CN-640000-CL065-A2.pdf

Program Specific Model Attachment I (PSMAI)

Comprehensive Tubal Ligation Support Services

June 2024 DOH Contract #: CL068

Attachment I

A. Services to be Provided:

1. General Description:

a. General Statement: This contract is for the provision of tubal ligation and/or salpingectomy support services for clients who have been counseled, provided informed consent, and are referred to the Provider by the Department.

b. Authority:

1) Federal Law: Title X of the Public Health Service Act of 1970, Public Law 91-572, Population Research and Voluntary Family

Planning Programs, as revised.

2) Federal Regulation: 42 CFR Part 50, Subpart B, Sterilization of

Persons in Federally Assisted Family Planning Projects, as revised.

3) Section 381.0051, Florida Statutes, Comprehensive Family

Planning Act.

2. Definition of Terms:

a. Federal Tubal ligation and/or salpingectomy Regulations: Federal requirements and standards that regulate all tubal ligation and/or salpingectomy procedures performed or arranged by programs and supported in whole or in part by federal financial assistance. See Exhibit

A.

b. Informed Consent: Permission granted with the knowledge of the possible consequences, typically given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.

c. Medical Complications: An abnormal outcome or accident affecting the prognosis of the original outcome.

d. Tubal ligation and/or salpingectomy: medical or surgical procedures which leaves the female client permanently incapable of reproduction.

e. Tubal Ligation and/or Salpingectomy Support Services: Services that support the tubal ligation and/or salpingectomy surgical procedure and that may include anesthesia, use of surgical facilities and staff, hospitalization and/or pathology.

3. Clients to be Served: Persons who are at least 21 years old at the time the informed consent form is signed and who have been referred by the Department to Provider.

B. Manner of Service Provision:

1. Scope of Work: Provider will provide Tubal Ligation and/or Salpingectomy

Support Services to clients referred to it by the Department.

a. Task List: Provider will perform the following tasks:

1) Comply with Federal Regulation 42 CFR 59.5(a)(2), by furnishing services without subjecting individuals to any coercion to accept services or to employ or not to employ any particular methods of family planning. Ensure that acceptance of tubal ligation and/or salpingectomy services is solely on a voluntary basis and not made a prerequisite to eligibility for, or receipt of, any other services or assistance from or participation in any other program of Provider.

2) Comply with Federal Regulation 42 CFR Part 50, Subpart B, as outlined in Exhibit A, to determine client eligibility for tubal ligation and/or salpingectomy services.

3) Coordinate with the Department so that the informed consent process and performance of the Tubal Ligation and/or

Salpingectomy Support Services meet federal regulation timeframes, as outlined in Exhibit A.

4) Provide Tubal Ligation and/or Salpingectomy Support Services only to those clients who have signed an informed consent form at least 30 days, but not greater than 180 days, before the date of the tubal ligation and/or salpingectomy, except in the case of premature delivery or emergency abdominal surgery.

5) Provide Tubal Ligation and/or Salpingectomy Support Services only to those clients who are at least 21 years old at the time the informed consent form is signed.

6) In the case of emergency abdominal surgery, deliver ubal Ligation and/or Salpingectomy Support Services only to those clients who have given consent for the tubal ligation and/or salpingectomy and where at least 72 hours have passed since the client signed the informed consent form for tubal ligation and/or salpingectomy .

7) In the case of premature delivery, provide Tubal Ligation and/or

Salpingectomy Support Services only to clients who have given consent for a tubal ligation and/or salpingectomy by signing the informed consent form at least 30 days before the expected date of delivery, and where at least 72 hours have passed since the client signed the informed consent form for tubal ligation and/or salpingectomy .

8) Document client consent and determine when Tubal Ligation and/or Salpingectomy Support Services may be performed using the client’s completed informed consent form, Exhibit B.

9) On the date a procedure is to be performed, check the dates on the informed consent form to ensure the required timeframes regarding the client’s signature are in compliance with Federal

Tubal ligation and/or salpingectomy Regulations, as outlined in

Exhibit A.

10) If the client is medically cleared, perform the Tubal Ligation and/or

Salpingectomy Support Services and necessary follow-up.

11) After performing the Tubal Ligation and/or Salpingectomy Support

Services, the "Physician’s Statement" portion of the informed consent form, Exhibit B, must be completed, signed, and dated verifying that the eligibility requirements were met prior to performing the tubal ligation and/or salpingectomy procedure.

12) Should medical complications occur, provide medical care and any referrals deemed medically necessary.

13) All medical complications must be reported to the Department’s

Contract Manager in writing within 10 calendar days of the medical complication.

14) Within 30 days following the completion of the Tubal Ligation and/or Salpingectomy Support Services, the following information must be submitted to the Department’s Contract Manager and maintained in the client’s health record:

a) A copy of the client’s informed consent form, with all information completed, including the completed

“Physician’s Statement” portion of the consent form, Exhibit B.

b) Written documentation providing a detailed description of the procedure performed which will consist of a final written surgical report, progress notes from the medical record, or equivalent documentation as agreed to by the

Department’s Contract Manager.

15) Collect fees from third parties legally obligated to pay for Tubal

Ligation and/or Salpingectomy Support Services prior to billing the

Department for services provided through this contract. This includes the submission of all. information and completed consent forms for Medicaid reimbursement for eligible clients. Fees or donations may not be collected from clients who are provided tubal ligation and/or salpingectomy services through this contract.

16) Maintain documentation of all visits and tests including, but not limited to, the written surgical report describing the procedure, surgical method used, follow-ups (lab reports, etc.), and any significant findings or adverse reactions the client has experienced.

17) Maintain a copy of Section 1008, Title X, Public Health Service Act of 1970 (Public Law 91-572) which prohibits use of Title X funds in programs where abortion is a method of family planning throughout the contract term.

18) Maintain a copy of 42 CFR 59.5(a)(2), federal regulations governing Title X throughout the contract term.

19) Have 24-hour emergency services accessible throughout the contract term. Provide the Department the emergency service information within 5 business days from the date of contract execution. Instruct the client on how to receive access to emergency services before, or during, the client’s first visit.

b. Deliverables: Provider must complete and submit the following

Deliverable in the time and manner specified:

1) Monthly: Completed Tubal Ligation and/or Salpingectomy Support

Services performed with submission of supporting documentation in the time and manner specified in Tasks B.1.a.1) through

B.1.a.19).

c. Performance Measures: Deliverables must be met at the following minimum level of performance:

1) Deliverable B.1.b.1):

a) Federal Regulation 42 CFR 59.5(a)(2) must be complied with as specified.

b) Federal Regulation 42 CFR Part 50, Subpart B, must be complied with as specified.

c) The informed consent process and performance of Tubal

Ligation and/or Salpingectomy Support Services must meet federal regulation timeframes as specified.

d) Tubal Ligation and/or Salpingectomy Support Services must only be provided to clients who have signed an informed consent form as specified.

e) Tubal Ligation and/or Salpingectomy Support Services must only be provided to clients who are at least 21 years old at the time the informed consent form is signed as specified.

f) The “Physician’s Statement” portion of the informed consent form must be completed as specified.

g) Necessary medical care and referrals must be provided as specified.

h) All medical complications must be reported to the

Department’s Contract Manager as specified.

i) Fees must be collected from third parties legally obligated to pay for Tubal Ligation and/or Salpingectomy Support

Services as specified.

j) Documentation of all visits and tests must be maintained for each client as specified.

k) Have 24-hour emergency services available as specified.

2. Financial Consequences: Failure of Provider to complete or submit a deliverable in the time and manner specified in Section B.1.b., will result in a reduction in payment for that deliverable as follows:

a. Failure to comply with Federal Regulation 42 CFR 59.5(a)(2), as specified will result in a 2% reduction from that invoice payment amount.

b. Failure to comply with Federal Regulation 42 CFR Part 50, Subpart B, as specified will result in a 2% reduction from that invoice payment amount.

c. Failure to meet the informed consent process and performance of Tubal

Ligation and/or Salpingectomy Support Services within the federal regulation timeframes as specified will result in a 2% reduction from that invoice payment amount.

d. Failure to provide Tubal Ligation and/or Salpingectomy Support Services only to clients who have signed an informed consent form as specified will result in a 2% reduction from that invoice payment amount.

e. Failure to provide Tubal Ligation and/or Salpingectomy Support Services only to clients who are at least 21 years old at the time the informed consent form is signed as specified will result in a 2% reduction from that invoice payment amount.

f. Failure to complete the "Physician’s Statement" portion of the informed consent form as specified will result in a 2% reduction from that invoice payment amount.

g. Failure to provide necessary medical care and referrals as specified will

h. Failure to report all medical complications to the Department’s Contract

Manager as specified will result in a 2% reduction from that invoice payment amount.

i. Failure to collect fees from third parties legally obligated to pay for Tubal

Ligation and/or Salpingectomy Support Services as specified will result in a 2% reduction from that invoice payment amount.

j. Failure to maintain documentation of all visits and tests for each client as specified will result a 2% reduction from that invoice payment amount.

k. Failure to have 24-hour emergency services available as specified will

3. Service Delivery Location, Times, and Equipment

a. Service Delivery Location

1) The Tubal Ligation and/or Salpingectomy Support Services will be provided at the following location(s):

Surgery Center of Naples

11161 Health Park Blvd

Naples, Florida 34110

2) Facilities in which the services are provided must be maintained in conformance with the standards required by local, state, and federal laws and regulations. Provider will notify the Department’s

Contract Manager in writing 10 calendar days prior to providing services in another location.

b. Service Times: Provider will perform the services required by this contract at times that meet the needs of the clients, which may include unanticipated premature delivery and emergency abdominal surgery.

c. Equipment: Provider will furnish all equipment needed to perform services under the terms of this contract.

4. Staffing Requirements:

a. Staffing Levels: Provider must maintain sufficient staff to deliver the tubal ligation and/or salpingectomy services for referred clients.

b. Professional Qualifications:

1) The physician performing the tubal ligation and/or salpingectomy procedure and all staff required by Florida Statutes to have a license to practice must have the requisite Florida-issued professional license, which is current and active. All health care professionals must have experience in the area of the procedure they are performing and practice according to the constraints of their individual practice, licenses, acts, statutes, rules, and protocols.

2) All medical staff providing services under this contract will provide adequate liability insurance or other form of acceptable financial responsibility coverage on a comprehensive basis and will maintain such liability insurance or other form of financial.

responsibility coverage at all times during the existence of the contract.

3) Copies of documentation must be provided to the Department upon request.

c. Subcontractors: Provider may not subcontract any of the services and/or activities in this contract, without prior written approval from the

Department.

C. Method of Payment:

1. Payment: This is a fixed price, unit cost contract. The Department will pay for the

Deliverables outlined in section B.1.b., a total dollar amount not to exceed

$10,400.00, subject to the availability of funds. Payments are as follows:

a. The service unit, the unit price, and the maximum number of units allowed are specified below:

Maximum # of Units Unit Price

(services)

Tubal Ligation and/or 13 x $ 800

Salpingectomy Support Services

b. Payment will be made only for completed Tubal Ligation and/or

Salpingectomy Support Services unless the client is found medically unable to proceed with the tubal ligation and/or salpingectomy. A completed tubal ligation and/or salpingectomy consists of a pre-procedure office visit, the tubal ligation and/or salpingectomy procedure performed as provided in Section B.1., and appropriate documentation provided to the Department’s Contract Manager. Payment of the unit price is contingent upon services being provided and required documentation being submitted. The unit prices specified include the cost of any post-procedure office visit provided.

c. If a client is referred but is medically unable to proceed with the tubal ligation and/or salpingectomy or does not return for the tubal ligation and/or salpingectomy procedure after the pre-procedure office visit, Provider will receive $0.00 for the client’s office visit.

2. Unit of Service: A unit of service will consist of one month of completed deliverables, as specified in Section B.1.b. A month will include all deliverables due in that month, including any monthly or annual deliverables scheduled for delivery in a particular month.

3. Invoice Requirements:

a. Provider will request payment on a monthly basis through submission of a properly completed invoice (Exhibit C, or an invoice approved by the

Department) to the Department’s Contract Manager within 15 days following the end of the month for which the payment is being requested.

b. Payments will be authorized only for service units on the invoice which are performed in accordance with Section B.1.b. and other terms and conditions of this contract. The service units for which payment is requested, must not, either by themselves or cumulatively by totaling service units on previous invoices, exceed the total number of units or dollars authorized by this contract.

4. Supporting Documentation:

a. Budget: Attach a copy of the Department approved budget and budget narrative for the initial contract year upon contract execution. Each subsequent contract year, the budget must be submitted to the Contract

Manager for approval by May 1. Any revisions to an approved budget or budget narrative must be submitted to the Contract Manager for review and approval prior to implementation.

b. Quarterly Financial Report: Each contract year, Provider must submit a Quarterly Financial Report in the quarter specified by the Contract Manager. Each Quarterly Financial Report must state, by line item, all contract fund expenditures made by Provider to complete the deliverables under this contract. All Quarterly Financial Reports must be submitted to the Contract Manager within 30 calendar days following the quarter the report is due. For the fourth quarter of each contract year, submit the Annual Financial Report in accordance with section I.C.6.c. of the Department’s Standard Contract.

c. Documentation for Travel: Provider is not entitled to reimbursement for travel under this contract.

D. Special Provisions:

1. Contract Renewals: This contract may be renewed for no more than three years beyond the initial contract or for the term of the original contract, whichever is longer, under the same terms and conditions as the original contract. Renewals will be in writing, made by mutual agreement, and will be contingent upon satisfactory fiscal and programmatic performance evaluations as determined by the Department. Renewals are subject to the availability of funds.

2. Background and Drug Screening Requirements: Provider must comply with section L. Background Screening Requirements and Drug Screening

Requirements outlined in the Department’s Standard Contract. Funds received from this Contract cannot be used to meet this requirement.

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