ESBD_362501_1718219234840_MH CA Open Enrollment FY2024 FINAL.doc

MH Child & Youth Services

FY 2024

FY 2016

MHMR TARRANT

Mental Health Child and Youth Services

OPEN ENROLLMENT APPLICATION

The Texas Department of Health and Human Services (HHS) has authorized MHMR of Tarrant County (MHMR) to assemble a network of service providers to provide mental health services to children and youth in Tarrant County.

The goals of this network are:

1. To provide a comprehensive community system of services and supports.

2. To identify, implement, and evaluate successful programs based on client outcomes so that these efforts can be replicated.

3. To create meaningful cooperative relationships between MHMR and providers in the community.

4. To increase client access and allow client choice in the selection of qualified providers.

5. To provide quality services and achieve the desired outcomes at the most efficient cost possible.

This document requests participation from applicants for the purpose of providing mental health services as described in Attachment B to individuals described in Attachment A who reside in Tarrant County.

There is no guarantee of referral volume to any provider. It is expected that contracted programs/services will address issues of consumer choice, quality, access, price, and ultimate cost-benefit while assuring adherence to standards of care and service requirements.

Target Population The target population recipients are individuals determined eligible in accordance with the definitions established by HHS. (See Attachment A – Covered Individual Definition.) Designation of an individual as eligible for services must be made by MHMR and documented in each individual’s record maintained by MHMR.

Eligible Applicants

Applicants must be registered with the Secretary of State in Texas and have a Tax Identification Number. Individuals providing professional services must hold valid Texas licenses and/or certifications as required by state law. In any situation where a consortium of providers is applying, a single entity responsible for services delivered must be identified and the financial agent must be an organization with a demonstrated ability to manage funds. Applicants may not subcontract responsibilities for these services. All service providers must be eighteen (18) years of age or older. Applicants may not have been convicted of a crime relevant to a person’s duties including any sexual offense, drug-related offense, homicide, theft, assault, battery, or any other crime involving personal injury or threat to another person.

Contractor Citizenship and Immigration Status

Each applicant must submit the following documentation according to the following categories:

1. Sole-proprietor or self-employed contractors (no employees) must submit documentation that establishes both the contractor’s identity and eligibility to work in the United States. Such documentation as can be found in the “Lists of Acceptable Documents” from the I-9 form.

2. Those contractors which are incorporated or have employees and are contracted to provide services must submit a copy of the “Maintain Company” page from U.S. Citizenship and Immigration E-Verify website to prove enrollment. Agency may request screenshot of contractor’s 3 most recent new hires as indicated by a State auditor.

MHMR Responsibilities

MHMR will be responsible for making referrals, authorizing services, reviewing claims, and paying for appropriate, authorized services rendered by the Applicant. MHMR is also responsible for utilization management and quality assurance. The length and type of service will be determined in collaboration with the individual, his/her family (when appropriate), the provider, and MHMR. All services contracted by MHMR are reviewed for effectiveness and continued value to the individual (and when appropriate, the family) Reauthorization of any service is based on that review. MHMR ensures that contracted services addressing the needs of Covered Individuals are provided as required by the Texas Department of State Health Services and comply with the rules and standards adopted under Section 534.052 of the Texas Health and Safety Code. MHMR does not guarantee any referral volume to any Network Provider.

Provider Responsibilities

The Provider will be responsible for providing services as authorized by MHMR and specified in the individual’s plan of care. Provider must maintain all records regarding services rendered to individuals referred by MHMR for a period of five (5) years, and must allow MHMR immediate access during regular business hours to such records upon request. The Provider is required to comply with all state and federal laws regarding the confidentiality of consumers’ records and nondiscrimination. The Provider must perform criminal history checks on employees to ensure that individuals convicted of crimes against persons are not allowed to work with MHMR consumers. The Provider will obtain prior authorization, provide acceptable levels of care, maintain acceptable levels of liability insurance and appropriate licenses and accreditations. The Provider also agrees that its name may be used, along with a description of its facilities, care, and services in any information distributed by MHMR listing its providers. The Provider must comply with the rules and standards adopted under Section 534.052 of the Texas Health and Safety Code and applicable local, state, and federal laws, rules and regulations.

Application Instructions Applicants must follow the attached outline for submissions (see below) to facilitate objective review. MHMR reserves the right to reject any and all applications, to waive technicalities, and to accept any advantages deemed beneficial to MHMR and its clients.

Please be sure to answer every question. If the question does not apply to you or your organization, simply and clearly document “N/A.” All supporting documentation should be attached, including the “Texas Standardized Credentialing Application” which must be completed for each licensed individual providing services to Covered Individuals.

MHMR reserves the right to not evaluate incomplete enrollment Applications. False statements by any Applicant may disqualify the Application. Interviews or site visits may be conducted to further evaluate applications.

Applications must be sent to:

Kevin McClean, Sr. Director of Contracts Administration MHMR of Tarrant County

P.O. Box 2603

Fort Worth, Texas 76113

Applications may be sent by regular mail or special carrier. Applications may not be faxed.

Send two (2) copies of the Application with original signatures and two (2) signed Assurances signature pages.

The contents of all applications may be made available upon written request. Therefore, any information contained in the Application that is deemed to be proprietary or confidential in nature must clearly be so designated in the Application. Such information may still be subject to disclosure under the Public Information Act depending on opinions from the Attorney General’s office.

Questions regarding this Application should be directed to Kevin McClean at Provider.Relations@mhmrtc.org

· APPLICATION –

Please indicate service(s) you are applying for by checking in the box(es) below.

Refer to Attachment B for descriptions of services and rates.

Community Services

( Therapeutic Summer Camp ( Partial Hospitalization ( Intensive Out-Patient ( CBT Counseling

* Services require completion of the “Texas Standardized Credentialing Application” for licensed providers: http://www.mhmrtarrant.org/Business-Opportunities/Credentialing I.

BUSINESS DEMOGRAPHICS

Social Security #

Legal Name:

and/or Tax ID #:

DBA:

Address:

City:

Zip Code:

Business Phone:

Fax #:

Contact Person:

Title:

Phone:

Email:

Billing Address (if different from above):

City:

State:

Zip:

Business locations in this market area:

Street City County Zip Code

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

Indicate if you provide any of the following:

1. TTY/TTD (Hearing Impaired Services/Capabilities ( Yes ( No

2. American Sign Language ( Yes ( No

3. Handicap Accessible ( Yes ( No

4. Public Transportation Access ( Yes ( No

5. Bilingual Services (please list below) ( Yes ( No

Owners/Partners:

Name % Ownership If corporate, list organization

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

Certification Number if a Historically Underutilized Business:

Years in Operation:

No employee of MHMR or HHS, and no member of MHMR’s Board of Trustees can directly or indirectly receive any pecuniary interest from an award of the proposed contract. If such a situation exists, please explain in detail:

II. QUALITY MANAGEMENT/UTILIZATION MANAGEMENT

A. Provide copies of all licenses, credentials, certifications, and/or accreditations the organization or provider currently holds relative to this Application. Label as II.A.

B. Provide a summary of the most recent consumer satisfaction surveys or other on-going efforts to obtain and evaluate consumer satisfaction. Describe how this information was obtained and how it is used to improve quality:

C. Describe or attach your process to track, monitor and investigate critical incidents (e.g. serious injuries, serious medication errors):

III. SERVICES

A. Identify the services that the organization/provider will provide (Attach additional sheets for each service type if applying to provide more than one service):

B. Will the organization/provider have qualified staff available to administer medications or to supervise individuals in the self-administration of medication?

C. What times of day and what days of the week are services available? (Complete for each service being applied for):

Service Type: __________________________________

Service Type: __________________________________

D. How many individuals can the organization/provider serve?:

E. How long do people currently wait to get into the organization’s/provider’s services?:

F. Detail the specific population the organization/provider would serve. Include ages and level of severity and concurrent diagnoses:

G. Are there any restrictions on who the organization/provider will serve?

If yes, please explain:

H. Describe the organization’s/provider’s experience in working with persons with mental illness, over the last five (5) years:

I. Describe the organization’s/provider’s ability to work with persons who are hearing impaired, persons who have limited language skills, and persons who speak a language other than English:

J. Describe the organization’s/provider’s experience in working with persons with physical impairments and adaptive equipment:

K. Describe any specialized services you provide (ability to assist with eating, supervision, or self-medication, etc.):

L. Describe any “after hours” system for responding to client needs:

M. Can MHMR clients access services outside usual business hours?

N. Describe or attach (Label as III.N.) the organization’s/provider’s in-service training requirements for employees:

IV. FINANCIAL

A. Is the organization/provider incorporated as “Profit,” “Not-for-profit,” or “Other?”

If “Other,” please explain:

B. Does the organization/provider have sufficient reserves or line of credit to operate during the time period between billing and receiving reimbursement from third party payors?

If not, please explain:

C. Has the organization/provider declared any type of bankruptcy in the prior seven (7) years?

D. Has the organization/provider received a “qualified” opinion on a financial statement in the past three (3) years? _________ If yes, please explain:

Does the most recent audit report have any material instance of non-compliance with standard accounting practices? _______ If yes, please explain:

E. Describe any arrangements to subcontract part or all of these services. Name all subcontractors and attach (Label as IV.E.) information on their staff credentials, licenses and certifications:

F. Is the organization/provider currently under investigation, or had a license or accreditation revoked by any state/federal/MHMR or licensure agency, within the last five (5) years?

G. Has the organization/provider had any judgments or settlements against it within the last ten (10) years? _________ If yes, please explain:

H. Has the organization/provider been placed on “vendor hold” by any agency or government entity in the past three (3) years? _______ If yes, please explain:

I. Does the organization/provider have a “Letter of Good Standing” which verifies that it is not delinquent in State Franchise Tax? ____________ Corporations that are non-profit or exempt from Franchise Tax are not required to have this letter, but will have a 501C IRS Exemption form from the Comptroller’s Office. Attach the letter or exception form. Label as IV.I.

J. Is the organization/provider delinquent in the payment of any court-ordered Child Support Payments? _________ If yes, explain:

K. Is the organization/provider currently held in abeyance or barred from the award of a federal or state contract? _______________ If yes, has this occurred in the last five (5) years? __________

If yes, explain:

L. Describe any contracts, Memoranda of Understanding, or employment relationship the organization or provider has with other state, city or county agencies in the Tarrant County community.

V. RISK ASSESSMENT

A. Does anyone working for the organization/provider providing direct care or in management have any felony convictions? __________ If yes, explain.

Describe the process, if any, the organization/provider uses to check on previous convictions of employees. Describe or attach (Label as V.A.) any policies and procedures regarding the hiring and retention of persons with criminal histories:

B. Has the organization/provider or its employees had any validated client abuse, client neglect, or rights violations claims in the last three (3) years? _________ If yes, explain in detail:

Describe or attach (Label as V.B.) any current policies and procedures regarding client abuse, client neglect, or rights violations and the training of staff on these issues:

C. Provide a Certificate of Insurance showing liability insurance coverage (property and vehicles, including riders) and include directors’ and officers’ professional liability, errors and omissions, and general liability insurance. Label as V.C.

D. Provide the name of Workers’ Compensation carrier if the organization/provider has Workers’ Compensation coverage, or self-funding documents if self-funded. Label as V.D.

E. Does the organization/provider currently have any malpractice claims pending or closed during the past five (5) years? _________ If yes, please supply the following information: Label as V.E.

1. Letter from your attorney explaining the facts of the case

2. Copies of the complaint and judgment

3. Name of malpractice carrier that handled the claim and firm representing the carrier

VI. INFORMATION SYSTEMS

Can the organization/provider report data by the following categories?:

1. Client name

2. Client’s MHMR identification number

3. Date, number, type, and duration of services rendered

4. Authorization number

5. Amount to be paid

6. If medications are administered or supervised, number, type, and severity of medication errors and adverse drug reactions for MHMR clients

7. Elopements or unauthorized departures from the program site

8. Confirmed abuse, neglect, or exploitation of MHMR clients.

9. Death or serious injury to MHMR clients occurring at program site

VII.

