ESBD_401953_1774903059215_MHMR IDD Provider Services Application_Rev03.pdf

IDD

HCCMHMRC | 819 WATER STREET, SUITE 300 KERRVILLE, TX 78028

Open Enrollment

HILL COUNTRY COMMUNITY MHMR CENTER

IDD Open Enrollment Application

Hill Country Community MHMR Center

Open Enrollment FY27

Contents Our Principles Who We Serve Services We Offer Our Commitment to Quality & Accessibility Becoming a Provider Our Goals Contact Us Application For Intellectual & Developmental Disabilities (IDD) Instructions for Submission Provider Information Business and Compliance Information Counties Served Services Provided Services Offered Supporting Documentation Other Resources

FORM 1. REFERENCES

FORM 2. W-9 IDENTIFICATION NUMBER & CERTIFICATION

FORM 3. CONFLICT OF INTEREST QUESTIONNAIRE

FORM 4. CERTIFICATE OF ASSURANCE

FORM 5. DEBARMENT CERTIFICATION

FORM 6. CERTIFICATION REGARDING LOBBYING, GRANTS, LOANS, & COOPERATIVE AGREEMENTS

Hill Country Community MHMR Center

Open Enrollment FY27

Empowering Choices, Enhancing Lives

At Hill Country Community MHMR Center (HCCMHMRC), we are committed to providing adults, adolescents, and children with intellectual and developmental disabilities (IDD) the opportunity to access high-quality services and supports. We believe in personal choice, accessibility, and person-centered care, ensuring that individuals and families have the flexibility to select the providers and services that best meet their needs.

Our Principles Personal Choice – We offer a network of providers, ensuring individuals have access to the best services available.

Personal Input – We collaborate with individuals, families, and community stakeholders to develop and improve services.

Personal Access – We ensure that services are easy to reach and convenient.

Person-Driven Care – Individuals are active participants in their treatment, policy decisions, and local planning efforts.

Who We Serve HCCMHMRC is committed to building a strong community-based network of services for individuals with IDD across 19 counties in Texas. Our goal is to provide high-quality, person-centered support that empowers individuals to live independently and fully participate in their communities.

We collaborate with dedicated providers who share our commitment to enhancing the lives of those we serve.

By fostering strong partnerships, we ensure individuals receive the care and resources they need to thrive.

Services We Offer Local Community Services (LCS)

Behavioral Support – Helping individuals develop positive behaviors and social skills.

Community Support – Supporting daily activities and community integration.

Day Habilitation (Site-Based) – Teaching self-help, socialization, and life skills.

Respite Care (Hourly, In-Home/Out-of-Home) – Providing short-term relief for caregivers.

Speech/Language Therapy – Helping individuals develop communication skills.

Specialized PASRR Services

(Pre-Admission Screening and Resident Review for individuals in nursing facilities)

Behavioral Support – Helping individuals adjust to daily life.

Independent Living Skills Training – Teaching personal care, health maintenance, and daily living skills.

Supported Employment – Providing long-term support for individuals in jobs.

Employment Assistance – Helping individuals find and secure jobs.

Day Habilitation – Developing self-help and community skills.

Crisis Services

In-Home Crisis Respite – Providing short-term, intensive support to individuals experiencing a crisis in their own homes.

Out-of-Home Crisis Respite – Provide short-term, intensive support out of the individuals home in response to a crisis experience.

Our Commitment to Quality & Accessibility At HCCMHMRC, we prioritize:

Multicultural and Multilingual Services – We ensure that services are accessible to diverse populations.

Least Restrictive, Most Integrated Settings – We focus on community inclusion and independence.

Provider Partnerships – We work with qualified providers to offer a comprehensive network of services.

Becoming a Provider HCCMHMRC partners with providers who meet our quality and compliance standards. Providers must:

Follow HIPAA and confidentiality requirements.

Maintain insurance, licenses, and professional accreditation.

Meet quality measures, including responding to referrals within three (3) days.

Be open to site visits and quality audits.

Our Goals Increase accessibility and choice for individuals and families.

Strengthen our provider network to offer the best care possible.

Enhance service delivery by reducing administrative costs and increasing efficiency.

Contact Us Address: Hill Country Community MHMR Center Email: LIDDA_Contracts@hillcountry.org Phone: (830) 792-3300 x2072

Visit our website for more information on services, provider enrollment, and community resources.

