client’s treatment when a diagnosis has yet to be established as specified in BHIN 22-013:

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

I. ICD-10 codes Z55-Z65 Potential health hazards related to socioeconomic and psychological circumstances: may be used by all providers as appropriate during the assessment period prior to diagnosis and do not require certification as, or supervision, of, an LPHA.

II. ICD-10 code Z03.89 Encounter for observation for other suspected diseases and conditions ruled out: may be used by an LPHA during the assessment phase of a client’s treatment when a diagnosis has yet to be established.

III. CMS approved diagnosis code on the ICD 10 tabular, available in the CMS 2022 ICD-

10-CM page at: https://www.cms.gov/medicare/icd-10/2022-icd-10-cm, which may include Z codes. LPHAs may use any clinically appropriate ICD-10 code, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services”.

7. COORDINATION AND CONTINUITY OF CARE

A. Contractor shall comply with the care and coordination requirements established by the

County and per 42 C.F.R. § 438.208.

B. Contractor shall follow the County’s continuity of care policy that is in accordance with applicable state and federal regulations, MHSUDS IN 18-059 and any BHINs issued by DHCS for parity in mental health and substance use disorder benefits subsequent to the effective date of this Agreement (42 C.F.R. § 438.62(b)(1)-(2).)

C. Contractor shall ensure that all care, treatment, and services provided pursuant to this

Agreement are coordinated among all providers who are serving the client. Coordination and continuity of care procedures shall meet the following requirements:

I. Ensure that each client has an ongoing source of care appropriate to their needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the client. The client shall be provided information on how to contact their designated person or entity.

II. All services provided to clients shall be coordinated:

a. Between settings of care, including appropriate discharge planning for short-term and long-term hospital and institutional stays.

https://www.cms.gov/medicare/icd-10/2022-icd-10-cm

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

b. With the services the client receives from any other managed care organization.

c. With the services the client receives in FFS Medi-Cal.

d. With the services the client receives from community and social support providers.

III. Share with other providers serving the client, as allowed by regulations, the results of any identification and assessment of that client’s needs to prevent duplication of those activities.

IV. Ensure that each provider furnishing services to clients maintains and shares, as appropriate, a client health record in accordance with professional standards.

V. Ensure that in the process of coordinating care, each client’s privacy is protected in accordance with the privacy requirements in 45 C.F.R. Parts 160 and 164 subparts A and E and 42 C.F.R. Part 2, to the extent that they are applicable.

D. Contractor shall engage in care coordination activities beginning at intake and throughout the treatment and discharge planning processes.

E. To facilitate care coordination, Contractor will request a HIPPA and California law compliant client authorization to share client information with and among all other providers involved in the client’s care, in satisfaction of state, and federal privacy laws and regulations.

8. SITE LICENSES, CERTIFICATIONS, PERMITS REQUIREMENTS

A. As specified in BHIN 21-001, or any subsequent superseding DHCS notices, and in accordance with Health and Safety Code § 11834.015, DHCS adopted the ASAM treatment criteria as the minimum standard of care for licensed AOD facilities. All licensed AOD facilities shall obtain at least one DHCS LOC Designation and/or at least one residential

ASAM LOC Certification consistent with all of its program services. If an AOD facility opts to obtain an ASAM LOC Certification, then that facility will not be required to obtain a DHCS

LOC Designation. However, nothing precludes a facility from obtaining both a DHCS LOC

Designation and ASAM LOC Certification.

B. Contractor shall obtain and comply with DMC site certification and ASAM designation or

DHCS Level of Care Designation for each type of contracted service being delivered, as well

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA as any additional licensure, registration or accreditation required by regulations for the contracted service being delivered.

C. Contractor shall obtain and maintain all appropriate licenses, permits, and certificates required by all applicable federal, state, and county and/or municipal laws, regulations, guidelines, and/or directives.

D. Contractor shall have and maintain a valid fire clearance at the specified service delivery sites where direct services are provided to clients.

9. MEDICATIONS

A. If Contractor provides or stores medications, the Contractor shall store and monitor medications in compliance with all pertinent statutes and federal standards.

