Perinatal Budget Template.xlsx
XLSX spreadsheet 46 KB Posted
- Attached to
- SUDRS Perinatal Services
- Solicitation number
- DBHE26-ADMN-6323
- Issued by
- San Bernardino County, San Francisco City, California
About this file
Summary
This is a budget template for the San Bernardino County Department of Behavioral Health's Substance Use Disorder and Recovery Services Perinatal Contract, covering a six-year period from January 1, 2027, through December 31, 2031. The template establishes the budget structure for perinatal substance use disorder treatment and recovery services to be provided by contracted agencies. Questions regarding the contract opportunity must be submitted by noon on Wednesday, July 15, 2026, with proposals due by 4:00 PM on Wednesday, August 5, 2026, to DBH Administration at 550 Hospitality Lane, 1st Floor, San Bernardino, CA 92415-0026.
The budget template encompasses six fiscal periods with funding derived from multiple sources including Medi-Cal Non-DMC, Perinatal Realignment, Perinatal SUBG, CalWORKs, and CFS. Reimbursable services include Intensive Outpatient Treatment (IOT), Medications for Addiction Treatment (MAT), Care Coordination, Peer Support Services, and Recovery Services at a fixed rate of $75 per perinatal day charge. Federal funding sources include the Substance Abuse Prevention & Treatment Block Grant (CFDA 93.959) administered by SAMHSA and the Medi-Cal Assistance Program/DMC-ODS (CFDA 93.778) administered by DHHS, both passed through the State DHCS. All costs must be rounded to the nearest dollar, and CalWORKs and CFS funding categories are subject to specific restrictions. The contract requires authorized signatures from the provider, DBH Provider Support, and the DBH Program Manager or Designee for approval.
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Text version
2026-27
| SAN BERNARDINO COUNTY |
| DEPARTMENT OF BEHAVIORAL HEALTH |
| Substance Use Disorder and Recovery Services - Perinatal Contract |
| SCHEDULE A - Proposed Budget |
BUDGET PERIOD: January 1, 2027 to June 30, 2027
| Contractor Name: | Prepared by: |
| Facility Address: 1 | Title: |
| Facility Address: 2 | Date Prepared: |
| Provider Number: | |
| Maximum Annual Obilgation: | $ - 0 |
FUNDING SOURCE Medi-Cal Non-DMC Perinatal Realignment Perinatal SUBG CalWORKs** CFS** TOTAL
| Level of Care | |||
| Intensive Outpatient Treatment (IOT) | $ - 0 | ||
| Stand Alone Services | |||
| Medications for Addiction | |||
| Treatment (MAT) | $ - 0 | ||
| Care Coordination | $ - 0 | ||
| Peer Support Services | $ - 0 | ||
| Recovery Services | |||
| $75 perinatal day charge | $ - 0 |
| SUMMARY OF ALL SERVICES | ||||||
| Total Cost of Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| * Round Costs to nearest dollar | ||||||
| **Subject to CFS/CalWORKs funding |
APPROVED BY:
PROVIDER AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROVIDER SUPPORT AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROGRAM MANAGER or DESIGNEE SIGNATURE PRINTED NAME DATE
| Federal funds include: | ||||
| CFDA Title | CFDA No. | Award Name | Federal Agency | Pass-through |
Agency
| Substance Abuse Prevention & Treatment Block Grant | 93.959 | SABG | SAMHSA | State DHCS |
| Medi-Cal Assistance Program | 93.778 | DMC-ODS | DHHS | State DHCS |
2027-28
| SAN BERNARDINO COUNTY |
| DEPARTMENT OF BEHAVIORAL HEALTH |
| Substance Use Disorder and Recovery Services - Perinatal Contract |
| SCHEDULE A - Proposed Budget |
BUDGET PERIOD: July 1, 2027 to June 30, 2028
| Contractor Name: | Prepared by: |
| Facility Address: 1 | Title: |
| Facility Address: 2 | Date Prepared: |
| Provider Number: | |
| Maximum Annual Obilgation: | $ - 0 |
FUNDING SOURCE Medi-Cal Non-DMC Perinatal Realignment Perinatal SUBG CalWORKs** CFS** TOTAL
| Level of Care | |||
| Intensive Outpatient Treatment (IOT) | $ - 0 | ||
| Stand Alone Services | |||
| Medications for Addiction | |||
| Treatment (MAT) | $ - 0 | ||
| Care Coordination | $ - 0 | ||
| Peer Support Services | $ - 0 | ||
| Recovery Services | |||
| $75 perinatal day charge | $ - 0 |
| SUMMARY OF ALL SERVICES | ||||||
| Total Cost of Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| * Round Costs to nearest dollar | ||||||
| **Subject to CFS/CalWORKs funding |
APPROVED BY:
PROVIDER AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROVIDER SUPPORT AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROGRAM MANAGER or DESIGNEE SIGNATURE PRINTED NAME DATE
| Federal funds include: | ||||
| CFDA Title | CFDA No. | Award Name | Federal Agency | Pass-through |
Agency
| Substance Abuse Prevention & Treatment Block Grant | 93.959 | SABG | SAMHSA | State DHCS |
| Medi-Cal Assistance Program | 93.778 | DMC-ODS | DHHS | State DHCS |
2028-29
| SAN BERNARDINO COUNTY |
| DEPARTMENT OF BEHAVIORAL HEALTH |
| Substance Use Disorder and Recovery Services - Perinatal Contract |
| SCHEDULE A - Proposed Budget |
BUDGET PERIOD: July 1, 2028 to June 30, 2029
| Contractor Name: | Prepared by: |
| Facility Address: 1 | Title: |
| Facility Address: 2 | Date Prepared: |
| Provider Number: | |
| Maximum Annual Obilgation: | $ - 0 |
FUNDING SOURCE Medi-Cal Non-DMC Perinatal Realignment Perinatal SUBG CalWORKs** CFS** TOTAL
| Level of Care | |||
| Intensive Outpatient Treatment (IOT) | $ - 0 | ||
| Stand Alone Services | |||
| Medications for Addiction | |||
| Treatment (MAT) | $ - 0 | ||
| Care Coordination | $ - 0 | ||
| Peer Support Services | $ - 0 | ||
| Recovery Services | |||
| $75 perinatal day charge | $ - 0 |
| SUMMARY OF ALL SERVICES | ||||||
| Total Cost of Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| * Round Costs to nearest dollar | ||||||
| **Subject to CFS/CalWORKs funding |
APPROVED BY:
PROVIDER AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROVIDER SUPPORT AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROGRAM MANAGER or DESIGNEE SIGNATURE PRINTED NAME DATE
| Federal funds include: | ||||
| CFDA Title | CFDA No. | Award Name | Federal Agency | Pass-through |
Agency
| Substance Abuse Prevention & Treatment Block Grant | 93.959 | SABG | SAMHSA | State DHCS |
| Medi-Cal Assistance Program | 93.778 | DMC-ODS | DHHS | State DHCS |
2029-30
| SAN BERNARDINO COUNTY |
| DEPARTMENT OF BEHAVIORAL HEALTH |
| Substance Use Disorder and Recovery Services - Perinatal Contract |
| SCHEDULE A - Proposed Budget |
BUDGET PERIOD: July 1, 2029 to June 30, 2030
| Contractor Name: | Prepared by: |
| Facility Address: 1 | Title: |
| Facility Address: 2 | Date Prepared: |
| Provider Number: | |
| Maximum Annual Obilgation: | $ - 0 |
FUNDING SOURCE Medi-Cal Non-DMC Perinatal Realignment Perinatal SUBG CalWORKs** CFS** TOTAL
| Level of Care | |||
| Intensive Outpatient Treatment (IOT) | $ - 0 | ||
| Stand Alone Services | |||
| Medications for Addiction | |||
| Treatment (MAT) | $ - 0 | ||
| Care Coordination | $ - 0 | ||
| Peer Support Services | $ - 0 | ||
| Recovery Services | |||
| $75 perinatal day charge | $ - 0 |
| SUMMARY OF ALL SERVICES | ||||||
| Total Cost of Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| * Round Costs to nearest dollar | ||||||
| **Subject to CFS/CalWORKs funding |
APPROVED BY:
PROVIDER AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROVIDER SUPPORT AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROGRAM MANAGER or DESIGNEE SIGNATURE PRINTED NAME DATE
| Federal funds include: | ||||
| CFDA Title | CFDA No. | Award Name | Federal Agency | Pass-through |
Agency
| Substance Abuse Prevention & Treatment Block Grant | 93.959 | SABG | SAMHSA | State DHCS |
| Medi-Cal Assistance Program | 93.778 | DMC-ODS | DHHS | State DHCS |
2030-31
| SAN BERNARDINO COUNTY |
| DEPARTMENT OF BEHAVIORAL HEALTH |
| Substance Use Disorder and Recovery Services - Perinatal Contract |
| SCHEDULE A - Proposed Budget |
BUDGET PERIOD: July 1, 2030 to June 30, 2031
| Contractor Name: | Prepared by: |
| Facility Address: 1 | Title: |
| Facility Address: 2 | Date Prepared: |
| Provider Number: | |
| Maximum Annual Obilgation: | $ - 0 |
FUNDING SOURCE Medi-Cal Non-DMC Perinatal Realignment Perinatal SUBG CalWORKs** CFS** TOTAL
| Level of Care | |||
| Intensive Outpatient Treatment (IOT) | $ - 0 | ||
| Stand Alone Services | |||
| Medications for Addiction | |||
| Treatment (MAT) | $ - 0 | ||
| Care Coordination | $ - 0 | ||
| Peer Support Services | $ - 0 | ||
| Recovery Services | |||
| $75 perinatal day charge | $ - 0 |
| SUMMARY OF ALL SERVICES | ||||||
| Total Cost of Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| * Round Costs to nearest dollar | ||||||
| **Subject to CFS/CalWORKs funding |
APPROVED BY:
PROVIDER AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROVIDER SUPPORT AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROGRAM MANAGER or DESIGNEE SIGNATURE PRINTED NAME DATE
| Federal funds include: | ||||
| CFDA Title | CFDA No. | Award Name | Federal Agency | Pass-through |
Agency
| Substance Abuse Prevention & Treatment Block Grant | 93.959 | SABG | SAMHSA | State DHCS |
| Medi-Cal Assistance Program | 93.778 | DMC-ODS | DHHS | State DHCS |
2031-32
| SAN BERNARDINO COUNTY |
| DEPARTMENT OF BEHAVIORAL HEALTH |
| Substance Use Disorder and Recovery Services - Perinatal Contract |
| SCHEDULE A - Proposed Budget |
BUDGET PERIOD: July 1, 2031 to December 31, 2031
| Contractor Name: | Prepared by: |
| Facility Address: 1 | Title: |
| Facility Address: 2 | Date Prepared: |
| Provider Number: | |
| Maximum Annual Obilgation: | $ - 0 |
FUNDING SOURCE Medi-Cal Non-DMC Perinatal Realignment Perinatal SUBG CalWORKs** CFS** TOTAL
| Level of Care | |||
| Intensive Outpatient Treatment (IOT) | $ - 0 | ||
| Stand Alone Services | |||
| Medications for Addiction | |||
| Treatment (MAT) | $ - 0 | ||
| Care Coordination | $ - 0 | ||
| Peer Support Services | $ - 0 | ||
| Recovery Services | |||
| $75 perinatal day charge | $ - 0 |
| SUMMARY OF ALL SERVICES | ||||||
| Total Cost of Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| * Round Costs to nearest dollar | ||||||
| **Subject to CFS/CalWORKs funding |
APPROVED BY:
PROVIDER AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROVIDER SUPPORT AUTHORIZED SIGNATURE PRINTED NAME DATE
DBH PROGRAM MANAGER or DESIGNEE SIGNATURE PRINTED NAME DATE
| Federal funds include: | ||||
| CFDA Title | CFDA No. | Award Name | Federal Agency | Pass-through |
Agency
| Substance Abuse Prevention & Treatment Block Grant | 93.959 | SABG | SAMHSA | State DHCS |
| Medi-Cal Assistance Program | 93.778 | DMC-ODS | DHHS | State DHCS |
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