Together, we are building a stronger, more inclusive community for individuals with intellectual and developmental disabilities.

mailto:LIDDA_Contracts@hillcountry.org

Application For Intellectual & Developmental Disabilities (IDD) Service Providers

Instructions for Submission

1. Complete all sections of this application. Incomplete application will not be processed.

2. Submit your completed application via email or postal mail:

Email: LIDDA_Contracts@hillcountry.org

Address: Hill Country Community MHMR Center Attn: Analaura McCrae, Director of IDD Authority 819 Water Street, Suite 300 Kerrville, TX 78028

Provider Information Business Name:

First and Last Name:

Address:

Phone:

Email:

Website:

Business and Compliance Information Business Type: [ ] Sole Proprietorship [ ] Partnership [ ] Corporation [ ] LLC [ ] Nonprofit

Tax Identification Number:

Years in Operation:

Do you have Insurance coverage as required? [ ] Yes [ ] No Requirement: The provider will maintain acceptable levels of general liability insurance in a minimum amount of 1,000,000 per occurrence and 3,000,000 in aggregate and will name HCCMHMR as an additional insured. The comprehensive general liability and professional coverage includes premises liability, employee misconduct and/or errors and omissions liability insurance to cover privacy breaches. Proof of Insurance is required upon execution of an Agreement.

Are you currently licensed/accredited to provide these services, if applicable? [ ] Yes [ ] No

Counties Served Select the counties where you are willing to provide services:

[ ] Bandera [ ] Blanco [ ] Comal [ ] Edwards [ ] Gillespie

[ ] Hays [ ] Kendall [ ] Kerr [ ] Kimble [ ] Kinney

[ ] Llano [ ] Mason [ ] Medina [ ] Menard [ ] Real

[ ] Schleicher [ ] Sutton [ ] Uvalde [ ] Val Verde mailto:LIDDA_Contracts@hillcountry.org

Hill Country Community MHMR Center

Open Enrollment FY27

Services Provided If more space is needed for answers, attach a separate document.

1. What is your or the organization’s service capacity? Are there any restrictions on the number or type of individuals you can serve? Additionally, specifically the locations, hours, and days when services will be available.

2. How do you or the organization ensure accessibility and inclusivity? Describe how your organization accommodates individuals from diverse backgrounds, including multilingual capabilities, cultural inclusivity, and compliance with the Americans with Disabilities Act (ADA).

3. What experience do you or the organization have in serving individuals with intellectual and developmental disabilities (IDD)? Provide a summary of your experience over the past five (5) years.

4. How do you support individuals with additional needs? Describe your approach to serving individuals with disabilities who also have co-occurring mental health conditions or substance use disorders.

5. What accommodation(s) do you or the organization offer for communication barriers? Explain how you support individuals who are hearing impaired, have limited language skills, or speak a language other than English.

6. How accessible is your service location via public transportation? Describe available transit options and how individuals can reach your facilities.

Services Offered Select the services you are interested in providing:

[ ] Behavior Support [ ] Community Support [ ] Day Habilitation (Site-Based) [ ] Respite Hourly - Out-of-Home [ ] Respite Daily - Out of Home

[ ] Respite Hourly - In-Home [ ] Respite Daily - In-home [ ] Speech/Language Therapy [ ] PASRR Behavioral Support [ ] RASRR Day Habilitation 1-2.9 hours

[ ] RASRR 3-6 hours [ ] PASRR Independent Living Skills Training [ ] PASRR Supported Employment [ ] PASRR Employment Assistance [ ] Crisis Respite (In-Home)

7. How will you or the organization provide the selected services? Describe in detail how you intend to deliver each of the services you have selected in the application.

8. What managed care companies do you or the organization currently contract with? Please list all managed care companies with which you have existing contracts.

9. Have you or the organization ever filed bankruptcy? If yes, provide a detailed explanation, including dates and circumstances.

10. Has the organization ever defaulted on any business lease arrangement? If yes, describe the details of the default, including the impact and resolution.

11. Do you or the organization own or lease current business properties? Specify whether the organization owns or leases its operating locations and provide the geographic areas where services will be provided.

Also, list the street addresses of all locations from which program services will operate.