RATE SCHEDULE

Applicant agrees to accept the fees listed in Attachment B as payment in full for approved Covered Services. The Applicant will not submit a claim or bill or collect compensation from MHMR for any non-covered service. Applicant agrees that compensation for providing non-covered services will be solely between the client and the Applicant. The Covered Individual must be informed in writing, before any non-covered services are provided, that MHMR is not responsible for payment for such services. Clients are responsible for payment for non-covered services only if the Covered Individual consents in writing to the provision of such non-covered services. MHMR is the payor of last resort. If the services authorized for a Covered Individual are currently paid for by a third-party payor, applicant may not bill both entities for the same service.

ASSURANCES DOCUMENT

Applicant assures the following:

1. That all addenda and attachments to the Application as distributed by MHMR have been received.

2. No attempt will be made by the Applicant to induce any person or firm to submit or not to submit an Application, unless so described in the response document.

3. The Applicant does not discriminate in its services or employment practices on the basis of race, color, religion, sex, national origin, ethnicity, disability, veteran status, or age.

4. That no employee of MHMR or HHS, and no member of MHMR’s Board of Trustees will directly or indirectly receive any pecuniary interest from an award of the proposed contract. If the applicant is unable to make the affirmation, then the applicant must disclose any knowledge of such interests.

5. All cost and pricing information is reflected in the Application response document or attachments.

6. Applicant accepts the terms, conditions, criteria, and requirements set forth in the Application.

7. Applicant accepts MHMR’s right to cancel the Application at any time prior to contract award.

8. Applicant accepts MHMR’s right to alter the timetables for procurement as set forth in the Application.

9. The application submitted by the Applicant has been arrived at independently without consultation, communication, or agreement for the purpose of restricting competition.

10. Unless otherwise required by law, the information in the application submitted by the Applicant has not been knowingly disclosed by the Applicant to any other Applicant prior to the notice of intent to award.

11. No claim will be made for payment to cover costs incurred in the preparation of the submission of the application or any other associated costs.

12. MHMR has the right to complete background checks and verify information.

13. The individual signing this document and the contract is authorized to legally bind the Applicant.

14. The address submitted by the Applicant to be used for all notices sent by MHMR is current and correct.

Signature Authority for the Applicant Title Date

ATTACHMENT A

Covered Individual Definition Community Services Participant - Child and Youth Mental Health (MH) Priority Population – children/youth ages 3 through 17 with a diagnosis of mental illness (excluding a single diagnosis of substance abuse, Intellectual and Developmental Disabilities (IDD), or autism spectrum disorders) who exhibit serious emotional, behavioral or mental health disorders and who:

a. Have a serious functional impairment; or

b. Are at risk of disruption of a preferred living or child care environment due to psychiatric symptoms; or

c. Are enrolled in a school system’s special education program because of serious emotional disturbance.

d. Age Limitations:

i. Children under the age of three who have a diagnosed physical or mental health condition are to be served through the Early Childhood Intervention (ECI) program; and

ii. Youth 17 years old and younger must be screened for Children’s Mental Health (CMH) services. Youth receiving CMH services who are approaching their 18th birthday and continue to need mental health services shall either be transferred to Adult Mental Health (AMH) Services on their 18th birthday or referred to another community provider, dependent upon the individual’s needs. Individuals reaching 18 years of age who continue to need mental health services may be transferred to AMH services without meeting the adult priority population criteria and served for up to one additional year. Individuals who are 18 years of age or older and have previously received CMH services must be screened for AMH services using HHS-approved Uniform Assessment (UA).

iii. For purposes of this contract definitions of “child” and “youth” are as follows:

1. Child: An individual who is at least three years of age, but younger than 13 years of age.

2. Youth: An individual who is at least 13 years of age, but younger than 18 years of age.

e. Service Determination:

i. In determining services and supports to be provided to the child/youth and family, the choice of and admission to medically necessary services and supports are determined jointly by the child/youth and family seeking services and supports and by Contractor;

ii. Criteria used to make these determinations are from the recommended Level of Care (LOC) (LOC-Recommended) of the individual as derived from the UA, the needs of the individual, Texas Resilience and Recovery Utilization Management Guidelines and the availability of resources;

iii. The Global Assessment of Functioning (GAF) is not used to determine eligibility for CMH services; and

iv. Children/Youth authorized for care by Contractor through a clinical override are eligible for the duration of the authorization. A clinical override for ineligible children/youth may not exceed a maximum of two consecutive authorizations.

ATTACHMENT B

Service Definitions and Rates Community Services

D ay Treatment

1. Partial Hospitalization Child

$355 per day per child

2. Partial Hospitalization Youth

$275 per day per youth

3. Intensive Outpatient Services $135 per day per patient

4. Therapeutic Summer Camp

$100 per day per patient

5. Camp Transportation

$10 per day per patient Partial Hospitalization for Children and Youth -- A hospital affiliated day program with medical supervision which focuses on short-term acute treatment of children and youth in the Priority Population who are experiencing acute psychiatric symptoms and are at risk for hospitalization unless they receive intensive intervention, or as a step-down from Inpatient Services. Services are provided in a highly structured and safe environment with constant supervision. A multidisciplinary treatment approach is used to achieve maximum symptom control and stabilization. Contacts with staff are frequent, and services are constantly available. Developmental and social supports are encouraged and facilitated. This service is inclusive of charges for psychiatric assessment, treatment, and case oversight and professional services including therapy and counseling, routine laboratory, ancillary services and physician fees.

Intensive Outpatient Services -- A hospital-based evening outpatient program which focuses on short-term acute treatment of children and youth in the Priority Population who are experiencing acute psychiatric symptoms and are at risk for hospitalization unless they receive intensive intervention, or as a step-down from Inpatient or Partial Hospitalization services. Services are provided in a highly structured and safe environment with constant supervision. A multidisciplinary treatment approach is used to achieve maximum symptom control and stabilization. Contacts with staff are frequent and services constantly available. Development and social supports are encouraged and facilitated. This service is inclusive of charges for psychiatric assessment, treatment, and case oversight and professional services including therapy and counseling, routine laboratory, ancillary services and physician fees.

Therapeutic Summer Camp – A hospital affiliated program that includes, recreational activities, daily skills groups and other therapeutic activities deemed appropriate for camp. The service includes transportation of the Covered Individual to and from the Camp provided by the Provider.

S pecialized Therapies

Cognitive Behavioral Therapy $100.00 per 53-60 minute session with patient

$75.00 per 38-52 minute session with patient

$50.00 per 16-37 minute session with patient

$75.00 per 26-50 minute session with patient & family

$20.00 per No Show

$50.00 per Court Appearance

Service Definition:

Services to Covered Individuals are to assist them in meeting recovery goals. The intent of these services is to maintain or improve health, welfare, and/or effective functioning in the community.

***All authorized services are to be provided at an MHMR clinic or other MHMR facility. In some cases, services may be provided in the patient’s home or community setting as authorized by MHMR.*** Child/Youth Cognitive Behavioral Therapy: Individual, family, and group therapy focused on the reduction or elimination of a child/youth’s symptoms of serious emotional disturbance and increasing the individual’s ability to perform activities of daily living. Counseling services include treatment planning to enhance recovery and resiliency. All counseling services shall be provided by a Licensed Practitioner of the Healing Arts (LPHA), practicing within the scope of his or her own license.

· Cognitive Behavioral Therapy (CBT) is the selected treatment model for MHMR Children’s Mental Health (CMH) counseling services.

· Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is the approved counseling treatment model for children/youth with trauma disorders or children/youth whose functioning or behavior is affected by their history of traumatic events.

HHSC approved CBT protocols for treating children/youth for depression and anxiety are outlined in the Texas Resilience and Recovery (TRR) Utilization Management (UM) Guidelines: https://www.hhs.texas.gov/providers/behavioral-health-services-providers/behavioral-health-provider-resources/utilization-management-guidelines-manual Cognitive-Behavioral Therapy (CBT) is provided by:

1. A Licensed Practitioner of the Healing Arts (LPHA), practicing within the scope of a license:

2. An LPHA that meets HHSC competency requirements as outlined in the Information Item A, which is posted at:

https://www.hhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services- providers/behavioral-health-provider-resources/community-mental-health-contracts;

i MH CA Open Enrollment FY2024.doc

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