B. Contractor shall have written policies and procedures regarding prescribed medications by clients, and for monitoring and storing of medications.

C. Prescription and over the counter medications which expire and other bio-hazardous pharmaceutics including used syringes or medications which are not removed by the client upon termination of services shall be disposed of by the program director or a designated substitute, and one other adult who is not a client. Both shall sign a record, to be retained for at least one year.

D. Contractor shall have at least one program staff on duty at all times trained to adequately monitor clients for signs and symptoms of their possible misuse of prescribed medications, adverse medication reactions and related medical complications.

10. ALCOHOL AND/OR DRUG-FREE ENVIRONMENT

A. Contractor shall provide an alcohol and/or drug-free environment for clients. The use of medications for the treatment of SUD, mental illness, or physical conditions, shall be allowed and controlled as per Contractor’s written policies and procedures.

B. Contractor shall have written policies regarding service delivery for when clients experience relapse episodes. These policies shall be supportive of and consistent with the alcohol and/or drug-free environment of the program.

11. ASSESSMENT OF TOBACCO USE DISORDER

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

A. As required by Assembly Bill (AB) 541 and BHIN 22-024, all licensed and/or certified SUD recovery or treatment facilities shall conduct an assessment of tobacco use at the time of the client’s initial intake. The assessment shall include questions recommended in the most recent version of Diagnostic and Statistical Manual of Mental Disorders (DSM) under

Tobacco Use Disorder, or County’s evidence-based guidance, for determining whether a client has a tobacco use disorder.

B. The licensed and/or certified SUD recovery or treatment facility shall do the following:

I. Provide information to the client on how continued use of tobacco products could affect their long-term success in recovery from SUD.

II. Recommend treatment for tobacco use disorder in the treatment plan.

III. Offer either treatment, subject to the limitation of the license or certification issued by DHCS, or a referral for treatment for tobacco use disorder.

C. Licensed and/or certified SUD recovery or treatment facilities can also adopt tobacco free campus policies, to change the social norm of tobacco use, promote wellness, and reduce exposure to secondhand smoke.

12. NALOXONE REQUIREMENTS

A. As required by AB 381, Health and Safety Code, § 11834.26, and BHIN 22-025, or any subsequent superseding DHCS notices, all licensed and/or certified SUD recovery or treatment facilities shall comply with the following requirements:

I. Maintain, at all times, at least 2 unexpired doses of naloxone, or any other opioid antagonist medication that is approved by the FDA for the treatment of an opioid overdose, on the premises of the licensed SUD recovery or treatment facility.

II. Have at least one staff member, at all times, on the premises who knows the specific location of the naloxone, or other FDA-approved opioid antagonist medication, and who has been trained in its administration. Training shall include review of online resources and the National Harm Reduction Coalition’s Opioid Overdose Basics website to respond effectively to an opioid-associated overdose emergency. Staff shall certify that they have reviewed and undergone training in opioid overdose prevention and treatment.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

III. The proof of completion of such training shall be documented in the staff member’s individual personnel file, in accordance with California Code of Regulations (CCR), Title

9, § 10564(k).

Article 4. AUTHORIZATION AND DOCUMENTATION PROVISIONS

1. SERVICE AUTHORIZATION

A. Contractor will collaborate with County to complete authorization requests in line with

County and DHCS policy.

B. Contractor shall respond to County in a timely manner when consultation is necessary for

County to make appropriate authorization determinations.

C. County shall provide Contractor with written notice of authorization determinations within the timeframes set forth in BHIN 24-001, or any subsequent superseding DHCS notices, the

Intergovernmental Agreement, or any subsequent DHCS notices.

D. For SUD Non-Residential and Non-Inpatient Levels of Care service authorization:

I. Contractor shall follow County’s policies and procedures around non-residential/non-inpatient levels of care according to BHIN 24-001, or any subsequent superseding

DHCS notices.

II. Contractor is not required to obtain service authorization for non-residential/non-inpatient levels of care. Prior authorization is prohibited for non-residential DMC-ODS services.

E. For SUD Residential and Inpatient Levels of Care service authorization:

I. Contractor shall have in place, and follow, County written authorization policies and procedures for processing requests for initial and continuing authorization, or prior authorization, for residential treatment services, including inpatient services, but excluding withdrawal management services.

II. County will review the DSM and ASAM Criteria to ensure that the beneficiary meets the requirements for the service.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

III. Prior authorization for residential and inpatient services (excluding withdrawal management services) shall be made within 24 hours of the prior authorization request being submitted by the provider.

F. County will ensure that prior authorization processes are completed in a manner that assures the provision of a covered SUD service to a client in a timely manner appropriate for the client’s condition.

G. Contractor shall alert County when an expediated service authorization decision is necessary due to a client’s specific needs and circumstances that could seriously jeopardize the client’s life or health, or ability to attain, maintain, or regain maximum function. Expediated service authorizations shall not exceed 72 hours after receipt of the request for service, with a possible extension of up to 14 calendar days if the client or provider requests an extension.

H. Contractor shall alert County when a standard authorization decision is necessary. Standard service authorizations shall not exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days if the client or provider requests an extension.

I. Contractor, if applicable, shall ensure that length of stay (LOS) in residential program complies with the following:

I. LOS shall be determined by individualized clinical need (statewide LOS goal is 30 days).

LOS for clients shall be determined by an LPHA and authorized by the County as medically necessary.

II. Clients receiving residential treatment must be transitioned to another LOC when clinically appropriate based on treatment progress.

III. Perinatal clients may receive a longer LOS than those described above, if determined to be medically necessary.

IV. Nothing in this section overrides any EPSDT requirements. EPSDT clients may receive a longer length of stay based on medical necessity.

2. CONCURRENT REVIEWS

A. Programs that do not require prior authorization may utilize the initial referral from the

County as initial authorization for the service in the County’s referral. However, the

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

Contractor shall provide all necessary documentation to the County for the purpose of reauthorization and concurrent reviews of such programs. The documentation shall clearly indicate the client’s mental health condition and justification of medical necessity.

B. If concurrent review results in denial of services, the Contractor shall not discontinue treatment until an appropriate care plan for the client has been identified and agreed upon with the County. The County will reimburse the Contractor for denied days at the

Administrative Day Rate as outlined in Exhibit B and according to the requirements detailed in Exhibit A .

3. DOCUMENTATION REQUIREMENTS

A. Contractor agrees to comply with documentation requirements for non-hospital services as specified in Article 4.2-4.9 inclusive in compliance with federal, state and County requirements.

B. All Contractor documentation shall be accurate, complete, legible, and shall list each date of service. Contractor shall document the face-to-face duration of the service, including travel and documentation time for each service. Services must be identified as provided in-person, by telephone, or by telehealth.

C. All services shall be documented utilizing an Electronic Health Record system which complies with state, federal, and County requirements. Contractor agrees to satisfy the chart documentation requirements set forth in BHIN 22-019, or any subsequent superseding

DHCS notices, and the contract between County and DHCS. Failure to comply with documentation standards specified in this Article require corrective action plans.

4. ASSESSMENT

A. Contractor shall use the American Society of Addiction Medicine (ASAM) Criteria assessment for DMC-ODS clients to determine the appropriate level of SUD care.

B. The assessment shall include a typed or legibly printed name, signature of the service provider and date of signature. Assessment shall include the provider’s LOC determination and recommendation for services. If the assessment of the client is completed by a registered or certified counselor, then the LPHA shall evaluate that assessment with the counselor and the LPHA shall make the initial diagnosis. The consultation between the LPHA

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA and the registered or certified counselor can be conducted in person, by video conferencing, or by telephone.

C. The problem list and progress note requirements shall support the medically necessary services or medical necessity of each service provided.

D. Assessments shall be updated as clinically appropriate when the beneficiary’s condition changes. Additional information on assessment requirements can be found in Article 3

Section 2 Access to Substance Use Disorder Services or BHIN 24-001, or any subsequent superseding DHCS notices.

5. ICD-10

A. Contractor shall use the criteria set forth in the current edition of the DSM as the clinical tool to make diagnostic determinations.

B. Once a DSM diagnosis is determined, the Contractor shall determine the corresponding diagnosis in the current edition of ICD. Contractor shall use the ICD diagnosis code(s) to submit a claim for SUD services to receive reimbursement from County.

C. Under the EPSDT mandate, for youth under the age of 21, a diagnosis from the ICD-10 for

Substance-Related and Addictive Disorders is not required for early intervention services.

D. The ICD Tabular List of Diseases and Injuries is maintained by CMS and may be updated during the term of this Agreement. Changes to the lists of ICD diagnoses do not require an amendment to this Agreement, and County may implement these changes as provided by

DHCS.

6. PROBLEM LIST

A. Contractor will create and maintain a Problem List for each client served under this

Agreement. The problem list is a list of symptoms, conditions, diagnoses, and/or risk factors identified through assessment, psychiatric diagnostic evaluation, crisis encounters, or other types of service encounters.

B. Contractor must document a problem list that adheres to industry standards utilizing at minimum SNOMED International, Systematized Nomenclature of Medicine Clinical Terms

(SNOMED CT®) U.S. Edition, March 2021 Release, and ICD-10-CM 2023.

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

C. A problem identified during a service encounter may be addressed by the service provider

(within their scope of practice) during that service encounter and subsequently added to the problem list.

D. The problem list shall be updated on an ongoing basis to reflect the current presentation of the client.

E. The problem list shall include, but is not limited to the following:

I. Diagnoses identified by a provider acting within their scope of practice, if any. Diagnosis-specific specifiers from the current DSM shall be included with the diagnosis, when applicable.

II. Problems identified by a provider acting within their scope of practice, if any.

III. Problems or illnesses identified by the client and/or significant support person, if any.

IV. The name and title of the provider that identified, added, or removed the problem, and the date the problem was identified, added, or removed.

F. Contractor shall add to or remove problems from the problem list when there is a relevant change to a beneficiary’s condition.

G. County does not require the problem list to be updated within a specific timeframe or have a requirement about how frequently the problem list should be updated after a problem has initially been added. However, Contractor shall update the problem list within a reasonable time such that the problem list reflects the current issues facing the client, in accordance with generally accepted standards of practice and in specific circumstances specified in BHIN 22-019, or any subsequent superseding DHCS notices.

7. PROGRESS NOTES

A. Contractor shall create progress notes for the provision of all DMC-ODS services provided under this Agreement.

B. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description.

C. Progress notes shall include all elements specified in BHIN 23-068, or any subsequent superseding DHCS notices, , whether the note be for an individual or group service, and shall include:

AGREEMENT FOR SUBSTANCE USE TREATMENT SERVICES FOR [ADULTS or ADOLESCENTS] BETWEEN THE COUNTY OF SANTA

I. The type of service rendered

II. A narrative describing the service, including how the service addressed the client’s behavioral health need (e.g., symptom, condition, diagnosis, and/or risk factors)

III. The date that the service was provided to the beneficiary

IV. Duration of the service, including travel and documentation time

V. Location of the client at the time of receiving the service

VI. A typed or legibly printed name, signature of the service provider and date of signature

VII. ICD-10 code

VIII. Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System

(HCPCS) code

D. Next steps, including, but not limited to, planned action steps by the provider or by the client, collaboration with the client, collaboration with other provider(s) and any update to the problem list as appropriate.

E. Contractor shall complete progress notes within three business days of providing a service, with the exception of notes for crisis services, which shall be completed within 24 hours.

F. Contractor shall complete a daily progress note for services that are billed on a daily basis, such as residential and inpatient services, if applicable.

G. When a group service is rendered by the Contractor, the following conditions shall be met:

I. A list of participants is required to be documented and maintained by the Contractor.

II. If more than one provider renders an outpatient group service, one progress note may be completed for a group session and signed by one provider.