Supporting Documentation Please attach the following documents for all applicants:

[ ] IRS Form W-9, Form 1

[ ] Letters of Support/References (3), Form 1

[ ] Certifications/Training Records, if any

[ ] Provider Credentialing Documents, if any

[ ] Forms 1-6, Attached to application

For Businesses Only (if applicable):

[ ] Business License/Registration

[ ] Organizational Chart

[ ] Most Recent Financial Statement or Tax Filing

[ ] Certified External Audits (past 3 years)

[ ] Tax Statements (past 3 years)

[ ] Current annual Financial Statements, including cash flow

[ ] Statement certifying all facilities are ADA compliant

[ ] Financial Plan inclusive of emergency funds, to support business expenses.

Other Resources Additional resources can be found at Hill Country Community MHMR Center Intellectual and Developmental Disabilities Service website (e.g. Rate Schedule, Provider Manual, and Respite Manual, etc).

Website link: https://hillcountry.org/intellectual-and-developmental-disabilities-services/

Signature and Certification I certify that the information provided is accurate and complete. I understand that any false statements may result in disqualification.

Authorized Representative Print Name:

Title:

Signature:

DATE

https://hillcountry.org/intellectual-and-developmental-disabilities-services/

FORM 1. REFERENCES

List three (3) references who are able to attest to the quality of the organization/individual’s work performance and have knowledge of the organization’s previous experience and ability to provide a healthy, safe, and therapeutic environment to Consumers served under this RFA:

Support/Reference Email Address Phone

FORM 2. W-9 IDENTIFICATION NUMBER & CERTIFICATION

Retrieve the W-9 Taxpayer Identification Number and Certification

Link: https://www.irs.gov/pub/irs-pdf/fw9.pdf

(Attach completed form as part of the application)

FORM 3. CONFLICT OF INTEREST QUESTIONNAIRE

Retrieve CIQ Form

Link: https://www.ethics.state.tx.us/data/forms/conflict/CIQ.pdf

(Attach completed form as part of the application)

NOTE: A signature is required in Box 7 of CIQ form regardless of any other entry on the form.

For the purpose of this Form 2, the term “Local government officer” means a member of Hill Country Community MHMR Center Board of Trustees, Chief Executive Officer, and/or an agent of Hill Country Community MHMR Center who exercises discretion in the planning, recommending, selecting, or contracting.

https://www.irs.gov/pub/irs-pdf/fw9.pdf https://www.ethics.state.tx.us/data/forms/conflict/CIQ.pdf

FORM 4. CERTIFICATE OF ASSURANCE

As an applicant for participation in the Hill Country Community MHMR Center (HCCMHMRC) Open Enrollment for IDD Service Providers, I confirm the following assurances:

1. Completion of Required Documents – I have completed all required addenda and attachments as provided in this application.

2. Fair Business Practices – I affirm that no attempts have been made to influence or discourage any individual or entity from submitting an application, except as outlined in this document.

3. Non-Discrimination Policy – Our organization does not discriminate in services or employment practices based on race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), genetic information, national origin, disability, veteran status, or age.

4. Conflict of Interest – No employee of HCCMHMRC, the Texas Health and Human Services Commission (HHSC), or any member of HCCMHMRC’s Board of Trustees has any direct or indirect financial interest in our application. If such a relationship exists, it has been fully disclosed.

5. Compliance with Terms and Conditions – I acknowledge and accept all terms, conditions, requirements, and evaluation criteria set forth in this application.

6. Application Withdrawal and Timelines – I understand that HCCMHMRC has the right to cancel or modify this open enrollment at any time before awarding a contract.

7. Independent Submission – This application was prepared independently, without consultation, communication or agreement with any other applicant to restrict competition.

8. Confidentiality of Information – Unless required by law, no information in this application has been knowingly disclosed to other applicants prior to the intent to award.

9. Financial Responsibility – I acknowledge that all costs associated with preparing and submitting this application are the sole responsibility of the applicant.

10. Verification and Background Checks – I understand that HCCMHMRC reserves the right to verify information and conduct background checks as necessary.

11. Authorized Signatory – The individual signing this certification has the legal authority to bind the applicant organization.

12. Notification Contact Information – The address provided in this application is accurate and will be used for all official communications from HCCMHMRC.

Authorized Representative Print Name:

Title:

Hill Country Community MHMR Center

Open Enrollment FY27

FORM 5. DEBARMENT CERTIFICATION

CAREFULLY BEFORE SIGNING THIS CERTIFICATION. Federal regulations require contractors, APPLICANTs, vendors, bidders, and sub-bidders to sign and abide by the terms of this certification, without modification, to participate in certain transactions directly or indirectly involving federal funds.

