Attachment E-Sample Contract.pdf

Contract Number SAMPLE

STATE OF OREGON

PERSONAL/PROFESSIONAL SERVICES CONTRACT

You can get this document in other languages, large print, braille, or a format you prefer free of charge. Contact the Contract Administrator at the contact information found below. We accept all relay calls.

This Contract is between the State of Oregon, acting by and through its Oregon Department of

Human Services, hereinafter referred to as “ODHS,” and

Contractor d.b.a. Facility or Assumed Name

Address

Address

Attention: (required)

Telephone: (required)

Fax: (optional)

E-mail address: (required) hereinafter referred to as “Contractor.”

Work to be performed under this Contract relates principally to ODHS’

(Fill in with name of Office, Program, etc.)

(Insert address)

(Insert city, state, zip)

Contract Administrator: (Insert Name) or delegate

Telephone: (Required)

E-mail address: (Required)

SAMPLE CONTRACT/KJM Page 2 of 53

ODHS PSK (reviewed by DOJ 8/30/2018) Updated: 5/2/2024

1. Effective Date and Duration. This Contract shall become effective on the later of: (I) the last date all required signatures in Section 6., below have been obtained, or (II)

[insert start date] provided it is (i) signed by all parties on or before such date, and (ii) when required, approved in writing by the Oregon Department of Justice on or before such date, and (iii) when required, approved in writing by the Oregon Department of

Administrative Services. Unless extended or terminated earlier in accordance with its terms, this Contract shall expire on March 31, 2025. Contract termination shall not extinguish or prejudice ODHS’ right to enforce this Contract with respect to any default by Contractor that has not been cured.

2. Contract Documents.

a. This Contract consists of this document and includes the following listed exhibits which are incorporated into this Contract:

(1) Exhibit A, Part 1: Statement of Work

(2) Exhibit A, Part 2: Payment and Financial Reporting

(3) Exhibit A, Part 3: Special Provisions

(4) Exhibit B: Standard Terms and Conditions

(5) Exhibit C: Insurance Requirements

(6) Exhibit D: Federal Terms and Conditions

There are no other contract documents unless specifically referenced and incorporated into this Contract.

b. This Contract and the documents listed in Section 2., “Contract Documents”, Subsection a. above, shall be in the following descending order of precedence:

this Contract less all exhibits, Exhibits D, B, A, and C.

3. Consideration.

a. The maximum, not-to-exceed compensation payable to Contractor under this

Contract, which includes any allowable expenses, is $[insert amount]. ODHS will not pay Contractor any amount in excess of the not-to-exceed compensation of this Contract for completing the Work, and will not pay for Work performed before the date this Contract becomes effective or after the termination or expiration of this Contract. If the maximum compensation is increased by amendment of this Contract, the amendment must be fully effective before

Contractor performs Work subject to the amendment.

b. Payments to Contractor shall be subject to ORS 293.462, and shall be made in accordance with the payment schedule and requirements in Exhibit A, Part 2., “Payment and Financial Reporting.”

c. ODHS will only pay for completed Work under this Contract. For purposes of this

Contract, “Work” means the tasks or services and deliverables accepted by ODHS as described in Exhibit A, Part 1, “Statement of Work.”

4. Contractor Determination. In accordance with the State Controller’s Oregon

Accounting Manual, policy 30.40.00.104, ODHS’ determination is that:

Contractor is a contractor Not applicable

Assistance Listings number(s) of federal funds to be paid through this Contract: 93.778

SAMPLE CONTRACT/KJM Page 3 of 53

5. Contractor Information and Certification.

(1) Contractor Information. This information is requested pursuant to ORS 305.385 and OAR 125-246-0330(1).

PLEASE PRINT OR TYPE THE FOLLOWING INFORMATION

Contractor Name (exactly as filed with the IRS):

Street address:

City, state, zip code:

Email address:

Telephone: ( ) Fax: ( )

Is Contractor a nonresident alien, as defined in 26 U.S.C. § 7701(b)(1), a foreign person, or a foreign entity? (Check one box): YES NO

Business Designation. (Check one box):

Professional Corporation Nonprofit Corporation Limited Partnership

Limited Liability Company Limited Liability Partnership Sole Proprietorship

Corporation Partnership Other

Contractor Proof of Insurance. Contractor shall provide the following information upon submission of the signed Contract. All insurance listed herein and required by Exhibit C must be in effect prior to Contract execution.

Professional Liability Insurance Company: ___________________________________________

Policy #: ______________________________________ Expiration Date: ________________

Commercial General Liability Insurance Company: ____________________________________

Policy #: ______________________________________ Expiration Date: ________________

Automobile Liability Insurance Company: ___________________________________________

Policy #: ______________________________________ Expiration Date: ________________

Workers’ Compensation. Does Contractor have any subject workers, as defined in ORS

656.027? (Check one box): YES NO If YES, provide the following information:

Workers’ Compensation Insurance Company: ________________________________________

Policy #: ______________________________________ Expiration Date: ________________

(2) Certification. Without limiting the generality of the foregoing, by signature on this Contract, the undersigned hereby certifies under penalty of perjury that:

(1) Contractor is in compliance with all insurance requirements in Exhibit C of this Contract, and notwithstanding any provision to the contrary, Contractor shall deliver to the ODHS Contract Administrator (see page

SAMPLE CONTRACT/KJM Page 4 of 53 one of this Contract) the required Certificate(s) of Insurance within 30 days of execution of this Contract. By certifying compliance with all insurance as required by this Contract, Contractor acknowledges it may be found in breach of the Contract for failure to obtain required insurance.

Contractor may also be in breach of the Contract for failure to provide

Certificate(s) of Insurance as required and to maintain required coverage for the duration of the Contract;

(2) Contractor acknowledges that the Oregon False Claims Act, ORS 180.750 to 180.785, applies to any “claim” (as defined by ORS 180.750) that is made by (or caused by) the Contractor and that pertains to this Contract or to the project for which the Contract work is being performed. Contractor certifies that no claim described in the previous sentence is or will be a

“false claim” (as defined by ORS 180.750) or an act prohibited by ORS

180.755. The Oregon Attorney General may enforce the liabilities and penalties provided by the Oregon False Claims Act against the Contractor, in addition to any remedies that may be available to ODHS under this

Contract;

(3) The undersigned is authorized to act on behalf of Contractor and represents and warrants that Contractor has complied with the tax laws of the State of Oregon and the applicable tax laws of any political subdivision of Oregon. Contractor shall, throughout the duration of this

Contract and any extensions, comply with all tax laws of this state and all applicable tax laws of any political subdivision of Oregon. For the purposes of this Section, “tax laws” includes: (i) All tax laws of Oregon, including but not limited to ORS 305.620 and ORS chapters 316, 317, and

318; (ii) Any tax provisions imposed by a political subdivision of Oregon that applied to Contractor, to Contractor’s property, operations, receipts, or income, or to Contractor’s performance of or compensation for any work performed by Contractor; (iii) Any tax provisions imposed by a political subdivision of Oregon that applied to Contractor, or to goods, services, or property, whether tangible or intangible, provided by

Contractor; and (iv) Any rules, regulations, charter provisions, or ordinances that implemented or enforced any of the foregoing tax laws or provisions.

Contractor acknowledges that the Oregon Department of Administrative

Services will report this Contract to the Oregon Department of Revenue

(DOR). The DOR may take any and all actions permitted by law relative to the collection of taxes due to the State of Oregon or a political subdivision, including: (i) garnishing the Contractor’s compensation under this Contract; or (ii) exercising a right of setoff against Contractor’s compensation under this Contract for any amounts that may be due and unpaid to the State of Oregon or its political subdivisions for which the

DOR collects debts;

(4) The information shown in Section 5.a., “Contractor Information” above is

Contractor’s true, accurate and correct information;

SAMPLE CONTRACT/KJM Page 5 of 53

(5) To the best of the undersigned’s knowledge, Contractor has not discriminated against and will not discriminate against minority, women or emerging small business enterprises certified under ORS 200.055 in obtaining any required subcontracts;

(6) Contractor and Contractor’s employees and agents are not included on the list titled “Specially Designated Nationals” maintained by the Office of

Foreign Assets Control of the United States Department of the Treasury and currently found at: https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx;

(7) Contractor is not listed on the non-procurement portion of the General

Service Administration’s “List of Parties Excluded from Federal procurement or Non-procurement Programs” currently found at:

https://www.sam.gov/SAM;

(8) Contractor is not subject to backup withholding because:

(a) Contractor is exempt from backup withholding;

(b) Contractor has not been notified by the IRS that Contractor is subject to backup withholding as a result of a failure to report all interest or dividends; or

(c) The IRS has notified Contractor that Contractor is no longer subject to backup withholding; and

(9) Contractor’s Federal Employer Identification Number (FEIN) or Social

Security Number (SSN) provided to ODHS is true and accurate. If this information changes, Contractor shall provide ODHS with the new FEIN or SSN within 10 days.

***Remainder of this Page Intentionally Left Blank*** https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx https://www.sam.gov/SAM

SAMPLE CONTRACT/KJM Page 6 of 53

CONTRACTOR, BY EXECUTION OF THIS CONTRACT, HEREBY

ACKNOWLEDGES THAT CONTRACTOR HAS READ THIS CONTRACT,

UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND

CONDITIONS.

6. Signatures. This Contract and any subsequent amendments may be executed in several counterparts, all of which when taken together shall constitute one agreement binding on all parties, notwithstanding that all parties are not signatories to the same counterpart.

Each copy of the Contract and any amendments so executed shall constitute an original.

Contractor Name

By:

Authorized Signature Printed Name

Title Date

State of Oregon, acting by and through its Oregon Department of Human Services

By:

Authorized Signature Printed Name

Title Date

Approved by the Oregon Department of Administrative Services:

With Protect Form on, click here

Authorized Signature Title Date

Approved for Legal Sufficiency:

With Protect Form on, click here With Protect Form on, click here

Oregon Department of Justice Date

Reviewed by Office of Contracts and Procurement:

Approved via e-mail by

Contract Specialist Date

SAMPLE CONTRACT/KJM Page 7 of 53

EXHIBIT A

Part 1

Statement of Work

Homecare Worker

Program 1

Statement of Work will be negotiated between the successful Proposer and ODHS based on the RFA Statement of Work, the Proposal submitted by the successful Proposer, and other Program requirements.

Parties agree that there is no guarantee that any services will be scheduled and performed under the contract.

Program(s): Under this RFA, the Agency is providing 3 separate Program Statements of Work

(SOW) as outlined below. Resulting Contract will include the SOW(s) that Contractor has applied for only. Agency reserves the right to makes changes to the services in any resultant contract(s), as long as it is within the general SOW/Specifications surrounding the Provider Navigator program.

1. Program #1: Homecare Workers (Office of Aging and People with Disabilities)

Statement of Work to be Performed for Homecare Workers as follows:

a. Contractor through their provider navigators must ensure that the Agency

Provider Navigator program is available in each county within the Contractor’s assigned Service Area(s). All services must be delivered timely and in a person-centered manner. A back-up provider navigator must be available to assist when needed or when the primary provider navigator is unavailable. Services will be paid on work that is performed and allowable according to this Contract.

b. Service Area(s) that the Contractor is responsible to deliver provider navigator services in are:

Service Area County

Total

SAMPLE CONTRACT/KJM Page 8 of 53

c. Provide a monthly report to Agency highlighting success stories and challenges.

d. Agency will survey applicants and enrolled providers who have participated in provider navigator services within Contractor’s Service Area(s).

e. Agency will survey entities that make referrals to the provider navigator program within the Contractor’s Service Area (s). Contractor will receive written feedback with the survey results.

2. Specific Work to be Performed:

Contractor shall:

a. Require provider navigators to participate in all scheduled Agency trainings and meetings. If Contractor has more than one provider navigator, each provider navigator must participate in trainings and meetings.

(1) Provider navigators must participate in Agency required trainings and meetings.

(2) Provider navigators should be in attendance for the entire training or meeting, exceptions are allowed, but require prior notification.

(3) Notify Agency prior to the training or meeting if the provider navigator will be late or unable to attend.

(3) Provider navigators must participate in technical assistance sessions, as needed.

b. Acknowledge provider navigator referrals, including: self-referrals, within three business days of receipt.

c. Attempt to contact the applicant or enrolled provider within five business days of receiving the referral.

d. Complete a Provider Navigator Plan for each participant. Provide a copy of the checklist to the following:

(1) Applicant or enrolled provider;

(2) OHCC.

The plan must be sent to all parties within 3 business days of completing the plan.

Since the plan contains personally identifiable information, it must be sent via secure electronic email or by the postal service.

e. Provide services directly to applicants and enrolled providers based upon the needs and preferences listed in the Provider Navigator Plan. Services may include helping the applicant or enrolled provider with the following:

(1) Complete enrollment paperwork;

(2) Using ORCHARDS to complete a background check;

(3) Registering for new worker orientation and training with Carewell SEIU

503 Training;

(4) How to effectively communicate with the local office during the enrollment process;

(5) Next steps to take once an individual receives their provider number;

(6) Monitoring the applicant’s progress through the enrollment process;

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(7) Providing direction to ensure the applicant completes the enrollment process;

(8) How to register for and effectively use the Carina registry to find work;

(9) How to highlight the individual’s skills, abilities, and interests on Carina;

(10) Resume building;

(11) Effective interviewing skills;

(12) Verbal and written communication skills;

(13) Professionalism;

(14) The benefits of professional development and training through Carewell

SEIU 503 Training and the Oregon Home Care Commission;

(15) How to effectively network with other in-home providers;

(16) How to use the appropriate electronic visit verification (EVV) payment system;

(17) When to contact the local office or the Oregon Home Care Commission for help or to report issues;

(18) How to find and use available resources as a provider;

(19) Planning and time management skills;

(20) How to read and understand a task list or service agreement;

(21) How to track the individual’s credential end date and complete all required tasks for timely renewal.

(22) Computer literacy.

f. Contractor may provide group training sessions if Contractor so chooses.

The time the applicant or enrolled provider spends in group training sessions will be deducted from the maximum number of hours the applicant or enrolled provider is eligible to receive through this program.

3. Conflict of Interest:

Contractor may not:

a. Permit a person to serve as a provider navigator if any of the following apply:

(1) Serving in this role is likely to benefit that person or a member of their immediate family beyond usual compensation and employee benefits provided by Contractor;

(2) The person has a family or business relationship, including within

Contractor’s agency, with person(s) to whom they are providing services.

(3) The person is providing paid services as a HCW, PSW, or PCA.

b. Permit provider navigators to use their position for a purpose that may lead to perceived or actual personal financial gain. Contractor must have internal policies in place that restrict such conflicts of interest.

4. Applicant and Enrolled Provider Materials:

Contractor is responsible to develop and offer trainings and materials in formats and languages required by the applicant or enrolled provider on topics covered in the

Statement of Work. These materials must be reviewed by the contract administrator prior to use to ensure information does not conflict with program polices or state or federal

SAMPLE CONTRACT/KJM Page 10 of 53 rules or statutes. Agency will provide materials for use by provider navigators without charge that includes, but is not limited to, OR PTC DCI (provider time capture system), eXPRS (provider payment system), ORCHARDS, Carina, required training through

Carewell SEIU 503 Training, guides, enrollment agreements, program flyers, Provider

Navigator Plan, referral documents, reporting templates, and invoice template.

**Remainder of this Page Intentionally Left Blank.***

SAMPLE CONTRACT/KJM Page 11 of 53

Part 2

Personal Care Attendants

Program(s): Under this RFA, the Agency is providing 3 separate Program Statements of Work

(SOW) as outlined below. Resulting Contract will include the SOW(s) that Contractor has applied for only. Agency reserves the right to makes changes to the services in any resultant contract(s), as long as it is within the general SOW/Specifications surrounding the Provider Navigator program.

1. Program #2: Personal Care Attendants (Oregon Health Authority – Medicaid

Division)

Statement of Work to be Performed for Personal Care Attendants as follows:

a. Contractor through their provider navigators must ensure that the Agency

Provider Navigator program is available in each county within the Contractor’s assigned Service Area(s). All services must be delivered timely and in a person-centered manner. A back-up provider navigator must be available to assist when needed or when the primary provider navigator is unavailable. Services will be paid on work that is performed and allowable according to this Contract.

c. Provide a monthly report to Agency highlighting success stories and challenges.

SAMPLE CONTRACT/KJM Page 12 of 53

d. Agency will survey applicants and enrolled providers who have participated in provider navigator services within Contractor’s Service Area(s).

e. Agency will survey entities that make referrals to the provider navigator program within the Contractor’s Service Area (s). Contractor will receive written feedback with the survey results.

2. Specific Work to be Performed:

Contractor shall:

a. Require provider navigators to participate in all scheduled Agency trainings and meetings. If Contractor has more than one provider navigator, each provider navigator must participate in trainings and meetings.

(1) Provider navigators must participate in Agency required trainings and meetings.

(2) Provider navigators should be in attendance for the entire training or meeting, exceptions are allowed, but require prior notification.

(3) Notify Agency prior to the training or meeting if the provider navigator will be late or unable to attend.

(3) Provider navigators must participate in technical assistance sessions, as needed.

b. Acknowledge provider navigator referrals, including: self-referrals, within three business days of receipt.

c. Attempt to contact the applicant or enrolled provider within five business days of receiving the referral.

d. Complete a Provider Navigator Plan for each participant. Provide a copy of the plan to the following:

(1) Applicant or enrolled provider;

(2) OHCC.

The plan must be sent to all parties within 3 business days of completing the plan.

Since the plan contains personally identifiable information, it must be sent via secure electronic email or by the postal service.

e. Provide services directly to applicants and enrolled providers based upon the needs and preferences listed in the Provider Navigator Plan. Services may include helping the applicant or enrolled provider with the following:

(1) Completing provider enrollment paperwork;

(2) Using ORCHARDS to complete a background check;

(3) Registering for new worker orientation and training with Carewell SEIU

503 Training;

(4) How to effectively communicate with the local office during the enrollment process;

(5) Next steps to take once an individual receives their provider number;

(6) Monitoring the applicant’s progress through the enrollment process;

(7) Providing direction to ensure the applicant completes the enrollment process;

SAMPLE CONTRACT/KJM Page 13 of 53

(8) How to register for and effectively use the Carina registry to find work;

(9) How to highlight the individual’s skills, abilities, and interests on Carina;

(10) Resume building;

(11) Effective interviewing skills;

(12) Verbal and written communication skills;

(13) Professionalism;

(14) The benefits of professional development and training through Carewell

SEIU 503 Training and the Oregon Home Care Commission;

(15) How to effectively network with other in-home providers;

(16) How to enroll in eXPRS, complete the user enrollment form (UEF) for eXPRS access, use eXPRS resources, and eXPRS for use electronic visit verification (EVV) payments;

(17) When to contact the local office or the Oregon Home Care Commission for help or to report issues;

(18) How to find and use available resources as a provider;

(19) Planning and time management skills;

(20) How to read and understand a task list or service agreement;

(21) How to track the individual’s credential end date and complete all required tasks for timely renewal;

(22) Computer literacy;

(23) How to enroll with the fiscal intermediary, use their resources and system, and complete all required employee paperwork.

f. Contractor may provide group training sessions if Contractor so chooses.

The time the applicant or enrolled provider spends in group training sessions will be deducted from the maximum number of hours the applicant or enrolled provider is eligible to receive through this program.

3. Conflict of Interest:

Contractor may not:

a. Permit a person to serve as a provider navigator if any of the following apply:

(1) Serving in this role is likely to benefit that person or a member of their immediate family beyond usual compensation and employee benefits provided by Contractor;

(2) The person has a family or business relationship, including within

Contractor’s agency, with person(s) to whom they are providing services.

(3) The person is providing paid services as a HCW, PSW, or PCA.

b. Permit provider navigators to use their position for a purpose that may lead to perceived or actual personal financial gain. Contractor must have internal policies in place that restrict such conflicts of interest.

4. Applicant and Enrolled Provider Materials:

Contractor is responsible to develop and offer trainings and materials in formats and languages required by the applicant or enrolled provider on topics covered in the to use to ensure information does not conflict with program polices or state or federal

SAMPLE CONTRACT/KJM Page 14 of 53 rules or statutes. Agency will provide materials for use by Consultants without charge that includes, but is not limited to, OR PTC DCI (provider time capture system), EXPRS

(provider payment system), ORCHARDS, Carina, required training through Carewell

SEIU 503 Training, guides, enrollment agreements, program flyers, Provider Navigator

Plan, referral documents, reporting templates, and invoice template.

SAMPLE CONTRACT/KJM Page 15 of 53

Part 3

Personal Support Workers

Program(s): Under this RFA, the Agency is providing 3 separate Program Statements of Work

(SOW) as outlined below. Resulting Contract will include the SOW(s) that Contractor has applied for only. Agency reserves the right to makes changes to the services in any resultant contract(s), as long as it is within the general SOW/Specifications surrounding the Provider Navigator program.

1. Program #3: Personal Support Workers (Office of Developmental Disabilities

Services)

Statement of Work to be Performed for Personal Support Workers as follows:

a. Contractor through their provider navigators must ensure that the Agency

Provider Navigator program is available in each county within the Contractor’s assigned Service Area(s). All services must be delivered timely and in a person-centered manner. A back-up provider navigator must be available to assist when needed or when the primary provider navigator is unavailable. Services will be paid on work that is performed and allowable according to this Contract.

SAMPLE CONTRACT/KJM Page 16 of 53

c. Provide a monthly report to Agency highlighting success stories and challenges.

d. Agency will survey applicants and enrolled providers who have participated in provider navigator services within Contractor’s Service Area(s).

e. Agency will survey entities that make referrals to the provider navigator program within the Contractor’s Service Area (s). Contractor will receive written feedback with the survey results.

2. Specific Work to be Performed:

Contractor shall:

a. Require provider navigators to participate in all scheduled Agency trainings and meetings. If Contractor has more than one provider navigator, each provider navigator must participate in trainings and meetings.

(1) Provider navigators must participate in Agency required trainings and meetings.

(2) Provider navigators should be in attendance for the entire training or meeting, exceptions are allowed, but require prior notification.

(3) Notify Agency prior to the training or meeting if the provider navigator will be late or unable to attend.

(4) Provider navigators must participate in technical assistance sessions, as needed.

b. Acknowledge provider navigator referrals, including: self-referrals, within three business days of receipt.

c. Attempt to contact the applicant or enrolled provider within five business days of receiving the referral.

d. Complete a Provider Navigator Plan for each participant. Provide a copy of the plan to the following:

(a) Applicant or enrolled provider;

(b) OHCC.

The plan must be sent to all parties within 3 business days of completing the checklist. Since the checklist contains personally identifiable information, it must be sent via secure electronic email or by the postal service.

e. Provide services directly to applicants and enrolled providers based upon the needs and preferences listed in the Provider Navigator Plan. Services may include helping the applicant or enrolled provider with the following:

(1) Completing provider enrollment paperwork;

(2) Using ORCHARDS to complete a background check;

(3) Registering for new worker orientation and training with Carewell SEIU

503 Training;

(4) How to effectively communicate with the local office during the enrollment process;

(5) Next steps to take once an individual receives their provider number;

(6) Monitoring the applicant’s progress through the enrollment process;

SAMPLE CONTRACT/KJM Page 17 of 53

(7) Providing direction to ensure the applicant completes the enrollment process;

(8) How to register for and effectively use the Carina registry to find work;

(9) How to highlight the individual’s skills, abilities, and interests on Carina;

(10) Resume building;

(11) Effective interviewing skills;

(12) Verbal and written communication skills;

(13) Professionalism;

(14) The benefits of professional development and training through Carewell

SEIU 503 Training and the Oregon Home Care Commission;

(15) How to effectively network with other in-home providers;

(16) How to use the appropriate electronic visit verification (EVV) payment system;

(17) When to contact the local office or the Oregon Home Care Commission for help or to report issues;

(18) How to find and use available resources as a provider;

(19) Planning and time management skills;

(20) How to read and understand a task list or service agreement;

(21) How to track the individual’s credential end date and complete all required tasks for timely renewal.

(22) Computer literacy.

f. Contractor may provide group training sessions if Contractor so chooses.

The time the applicant or enrolled provider spends in group training sessions will be deducted from the maximum number of hours the applicant or enrolled provider is eligible to receive through this program.

3. Conflict of Interest:

Contractor may not:

a. Permit a person to serve as a provider navigator if any of the following apply:

(1) Serving in this role is likely to benefit that person or a member of their immediate family beyond usual compensation and employee benefits provided by Contractor;

(2) The person has a family or business relationship, including within

Contractor’s agency, with person(s) to whom they are providing services.

(3) The person is providing paid services as a HCW, PSW, or PCA.

b. Permit provider navigators to use their position for a purpose that may lead to perceived or actual personal financial gain. Contractor must have internal policies in place that restrict such conflicts of interest.

4. Applicant and Enrolled Provider Materials:

Contractor is responsible to develop and offer trainings and materials in formats and languages required by the applicant or enrolled provider on topics covered in the

SAMPLE CONTRACT/KJM Page 18 of 53 to use to ensure information does not conflict with program polices or state or federal rules or statutes. Agency will provide materials for use by Consultants without charge that includes, but is not limited to, OR PTC DCI (provider time capture system), eXPRS

(provider payment system), ORCHARDS, Carina, required training through Carewell

SEIU 503 Training, guides, enrollment agreements, program flyers, Provider Navigator

Plan, referral documents, reporting templates, and invoice template.

SAMPLE CONTRACT/KJM Page 19 of 53

Payment and Financial Reporting

Homecare Worker

Program #1

Any financial reimbursement or reporting will be negotiated between ODHS, and the successful

Proposer based on the proposed Statement of Work, the Proposer’s successful Proposal and

Cost Proposal, and other Program factors.

1. Payment Provisions:

As consideration for the services provided by Contractor during the specified Section 1., Effective Date and Duration of this Contract, Agency will pay to Contractor, a maximum not to-exceed amount as specified in Section 3, Consideration Subsection a.

of this Contract, to be paid as follows:

a. Approved Billing Rates.

Billing maximums will be honored for each separate program.

(1) All Direct Services Provided: ODHS will pay to the Contractor the amount of $63.79 per hour, This hourly rate includes: individualized training and support, group training sessions, travel time to meet with applicants and enrolled providers or to a training site, and scheduling appointments. .

(2) All group training sessions: ODHS will pay to Contractor the amount of

$63.79 per hour regardless of the number of participants. Billing and reporting maximums will be honored for each separate program.

(3) All Billing Services ODHS will pay to the Contractor the amount of

$31.90 per hour. This hourly rate includes: reporting, group training session preparation and set-up, and compiling training materials for individual or group trainings. The hourly rate includes contractor attendance at required training and meetings with the Agency. Contractor may bill a maximum of four hours per month for billing and reporting.

Billing and reporting maximums will be honored for each separate program.

(4) ODHS will pay to Contractor a maximum of 20 hours per individual who receives provider navigator services. Additional hours may be approved at the discretion of the contract administrator. based on the specific needs of the applicant or enrolled provider, or if the individual is applying for multiple provider types or has multiple provider numbers (i.e., homecare worker, personal support worker, or personal care attendant).

SAMPLE CONTRACT/KJM Page 20 of 53

(5) Cancellation and No-Show Fees:

ODHS will pay the Contractor for the following circumstances:

(a) Contractor has a confirmed appointment with an applicant or enrolled provider who does not show up for their appointment:

i. $31.90, up to half-an-hour for- in-person appointments; or

ii. $15.95 for a quarter-hour for phone or virtual appointments.

2. Reimbursement.

Reimbursements will be made at the rate in effect at the time of travel. Reporting maximums will be honored for each separate program Reimbursements will be allowed for the following:

a. Mileage at the IRS per mile rate in effect at the time of travel.

b. Postage reimbursement will be allowed to mail materials to applicants and enrolled providers when in-person delivery is not possible. Receipts are required for reimbursement.

c. The cost of materials provided to applicants or enrolled providers as part of individual or group training such as binders, tab and pocket dividers, or page protectors. Receipts are required for reimbursement. The cost of other materials may be reimbursed if approved by the contract administrator.

d. The cost of interpreter services or translating materials with prior approval based on submitted quote. Receipts are required for reimbursement.

3. Monthly Billing and Statistical Reports:

a. Contractor shall submit an electronic Monthly Billing Report on a form supplied by Agency, no later than the 10th day of the month (or next business day, if the

10th falls on a weekend or holiday) following the month in which services were provided. Contractor shall email an invoice signed by an authorized representative within three business days of notice of acceptance by Agency. Invoices may be sent to the contract administrator named on the cover page of this contract.

(1) If contractor has more than one program, separate invoices will be due;

(2) If unable to provide billing on the appointed day, contractor shall request an extension from the contract administrator.

b. Contractor shall use the invoice template provided by the Agency. Contractor will be required to use the invoice to report the following:

(1) Applicant or enrolled provider’s name and provider type;

(2) Specific services provided with the date and total number of minutes or hours provided per service;

SAMPLE CONTRACT/KJM Page 21 of 53

(3) Expenses requiring reimbursement.

c. Contractor shall provide the following information when submitting monthly invoices:

(1) Number of referrals received by provider type during the month;

(2) Case management entities that submitted referrals during the month;

(3) Counties where services were provided during the month;

(4) Number of self-referrals received during the month;

(5) Number of applicants by applicant type who accepted services during the month;

(6) Number of enrolled providers by provider type who accepted services during the month;

(7) Number of applicants by applicant type who declined services during the month;

(8) Number of enrolled providers by provider type who declined services during the month;

(9) Reasons applicants or enrolled providers declined provider navigator services;

(10) Success stories;

(11) Challenging situations;

(12) Names of individuals discharged from the program during the month, the reason, and the total length of time they participated in the program.

4. Travel and Other Expenses:

Agency will reimburse Contractor for the services and travel identified in Exhibit A, Part

2, “Payment and Financial Reporting”, Section 1 “Payment Provisions”. Contractor shall not invoice, and Agency will not pay for any additional travel or other expenses not outlined above.

SAMPLE CONTRACT/KJM Page 22 of 53

Personal Care Attendants

Program #2

Effective Date and Duration of this Contract, Agency will pay to Contractor, a maximum not to-exceed amount as specified in Section 3, Consideration Subsection a. of this

Contract, to be paid as follows:

a. Approved Billing Rates.

(1) All Direct Services Provided: ODHS will pay to the Contractor the amount of $63.79 per hour, This hourly rate includes: individualized training and support, group training sessions, travel time to meet with applicants and enrolled providers or to a training site, and scheduling appointments. .

(2) ODHS will pay to Contractor the amount of $63.79 per hour for group training sessions regardless of the number of participants.

(3) All Billing Services Agency will pay to the Contractor the amount of

$31.90 per hour. reporting, group training session preparation and set-up, and compiling training materials for individual or group trainings. The hourly rate includes contractor attendance at required training and meetings with the Agency. Contractor may bill a maximum of four hours per month for billing and reporting. Billing and reporting maximums will be honored for each separate program.

(4) Agency will pay Contractor for a maximum of 20 hours per individual who receives provider navigator services. Additional hours may be approved at the discretion of the contract administrator. based on the specific needs of the applicant or enrolled provider, or if the individual is applying for multiple provider types or has multiple provider numbers (i.e.

homecare worker, personal support worker, or personal care attendant).

(5) Cancellation and No-Show Fees:

ODHS will pay the Contractor for the following circumstances:

(a) Contractor has a confirmed appointment with an applicant or enrolled provider who does not show up for their appointment:

SAMPLE CONTRACT/KJM Page 23 of 53

i. $31.90, up to half-an-hour for- in-person appointments; or

ii. $15.95 for a quarter-hour for phone or virtual appointments.

2. Reimbursement.

Reimbursements will be made at the rate in effect at the time of travel. Reimbursements will be allowed for the following:

a. Mileage at the IRS per mile rate in effect at the time of travel.

b. Postage reimbursement will be allowed to mail materials to applicants and enrolled providers when in-person delivery is not possible. Receipts are required for reimbursement.

c. The cost of materials provided to applicants or enrolled providers as part of individual or group training such as binders, tab and pocket dividers, or page protectors. Receipts are required for reimbursement. The cost of other materials may be reimbursed if approved by the contract administrator.

d. The cost of interpreter services or translating materials with prior approval based on submitted quote. Receipts are required for reimbursement.

3. Monthly Billing and Statistical Reports:

a. Contractor shall submit an electronic Monthly Billing Report on a form supplied by Agency, no later than the 10th day of the month (or next business day, if the

10th falls on a weekend or holiday) following the month in which services were provided. Contractor shall email an invoice signed by an authorized representative within three business days of notice of acceptance by Agency. Invoices may be sent to the contract administrator named on the cover page of this contract.

(1) If contractor has more than one program, separate invoices will be due;

(2) If unable to provide billing on the appointed day, contractor shall request an extension from the contract administrator.

b. Contractor shall use the invoice template provided by the Agency. Contractor will be required to use the invoice to report the following:

(1) Applicant or enrolled provider’s name and provider type;

(2) Specific services provided with the date and total number of minutes or hours provided per service;

(3) Expenses requiring reimbursement.

c. Contractor shall provide the following information when submitting monthly invoices:

(1) Number of referrals received by provider type during the month;

SAMPLE CONTRACT/KJM Page 24 of 53

(2) Case management entities that submitted referrals during the month;

(3) Counties where services were provided during the month;

(4) Number of self-referrals received during the month;

(5) Number of applicants by applicant type who accepted services during the month;

(6) Number of enrolled providers by provider type who accepted services during the month;

(7) Number of applicants by applicant type who declined services during the month;

(8) Number of enrolled providers by provider type who declined services during the month;

(9) Reasons applicants or enrolled providers declined provider navigator services;

(10) Success stories;

(11) Challenging situations;

(12) Names of individuals discharged from the program during the month, the reason, and the total length of time they participated in the program.

d. Travel and Other Expenses:

Agency will reimburse Contractor for the services and travel identified in Exhibit A, Part

2, “Payment and Financial Reporting”, Section 1 “Payment Provisions”. Contractor shall

***Remainder of This Page Intentionally Left Blank***

SAMPLE CONTRACT/KJM Page 25 of 53

Program #3

Personal Support Workers

Effective Date and Duration of this Contract, Agency will pay to Contractor, a maximum not to-exceed amount as specified in Section 3, Consideration Subsection a. of this

Contract, to be paid to the Contractor as follows:

a. Approved Billing Rates.

(1) All Direct Services Provided: The amount of $63.79 per hour, The hourly rate includes: individualized training and support, group training sessions, travel time to meet with applicants and enrolled providers or to a training site, and scheduling appointments. .

a. The amount of $63.79 per hour for group training sessions regardless of the number of participants.

(2) All Billing Services: The amount of $31.90 per hour. reporting, group training session preparation and set-up, and compiling training materials for individual or group trainings. The hourly rate includes contractor attendance at required training and meetings with the Agency. Contractor may bill a maximum of four hours per month for billing and reporting. Billing and reporting maximums will be honored for each separate program.

(3) A maximum of 20 hours per individual who receives provider navigator services.

Additional hours may be approved at the discretion of the contract administrator.

based on the specific needs of the applicant or enrolled provider, or if the individual is applying for multiple provider types or has multiple provider numbers (i.e., homecare worker, personal support worker, or personal care attendant).

(4) Cancellation and No-Show Fees:

ODHS will pay the Contractor for the following circumstances:

SAMPLE CONTRACT/KJM Page 26 of 53

a. Contractor has a confirmed appointment with an applicant or enrolled provider who does not show up for their appointment:

i. $31.90, up to half-an-hour for- in-person appointments; or

ii. $15.95 for a quarter-hour for phone or virtual appointments.

2. Reimbursement.

Reimbursements will be made at the rate in effect at the time of travel. Reimbursements will be allowed for the following:

a. Mileage at the IRS per mile rate in effect at the time of travel.

b. Postage reimbursement will be allowed to mail materials to applicants and enrolled providers when in-person delivery is not possible. Receipts are required for reimbursement.

c. The cost of materials provided to applicants or enrolled providers as part of individual or group training such as binders, tab and pocket dividers, or page protectors. Receipts are required for reimbursement. The cost of other materials may be reimbursed if approved by the contract administrator.

d. The cost of interpreter services or translating materials with prior approval based on submitted quote. Receipts are required for reimbursement.

3. Monthly Billing and Statistical Reports:

a. Contractor shall submit an electronic Monthly Billing Report on a form supplied by Agency, no later than the 10th day of the month (or next business day, if the

10th falls on a weekend or holiday) following the month in which services were provided. Contractor shall email an invoice signed by an authorized representative within three business days of notice of acceptance by Agency. Invoices may be sent to the contract administrator named on the cover page of this contract.

(1) If contractor has more than one program, separate invoices will be due;

(2) If unable to provide billing on the appointed day, contractor shall request an extension from the contract administrator.

b. Contractor shall use the invoice template provided by the Agency. Contractor will be required to use the invoice to report the following:

(1) Applicant or enrolled provider’s name and provider type;

(2) Specific services provided with the date and total number of minutes or hours provided per service;

(3) Expenses requiring reimbursement.

c. Contractor shall provide the following information when submitting monthly invoices:

(1) Number of referrals received by provider type during the month;

SAMPLE CONTRACT/KJM Page 27 of 53

(2) Case management entities that submitted referrals during the month;

(3) Counties where services were provided during the month;

(4) Number of self-referrals received during the month;

(5) Number of applicants by applicant type who accepted services during the month;

(6) Number of enrolled providers by provider type who accepted services during the month;

(7) Number of applicants by applicant type who declined services during the month;

(8) Number of enrolled providers by provider type who declined services during the month;

(9) Reasons applicants or enrolled providers declined provider navigator services;

(10) Success stories;

(11) Challenging situations;

(12) Names of individuals discharged from the program during the month, the reason, and the total length of time they participated in the program.

d. Travel and Other Expenses:

Agency will reimburse Contractor for the services and travel identified in Exhibit A, Part

2, “Payment and Financial Reporting”, Section 1 “Payment Provisions”. Contractor shall

SAMPLE CONTRACT/KJM Page 28 of 53

Part 3

Special Provisions

1. Confidentiality of Information.

a. Client Information.

(1) All information as to personal facts and circumstances obtained by the

Contractor on the client (“Client Information”) shall be treated as privileged communications, shall be held confidential, and shall not be divulged without the written consent of the client, his or her guardian, or the responsible parent when the client is a minor child, or except as required by other terms of this Contract. Nothing prohibits the disclosure of information in summaries, statistical, or other forms which does not identify particular individuals.

(2) The use or disclosure of Client Information shall be limited to persons directly connected with the administration of this Contract. Confidentiality policies shall be applied to all requests from outside sources.

(3) If Contractor, or any of its officers, directors, employees, agents, or subcontractors receives or has access to confidential Social Security

Administration (SSA), or Federal Tax Information (FTI) records in the performance of Work under this Contract, Contractor shall comply, and ensure that all of Contractor’s officers, directors, employees, agents and subcontractors comply, with the following provisions:

(a) With respect to SSA records:

i. Provide a current list of employees and employees of any agent or subcontractor with access to SSA records;

ii. Adhere to the same security requirements as employees of

ODHS;

iii. Abide by all relevant Federal laws, restrictions on access, use, disclosure, and the security requirements contained within ODHS’ agreement with SSA;

iv. Provide its employees and agents the same security awareness training as ODHS employees; and

v. Include the provisions of this Section 1.a.(3)(a) in any subcontract.

(b) With respect to Federal Tax Information (FTI), as defined in IRS

Publication 1075:

i. Contractor and its officers, directors and employees with access to, or who use FTI provided by ODHS must meet

SAMPLE CONTRACT/KJM Page 29 of 53 the background check requirements defined in IRS

Publication 1075;

ii. Any FTI made available to Contractor shall be used only for the purpose of carrying out the provisions of this Contract.

Contractor shall treat all information contained in FTI as confidential and that information shall not be divulged or made known in any manner to any person except as may be necessary in the performance of this Contract. Inspection by or disclosure to anyone other than an officer or employee of the Contractor is prohibited;

iii. Contractor shall account for all FTI upon receipt and shall properly store all FTI before, during, and after processing.

In addition, all FTI related output and products will be given the same level of protection as required for the source material;

iv. No work involving FTI furnished under this Contract will be subcontracted without prior written approval of the IRS;

v. Maintain a list of employees who are authorized access to

FTI. Such list will be provided to ODHS and, upon request, to the IRS reviewing office; and

vi. Include the…