1. By signing and submitting this certification, the prospective APPLICANT is attesting/acknowledging the representations set out below.

2. This certification is a material representation of fact upon which the HILL COUNTRY COMMUNITY MHMR CENTER (HCCMHMRC) will rely on when this transaction is entered. If it is later determined that the prospective APPLICANT knowingly rendered an erroneous certification, in addition to other remedies available to Federal or State departments or funding agency(s), HCCMHMRC may pursue on its own available remedies, including contract termination, suspension and debarment.

3. The prospective APPLICANT shall provide immediate written notice to

HILL COUNTRY COMMUNITY MHMR CENTER

ATT: ANALAURA MCCRAE, DIRECTOR OF IDD AUTHORITY

819 Water St., Suite 300 Kerrville, TX 78028

Email: lidda-mgmt@hillcountry.org Phone: 830-792-3300 if at any time it learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

4. The terms “covered contract”, “debarred”, “suspended”, “ineligible”, “participant”, “person”, “principal”, “APPLICATION”, and “voluntarily excluded”, as used in this certification, have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. You may contact the person to which this APPLICATION or contract is submitted for assistance in obtaining a copy of this regulation.

5. The prospective APPLICANT agrees, by submitting this certification, that should the proposed contract/grant be entered into, it shall not knowingly enter into any lower-tier- covered transaction or sub-contract with a person or entity that is proposed for debarment, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this transaction, unless pre-authorized by the appropriate federal or state department or agency, or by HCCMHMRC.

Do you have or do you anticipate having sub-vendors/sub-bidders under this proposed

AGREEMENT?

Yes No

6. The prospective APPLICANT further agrees by submitting this certification, that it will include this certification titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Contracts and Grants,” without modification, in all lower-tier covered transactions and sub-contracts and in all solicitations for lower-tier covered transactions and sub- contracts.

7. A APPLICANT may rely upon a certification of a prospective participant that is not proposed for debarment, debarred, suspended, ineligible, or voluntarily excluded from the transaction, unless it mailto:lidda-mgmt@hillcountry.org

Hill Country Community MHMR Center

Open Enrollment FY27 knows that the certification is erroneous. Each APPLICANT is required to check the list of parties excluded from Federal and State Procurement and Non- procurement Programs. HCCMHMRC checks this list for all parties to which it provides funds that are derived directly or indirectly from the Federal Government.

8. Nothing contained in the foregoing shall be construed to require the establishment of a system of records to render in good faith the certification required by this certification document. Participants are not required to have knowledge and information exceeding that which is normally possessed by a prudent person in the ordinary course of business activity.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a transaction knowingly enters into a lower-tier transaction or contract with a person who is proposed for debarment, debarred, suspended, ineligible, or voluntarily excluded from participation, in addition to other remedies available to the Federal Government, HCCMHMRC or its applicable funding agency(s) may pursue available remedies, including contract termination, suspension and/or debarment.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND

VOLUNTARY EXCLUSION FOR CONTRACTS AND GRANTS

Check the statement that applies to the potential APPLICANT:

1. The prospective APPLICANT certifies by submission of this Certification that neither it nor its principals:

a. Is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal or State department or agency; and

b. Have, within three years preceding this certification, been convicted of or had a civil judgment rendered against them for fraud; committed a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract;

violated Federal or State antitrust statutes; committed embezzlement, theft, forgery, bribery, falsification or inappropriate destruction of records; or received stolen property; and

c. Is presently indicted for or otherwise charged by a government entity (Federal, State, or local) with the commission of any of the offenses enumerated in the preceding paragraph (b) of this certification; and

d. Have, within three years preceding this certification, had one or more contracts or transactions (Federal, State, or local) terminated for cause or default.

2. The potential APPLICANT is unable to certify one or more of the terms in this certification. In this instance, the potential APPLICANT must attach a signed and dated explanation for each of the above terms, 1(a) through 1(d), to which it cannot certify.

Authorized Representative

Print Name:

Title:

FORM 6. CERTIFICATION REGARDING LOBBYING, GRANTS, LOANS, &

COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief that:

1. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

2. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress an officer or employee of Congress or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub awards at all tiers (including subcontractors, subgrant, and contracts under grants, loans and cooperative agreements) and that all sub recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Authorized Representative Print Name:

Title: