REPOST_TA_Providers_EHR_RFA_BPM044030_5.31.24.pdf

EXHIBIT A

STANDARD GRANT AGREEMENT (SGA)

REQUEST FOR APPLICATIONS (RFA)

(COMPETITIVE)

PROCUREMENT ID NUMBER – BPM044652/ BHA24-33

Issue Date: 5/31/2024

Technical Assistance for Interoperability Program for Behavioral Health Providers

NOTICE

A Prospective Applicant that has received this document from the Maryland Department of Health, or that has received this document from a source other than the Procurement Officer, and that wishes to assure receipt of any changes or additional materials related to this RFA, should immediately contact the Procurement Officer and provide the Prospective Applicant’s name and mailing address so that addenda to the RFA or other communications can be sent to the Prospective Applicant.

Minority Business Enterprises Are Encouraged to Respond to this Solicitation

10/2019

STATE OF MARYLAND

MARYLAND DEPARTMENT OF HEALTH

RFA KEY INFORMATION SUMMARY SHEET

Request for Proposals: Technical Assistance for Interoperability Program for Behavioral Health Providers

Solicitation Number: BPM044652/ BHA24-033

RFA Issue Date: 5/31/2024

RFA Issuing Office: Maryland Department of Health Behavioral Health Administration

Procurement Officer: Crystal Hack

Maryland Department of Health Behavioral Health Administration Finance &Procurement Division 55 Wade Avenue Voc. Rehab. Building Catonsville, MD 21228 Phone: 410-627-6814 e-mail: crystal.hack@maryland.gov

Grant Monitor: Amy Woodrum

Behavioral Health Administration 55 Wade Avenue Catonsville, MD 21228 Phone: 667-405-0184 e-mail:amy.woodrum1@maryland.gov

Applications are to be sent to: eMaryland Marketplace Only! (See section 1.5) eMMA is an electronic commerce system administered by the Maryland Department of General Services.

In order to receive a Contract award, a Contractor must be registered on eMMA.

Registration is free. Go to https://emaryland.buyspeed.com/bso/login.jsp, click on “Register” to begin the process, and then follow the prompts.

Closing Date and Time: June 21, 2024, No later than 2:00 PM EST Local Time mailto:crystal.hack@maryland.gov mailto:amy.woodrum1@maryland.gov

SECTION 1 - GENERAL INFORMATION

1.1.1 The Maryland Department of Health (MDH or the Department), Behavioral Health Administration (BHA), is issuing this Request for Applications (RFA) to provide investment in the hardware, software, and training needed to use Electronic Health Records (EHRs). MDH-BHA has established an Interoperability Program for Behavioral Health Providers. This program will:

• Adopt, upgrade, and/or upgrade/optimize EHR systems for behavioral health providers

• Provide initial and ongoing user education services to behavioral health providers

• Onboard and connect to CRISP, Maryland’s Health Information Exchange

Eligibility Criteria:

• A non-profit or for-profit entity or governmental entity

• Experience working with Maryland Medicaid providers

• Experience working with behavioral health providers licensed under COMAR 10.21 and/or 10.63.

There are three program tracks depending on the needs of the behavioral health provider. All tracks include connecting with the State designated Health Information Exchange (HIE) known as the Chesapeake Regional Information System for our Patients (CRISP) to enable providers’ ability to send encounter data and clinical notes.

• Program Track 1: Adopt & Implement a New HER

• Program Track 2: Implement & Upgrade an Existing HER

• Program Track 3: Upgrade/optimize an Existing EHR

1.1.2 It is the State’s intention to select an eligible Applicant(s) who respond to this solicitation and that the State determines can provide the necessary technical assistance, education, and training needed to establish, enhance, or optimize behavioral health providers’ EHRs, as specified in this RFA, from an Agreement between the selected Applicant and the State. The anticipated duration of services to be provided under this Agreement is for one year.

1.1.3 BHA intends to make multiple awards if needed to fulfill the requirements of this RFA.

1.1.4 Applicants, either directly or through their subcontractor(s), must be and meet all of the requirements requested in this solicitation and the successful Applicant shall remain responsible for performance regardless of subcontractor participation in the work.

The Agreement resulting from this solicitation shall be a firm fixed price.

The sole point of contact in the State for purposes of this solicitation prior to the award of any Agreement is the Procurement Officer at the address listed below:

1.1 Summary Statement

1.2 Contract Type

1.3 Procurement Officer

Procurement Officer:

Crystal Hack Maryland Department of Health Behavioral Health Administration Finance &Procurement Division 55 Wade Avenue Voc. Rehab. Building Catonsville, MD 21228 Phone: 410-627-6814 e-mail: crystal.hack@maryland.gov

The Department may change the Procurement Officer at any time by written notice.

The Grant Monitor is:

Amy Woodrum

Behavioral Health Administration 55 Wade Avenue Catonsville, MD 21228 Phone: 667-405-0184 e-mail:amy.woodrum1@maryland.gov

The Department may change the Grant Monitor at any time by written notice.

Each Applicant is requested to indicate its eMaryland Marketplace Advantage (eMMA) vendor number in the Transmittal Letter (cover letter) submitted at the time of its Application submission to this RFA.

eMMA is an electronic commerce system administered by the Maryland Department of General Services.

The RFA and associated materials, the solicitation and summary of the Pre-Proposal Conference, Applicant questions and the Procurement Officer’s responses, addenda, and other solicitation-related information will be provided via eMMA.

In order to receive a contract award, a vendor must be registered on eMMA. Registration is free. Go to https://procurement.maryland.gov/, click on “Register” to begin the process, and then follow the prompts.

Written questions from prospective Applicants will be accepted by the Procurement Officer. Questions to the Procurement Officer shall be submitted via to eMaryland Marketplace ONLY! Please identify in the subject line the Solicitation Number and Title.

1.4 Grant Monitor

1.5 eMaryland Marketplace Advantage

1.6 Questions

mailto:crystal.hack@maryland.gov mailto:amy.woodrum1@maryland.gov https://procurement.maryland.gov/

Questions are requested to be submitted at least 7 days prior to the Application due date. The Procurement Officer, based on the availability of time to research and communicate an answer, shall decide whether an answer can be given before the Application due date. All questions and answers will be posted to eMaryland Marketplace Advantage (eMMA) under the documents tab.

Applications, in the number and form set forth in Section 4.2 “Applications” must be received by the Procurement Officer, via eMaryland Marketplace Advantage (eMMa), no later than 2:00 PM. Local Time on June 21, 2024 in order to be considered.

Requests for extension of this time or date will not be granted. Applications received after the due date and time listed in this section will not be considered. Questions regarding this solicitation should be submitted to eMMa only.

Applications may be modified or withdrawn by written notice received by the Procurement Officer before the time and date set forth in this section for receipt of Application. Multiple and/or alternate Applications will not be accepted.

The Grant shall be awarded to responsible Applicants submitting Applications that have been determined to be the most advantageous to the State, considering price and evaluation factors set forth in this RFA, for providing the activities as specified in this RFA. See RFA Section 5 for further award information.

If it becomes necessary to revise this RFA before the due date for Applications, the Department shall endeavor to provide addenda to all prospective Applicants that were sent this RFA or which are otherwise known by the Procurement Officer to have obtained this RFA. Addenda made after the due date for Applications will be sent only to those Applicants that submitted a timely Application and that remain under award consideration as of the issuance date of the addenda.

Acknowledgment of the receipt of all addenda to this RFA issued before the Application due date shall be included in the Transmittal Letter accompanying the Applicant’s Project Narrative. Acknowledgment of the receipt of addenda to the RFA issued after the Application due date shall be in the manner specified in the addendum notice. Failure to acknowledge receipt of an addendum does not relieve the Applicant from complying with the terms, additions, deletions, or corrections set forth in the addendum.

The State reserves the right to cancel this RFA, accept or reject any and all Applications, in whole or in part, received in response to this RFA, to waive or permit the cure of minor irregularities, and to conduct discussions with all qualified or potentially qualified Applicants in any manner necessary to serve the best interests of the State. The State also reserves the right, in its sole discretion, to award a Grant based upon the written Applications received without discussions or negotiations.

1.7 Application Due (Closing) Date and Time

1.8 Award Basis

1.9 Revisions to the RFA

1.10 Cancellations

SECTION 2 – MANDATORY REQUIREMENTS

The Applicant must provide proof with its Application that the following Mandatory Requirements have been met:

2.1.1 The Applicant shall have a demonstrated record of implementing (and optimizing) certified electronic health records and health information exchange for Maryland providers.

2.1.2 The Applicant shall have two years of experience providing tailored technical assistance and training to behavioral health providers on (certified) EHR Technology or case management systems.

2.1.3 The Applicant shall have an understanding of workflows, challenges, and opportunities using technologies that support interoperability with CRISP.

2.1.4 The Applicant shall be a non-profit or for-profit entity or governmental entity. As proof of meeting this requirement, the Applicant shall provide with its Application a copy of the Employer ID Number (EIN) or non-profit status.

THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

2.1 Applicant Mandatory Requirements

SECTION 3 – SCOPE OF WORK

The State is issuing this solicitation for the purposes of procuring technical assistance investing in behavioral health providers’ Electronic Health Records (EHRs). The performance period will be September 1, 2024, to August 31, 2025. The range of funding available for this RFA is a total of 500,000 dollars. This investment includes hardware, software, and training needed to use EHRS.

The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act) was implemented as a way to increase the implementation of Health Information Technology.

However, behavioral health providers [were] largely excluded from obtaining access to the funds provided by the HITECH Act.1 Due to narrow operating margins, behavioral health providers often have little capital available to invest in the hardware, software, and training needed to use EHRs.2

The Maryland Department of Health (MDH or the Department), Behavioral Health Administration (BHA), is issuing this Request for Applications (RFA) to provide investment in the hardware, software, and training needed to use EHRs. The selected applicant shall create a tailored TA program to support behavioral health providers’ adoption and use of EHRs and enable population health management to support whole-person care via HIE connectivity. MDH-BHA has established an Interoperability Program for Behavioral Health Providers. This program will:

• Adopt, implement, and/or upgrade/optimize EHR systems for behavioral health providers

• Provide initial and ongoing user education services to behavioral health providers

• Onboard and connect to CRISP, Maryland’s Health Information Exchange

Eligibility Criteria

• A non-profit or for-profit entity or governmental entity

• Experience working with Maryland Medicaid providers

• Experience working with behavioral health providers licensed under COMAR 10.21 and/or 10.63.

Key Responsibilities

• The Applicant will be responsible for providing tailored TA and training to providers by:

o Assessing provider readiness to adopt new health IT systems, o Assisting providers with the selection of appropriate systems (EHR or case management systems) capable of meeting the requirements of the incentive program, o Supporting system implementation and use, o Supporting meaningful use of the system, including connectivity to and use with CRISP, o Assisting providers with the documentation required by MDH-BHA to receive the allowable

Interoperability Program incentive payment, and o As needed, assist providers with the Medicaid compliance requirements to meet the Administrative

Simplification provisions of HIPAA.

The Interoperability Program participants will select among three tracks, according to the needs of the practice. For each milestone met, there is an associated financial incentive. All tracks include connecting with the State designated HIE, known as CRISP, to enable providers’ ability to send

1 Cohen D. Effect of the Exclusion of Behavioral Health from Health Information Technology (HIT) Legislation on the Future of Integrated Health Care. J Behav Health Serv Res. 2015 Oct;42(4):534-9. doi: 10.1007/s11414-014-9407-x. PMID: 24807647 2 Medicaid and CHIP Payment and Access Commission (MACPAC). 2016. Chapter 4: Integration of behavioral and physical health services in Medicaid. In Report to Congress on Medicaid and CHIP. March 2016. Washington, DC: MACPAC.

https://www.macpac.gov/wp-content/ uploads/2016/03/Integration-of-Behavioral-and-PhysicalHealth-Services-in-Medicaid.pdf.

3.1 Background and Purpose

encounter data and clinical notes. The program tracks are described in Table 1:

Table 1.

Program Track Description

Track 1 Appropriate for provider organizations that have not yet adopted an EHR in their practice. Track 1 organizations will receive TA to acquire, purchase or secure access to CEHRT. Additionally, TA will support and assist with the installation or commence utilization of CEHRT.

Track 2 Appropriate for provider organizations that need to upgrade to a certified EHR. Track 2 organizations will receive TA to update and expand the functionality of CEHRT.

Track 3 Appropriate for provider organizations that would like to optimize their existing (certified or non-certified) EHR. Track 3 organizations will receive TA to purchase potential gap tools or other direct integration tools to ultimately enable a secure connection to CRISP.

The Applicant shall:

1. Meet the eligibility criteria denoted in Section 1.1 and 3.1.

2. Agree to deliver on the Key Responsibilities outlined in Section 3.1.

3. Sign a Participation Agreement.

4. Sign scope of services and work plan.

5. Submit reports on a monthly basis.

3.2.1 General Requirements

3.2.1.1 Program Tracks

A. Program Track 1: Adopt & Implement a New HER

a. Milestone 1.1: Participation Agreement

b. Milestone 1.2: Sign scope of services and work plan

c. Milestone 1.3: New technology purchase

d. Milestone 1.4: Complete technology go-live and training

e. Milestone 1.5: Connect to CRISP and send encounter data

f. Milestone 1.6: Connect to CRISP and send clinical notes

B. Program Track 2: Implement & Upgrade an Existing EHR

a. Milestone 2.1: Participation Agreement

b. Milestone 2.2: Sign scope of services and work plan

c. Milestone 2.3: Technology upgrade purchase

d. Milestone 2.4: Complete technology go-live and training

e. Milestone 2.5: Connect to CRISP and send encounter data

f. Milestone 2.6: Connect to CRISP and send clinical notes

C. Program Track 3: Upgrade/Optimize Existing HER

a. Milestone 3.1: Participation Agreement

b. Milestone 3.2: Sign scope of services and work plan

c. Milestone 3.3: Integration technology purchase

d. Milestone 3.4: Complete technology go-live and training

e. Milestone 3.5: Connect to CRISP and send encounter data

f. Milestone 3.6: Connect to CRISP

D. The Applicant(s) will offer robust program management across all Program Tracks. Through this RFA, this includes provider identification, conducting practice readiness assessments, outreach, and enrollment into the Interoperability Program for Behavioral Health Providers.

a. This program would:

i. Adopt, implement, and/or upgrade/optimize EHR systems for behavioral health providers

ii. Provide initial and ongoing user education services to behavioral health providers

iii. Onboard and connect to CRISP, Maryland’s Health Information Exchange

b. The Applicant(s) shall also enable providers to report on one or more of the following metrics collected through their EHR or administratively in order to align with the funding mechanism:3

i. Initiation and Engagement of Substance Use Disorder Treatment (IET-AD)

ii. Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD)

3 2024 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set):

https://www.medicaid.gov/sites/default/files/2023-08/2024-adult-core-set_0.pdf

3.2 Scope of Work - Requirements

http://www.medicaid.gov/sites/default/files/2023-08/2024-adult-core-set_0.pdf

iii. Follow-Up After Emergency Department Visit for Substance Use: Age 18 and Older (FUA-

AD)

3.2.1.2 Eligibility Criteria

A. A non-profit or for-profit entity or governmental entity B. Demonstrated experience working with Maryland Medicaid providers C. Demonstrated experience working with behavioral health providers licensed under COMAR 10.21 or

10.63.4

3.2.1.3 Participation Agreement

A. Host a kick-off meeting with the participating providers and MDH-BHA.

B. Agree to provide participating practices technical assistance services that may include the following:

a. Assessing Practice readiness to adopt new health IT systems,

b. Assisting Practice with the selection of an appropriate system (EHR) capable of meeting the requirements of the incentive program,

c. Supporting system implementation and use,

d. Supporting system connectivity to and utilization of the CRISP,

e. Assisting Practice with preparing the documentation required by MDH-BHA to receive the allowable Interoperability Program incentive payment.

3.2.2 Staffing

A. Submit names, titles, and roles of staff who will be providing the services required in this RFA (training, educational, and technical assistance).

3.2.3 Reports

3.2.3.1 Reporting Requirements

A. The Applicant(s) will be required to submit financial reports, monthly programmatic reports, and financial requests for reimbursement.

a. The programmatic reports will indicate the status of goals and performance measures, as well as any successes or challenges encountered during the report period.

b. The financial reports will indicate the status of program spending by category and will be submitted along with all receipts, invoices, or other documentation of incurred expenses.

c. Reports are due no later than the 10th after the end of the reported month.

d. The Applicant(s) will be required to submit a final programmatic report and a final financial report within thirty (30) calendar days after expiration of the grant agreement.

i. The final programmatic report will include a review of the initiative, work conducted by the grantee, and if applicable, subgrantee(s), status of goals and performance measures, plans for how the initiative will be leveraged in the future, and recommendations to MDH-BHA, if any, based on the grant.

ii. The final financial report will include detailed accounting of all grant expenditures over the grant period. Applicants are expected to complete the reports listed above on time and show adequate progress at each reporting interval. Failure to meet these requirements may result in withholding of grant funds and/or termination of the grant due to non-performance or lack of capacity.

4 COMAR 10.63.02.02: https://dsd.maryland.gov/regulations/Pages/10.63.02.02.aspx

3.3.1 General

(a) All invoices for services shall be signed by the Grantee and submitted to the Grant Monitor. All invoices shall include the following information:

● Grantee name;

● Remittance address;

● Federal taxpayer identification number (or if sole proprietorship, the individual’s social security number);

● Invoice period;

● Invoice date;

● Invoice number

● State assigned Contract number;

● State assigned (Blanket) Purchase Order number(s);

● Goods or services provided; and

● Amount due.

Invoices submitted without the required information cannot be processed for payment until the Contractor provides the required information.

(b) The Department reserves the right to reduce or withhold Grant payment in the event the Grantee does not provide the Department with all required deliverables within the time frame specified in the Grant or in the event that the Grantee otherwise materially breaches the terms and conditions of the Grant until such time as the Grantee brings itself into full compliance with the Grant.

3.3.2 Invoice Submission Schedule

The Grantee shall submit invoices in accordance with the following schedule:

Invoices are due by the 15th of the month following the month in which services were performed.

3.3 Invoicing

SECTION 4 – APPLICATION FORMAT

Offerors shall submit Proposals in separate volumes:

▪ Volume I – Project Narrative

▪ Volume II – Budget Justification/Narrative

4.2.1 Applications must be submitted via eMaryland Marketplace Advantage (eMMA). The Procurement Officer will not accept submission by any other means or after the date and exact time stated in the Key Information Summary Sheet. The date and time of submission is determined by the date and time of arrival in eMMA.

4.2.1.1 Two Part Submission:

A. Technical Proposal (See 4.3.)

B. Budget Narrative (See 4.4)

4.2.2 Applications will be shown only to State employees, members of the Evaluation Committee, or other persons deemed by the Department to have a legitimate interest in them.

*All information submitted as part of this proposal is subject to release under the Public Information Act (PIA). If you would like the Maryland Department of Health (MDH) to consider redactions in the event that your proposal is subject to a PIA request, submit a proposed PIA copy including justifications for each redaction and under what statute that justification is qualified for redaction.

Note: No pricing information is to be included in the Project Narrative (Volume 1). Pricing information is to be included only in the Budget Justification/Narrative (Volume II).

4.3.1 The Technical Proposal shall include the following documents and information in the order specified as follows:

4.3.1.1 Transmittal Letter:

● Applicant;

● Solicitation Title and Solicitation Number that the Proposal is in response to;

● Signature, typed name, and title of an individual authorized to commit the Applicant to its Proposal;

● Federal Employer Identification Number (FEIN) of the Applicant, or if a single individual, that individual’s Social Security Number (SSN);

● Applicant’s eMMA number;

● Applicant’s MBE certification number (if applicable);

4.1 Two Part Submission

4.2 Proposals

4.3 Volume I – Project Narrative

● Applicant’s SBR number (if applicable) – please contact eMMA at 410-767-1492 if you don’t know your number.

4.3.1.2 The Project Narrative shall include the Scope of Work, including the Work Plan (as described in Section 3.2).

4.3.1.3 Mandatory Requirements Documentation

4.3.1.4 Applicant Technical Response to RFA Requirements and Proposed Work Plan:

a. The Applicant shall address each Scope of Work requirement (Section 3.2) in its Project Narrative and describe how its proposed services, including the services of any proposed subcontractor(s), will meet or exceed the requirement(s). If the State is seeking Applicant agreement to any requirement(s), the Applicant shall state its agreement or disagreement. Any paragraph in the Project Narrative that responds to a Scope of Work (Section 3.2) requirement shall include an explanation of how the work will be done. Any exception to a requirement, term, or condition may result in having the Application classified as not reasonably susceptible of being selected for award or the Applicant deemed non-responsive.

4.4.1 Under separate sealed cover from the Project Narrative and clearly identified in the format identified in Section 4.2 “Applications,” the Applicant shall submit an original copy of the Budget Narrative. The Budget Narrative shall contain all price information in the format specified in Exhibit B.

The Applicant shall complete the Budget Narrative Form only as provided in the Budget Narrative Form.

4.4.2 The Applicant shall attach to the Budget Form a Budget Narrative document that details the total cost of the proposed activities. The budget categories may include: Personnel (salary and fringe), Consultants; Travel; Contractual; Supplies; Operating Costs; and Other project-related costs.

4.4 Volume II – Budget Narrative

SECTION 5 – EVALUATION COMMITTEE, EVALUATION CRITERIA,

AND SELECTION PROCEDURE

Evaluation of Applications will be performed by a committee established for that purpose and based on the evaluation criteria set forth below. The Evaluation Committee will review Applications, participate in Applicant oral presentations and discussions, and provide input to the Procurement Officer. The Department reserves the right to utilize the services of individuals outside of the established Evaluation Committee for advice and assistance, as deemed appropriate.

The criteria to be used to evaluate each Project Narrative are listed below in descending order of importance.

1. Mandatory Requirements

a. Does the Applicant fulfill all of the mandatory requirements outlined in Section 2.1 and provide documentation of meeting the requirement of having a demonstrated record of implementing (and optimizing) certified electronic health records and health information exchange for Maryland providers?

b. Does the Applicant fulfill all of the mandatory requirements outlined in Section 2.1 and provide documentation of meeting the requirement of having three years of experience providing tailored technical assistance and training to behavioral health providers on (certified) EHR Technology or case management systems?

2. Program Development

a. To what extent does the Applicant's technical proposal contain a response to each component of the Scope of Work?

3. Organizational Capacity

a. To what extent was there an overview of the organization’s experience working with behavioral health providers licensed under COMAR 10.21 and/or 10.63?

4. Work Plan

a. Is the work plan consistent with the description provided in the narrative?

b. Are the timeframes to deliver training services in alignment with the Scope of Work?

All Qualified Applicants will be ranked from the lowest (most advantageous) to the highest (least advantageous) based on the rating of the Project Narratives. The Budget Narrative (including the Budget Form and Budget Narrative), will be evaluated based on reasonable cost given the time and effort described in the Project Narrative. The budget line items must be within the stated guidelines set forth in this RFA and as submitted on Exhibit C – Budget Narrative.

5.1 Evaluation Committee

5.2 Project Narrative Evaluation Criteria

5.3 Budget Narrative Evaluation Criteria

5.4.1 General

The Grant will be awarded in accordance with the Standard Grant Agreement method outlined in the Announcement. The State may determine an Applicant to be non-responsive and/or an Applicant’s Application to be not reasonably susceptible of being selected for award at any time after the initial closing date for receipt of Applications and prior to Grant award. If the State finds an Applicant to be not responsive and/or an Applicant’s Project Narrative to be not reasonably susceptible of being selected for award, that Applicant’s Budget Narrative will be returned if the Budget Narrative is unopened at the time of the determination.

5.4.2 Award Determination

Upon completion of the Project Narrative and Budget Narrative evaluations and rankings, each Applicant will receive an overall ranking. The Procurement Officer will recommend award of the Grant to the responsible Applicant that submitted the Application determined to be the most advantageous to the State.

In making this most advantageous Application determination, technical factors and financial factors will be weighted equally.

5.4 Selection Procedures

RFA ATTACHMENTS

EXHIBIT B – Budget Form This must be completed and submitted with the Project Narrative separately from Technical Proposal via eMaryland Marketplace Advantage (eMMAEmma)

EXHIBIT C—Budget Narrative This must be completed and submitted with the Project Narrative, along with the Budget Narrative FormeMaryland Marketplace Advantage (eMMAEmma).

REFERENCE DOCUMENT A - Standard Grant Agreement “Sample” This is the sample grant agreement used by the Department. It is provided with the RFA for informational purposes and is not required to be submitted an Application submission time. Upon notification of recommendation for award, a completed standard grant agreement will be sent to the recommended awardee for signature. The recommended awardee must return to the Procurement Officer three (3) executed copies of the Standard Grant Agreement within five (5) Business Days after receipt.

Upon award, a fully executed copy will be sent to the Grantee.

ATTACHMENT B – RFA Document Checklist Use this checklist to ensure that the required documents for the Project Narrative and Budget Narrative are completed.

ATTACHMENT C – Work Plan Template (sample provided by the program)

FINANCIAL PROPOSAL FORM

The Budget Narrative shall contain all price information in the format specified on these pages. Complete the Budget Form only as provided in the Budget Form format. Do not amend, alter or leave blank any items on the Budget Form. Failure to adhere to any of these instructions may result in the Budget Narrative being determined non-responsive and rejected by the Department.

Submitted By:

Authorized Signature: _______________________________________________ Date: ________________________ Printed Name and Title: ___________________________________________________________________________ Company Name : ________________________________________________________________________________ Company Address: _______________________________________________________________________________ Location(s) from which services will be performed (City/State): ___________________________________________

FEIN: _________________________________________

eMMA #: ________________________________________ Telephone: (_______) _______-- ____________________ Fax: (_______) _______--____________________ E-mail: _________________________________________

Budget Summary (SAMPLE)

Line Item Qty Unit Cost Total Cost

Salary

Fringe

Contractual

Travel

Operating Costs

Supplies

Other

Other

Other

Other

TOTAL

EXHIBIT B – BUDGET FORM SAMPLE

BUDGET NARRATIVE TEMPLATE

Sample Line Item Justification

Personnel (Preventionist): $15,600

Justification: The Preventionist will be responsible for: conducting project-related relationship-building activities with new and existing partners; developing informational materials for community leaders and the public, including fact sheets and social media posts related to the project topic; coordinating and facilitating monthly project meetings with partners; conducting awareness-building activities within key demographic areas in the community to engage the project target audience; developing and providing professional training at targeted local governmental agencies and private businesses; attending community events relevant to the project and the project’s partners. The Project Coordinator will also attend RISEMD meetings, collect data, conduct evaluation activities, prepare reports, and act as a liaison with the MDH Grant Monitor.

$30/hr x 520 hours = $15,600

EXHIBIT C – BUDGET NARRATIVE

ORGANIZATIONS RECEIVING APPROPRIATIONS FROM THE STATE

STANDARD GRANT AGREEMENT

This Agreement, which is executed in compliance with Section 7-402 of the State Finance and Procurement Article of the Annotated Code of Maryland, is made this <enter day> day of <month, year> , between the State of Maryland (the “State”), acting through the Maryland Department of Health, (the “Department”), located at <enter MDH Address> and the <grantee name> (the “Grantee” ), located at <grantee address> in <county / city> County, <state, zip> , a Maryland Limited Liability Company / Corporation. .

1. Effective on the date of execution of this Agreement, the State is extending to the Grantee a grant in the amount of <amount in words> Dollars ($ xx,xxx.xx) (the “Grant”), which the Grantee shall use only for the following purposes: <grant purpose>

2. Any expenditure of Grant funds that is not consistent with purposes stated in paragraph 1 may, at the sole discretion of the Department, be disallowed. Should any expenditure be disallowed or should the Grantee violate any of the terms of this Agreement, the State may require repayment to the State Treasury, an offset from any State Grant to the Grantee in the current or succeeding fiscal year, or other appropriate action. The Grantee shall repay to the State any part of the Grant that is not used for the purposes stated in paragraph 1 within 3 months after the date of this Agreement.

3. The Grantee may not sell, lease, exchange, give away, or otherwise transfer or dispose of real or personal property, or any part of or interest in real or personal property, acquired with Grant funds without the prior written consent of the Department. This includes transfer or disposition to a successor on the merger, dissolution, or other termination of the existence of the Grantee.

The Grantee shall give the Department written notice at least 30 calendar days before any proposed transfer or disposition. Any proceeds from a permitted transfer or disposition shall be applied to repay to the State a percentage of that portion of the Grant allocable to the particular real or personal property transferred or disposed of, unless the Department and the Grantee agree to other terms and conditions. The percentage shall be equal to the percentage of the unadjusted basis of the property that would remain if the property had been recovery property placed in service after December 31, 1980 and if all allowable deductions had been taken up to the time of disposition under the Accelerated Cost Recovery System (ACRS) specified in the United States Internal Revenue Code, Section 168(b)(1).

4. For any item of real or personal property that is acquired with Grant funds and has an original fair market value of Five Thousand Dollars ($5,000) or more, the Grantee shall, at its own expense, and for the reasonable useful life of that item or for 5 years, whichever is less, obtain and maintain insurance. The insurance shall provide full protection for the Grantee and the State against loss, damage, or destruction of or to the real or personal property. The Grantee shall, on request, provide the Department with satisfactory evidence of its compliance with this requirement. Proceeds of insurance required by this paragraph shall be applied toward replacement of the real or personal property or toward the partial or total repayment of the State of the Grant, in the sole discretion of the Department.

5. The Grantee may not discriminate against any employee or applicant for employment because of race, color, religion, sex, national origin, or any other characteristic forbidden as a basis for discrimination by applicable laws, and certifies that its Constitution or by-laws contains a non-discrimination clause consistent with the Governor’s Code of Fair practices.

6. The person executing this Agreement on behalf of the Grantee certifies, to the best of that person’s knowledge and belief, that:

A.) Neither the Grantee, nor any of its officers or directors, nor any employee of the Grantee involved in obtaining contracts with or grants from the State or any subdivision of the State, has engaged in collusion with respect to the Grantee’s application for the Grant or this Agreement or has been convicted of bribery, attempted bribery, or conspiracy to bribe under the laws of any state or of the United States;

B.) The Grantee has not employed or retained any person, partnership, corporation, or other entity, other than a bona fide employee or agent working for the Grantee, to solicit or secure the Grant or this Agreement, and the Grantee has not paid or agreed to pay any such entity any fee or other consideration contingent on the making of the Grant or this Agreement; the grantee understands and complies with the Conflicts of Interest provision of the Public Ethics Law, Maryland Code Annotated, General Provisions, Title 5, Subtitle 5.

Reference Document A - Standard Grant Agreement “Sample” ( Page 18-36)

C.) The Grantee, if incorporated, is registered or qualified in accordance with the Corporations and Associations Article of the Annotated Code of Maryland, is in good standing, has filed all required annual reports and filing fees with the Department of Assessments and Taxation and all required tax returns and reports with the Comptroller of the Treasury, the Department of Assessments and Taxation, and the Department of Labor, Licensing and Regulation, and has paid or arranged for the payment of all taxes due to the State; and

D.) No money has been paid to or promised to be paid to any legislative agent, attorney, or lobbyist for any services rendered in securing the passage of legislation establishing or appropriating funds for the Grant.

E.) Neither the Grantee, nor any of its officers or directors, nor any person substantially involved in the contracting or fund raising activities of the Grantee, is currently suspended or debarred from contracting with the State or any other public entity or subject to debarment under the Code of Maryland Regulations, COMAR 21.08.04.04.

7. Within 60 calendar days after the close of any grant period in which the Grantee receives funds under this Agreement, the Grantee shall provide to the Department an itemized statement of expenditures, showing how the funds were expended for that grant period. In addition, a copy of the statement shall be mailed to the Director, General Accounting Division, Office of the Comptroller of the Treasury, Room 200, Louis L. Goldstein Treasury Building, Annapolis, Maryland 21401. The Grantee shall retain bills of sale or other satisfactory evidence of the acquisition of any real or personal property for at least 3 years after the date of this Agreement. The Department, the Department of Budget and Management, the State Comptroller, and the Legislative Auditor, or any of them, may examine and audit this evidence, on request, at any reasonable time within the retention period.

8. The Grantee shall comply with Section 7-221, 7-402, and 7-403 of the State Finance and Procurement Article of the Annotated Code of Maryland, as applicable.

9. The laws of Maryland shall govern the interpretation and enforcement of this Agreement.

10. This Agreement shall bind the respective successors and assigns of the parties.

11. The Grantee may not sell, transfer, or otherwise assign any of its obligations under this Agreement, or its rights, title, or interest in this Agreement, without the prior written consent of the Department.

12. No amendment to this Agreement is binding unless it is in writing and signed by both parties.

13. The following items are incorporated by referenced and made a part of this Agreement .Appendix A & B, Attachment A, B, C, D, E.&F.

IN TESTIMONY WHEREOF, WITNESS the hands and seals of the parties.

GRANTEE

(Name of Corporation or Association)

By:

. SEAL

Name: .

Title:

DEPARTMENT

Maryland Department of Health.

(Name of Corporation or Association)

By:

SEAL

Name:

Date: Date:

APPENDIX A

The Department’s Grant Monitor is: The Grantee’s Grant Monitor is:

<Name and Title of MDH grant monitor> <enter name, title, office, grantee agency, address, <Office> phone number and email > Maryland Department of Health 201 W. Preston Street Baltimore, Maryland 21201 Phone:

Email:

I. BACKGROUND INFORMATION OF AGREEMENT

<Enter background information of the agreement>

II. DUTIES OF THE GRANTEE

SCOPE OF WORK:

<Enter all duties and scopes of work for the grant agreement>

The Remainder of This Page is Left Blank

APPENDIX B (insert revised budget)

Cost Estimate for:

<Name of Project>

PERIOD OF PERFORMANCE - <Date of Project>

<Enter Budget>

II. DUTIES OF THE DEPARTMENT

Other than awarding the funds to the <grantee/sub-recipient/sub-awardee> for this project <MDH awarding agency> will:

● Provide necessary technical support and monitoring to <grantee/sub-recipient/sub-awardee> to ensure state and federal grant compliance.

This includes but is not limited to:

● Completion of the MDH Office of the Inspector General Risk Assessment

● Completion of the Standard Grant Agreement Checklist

● Determination of Good Standing with The State of Maryland

● Review for Debarment, Suspension, or any Exclusion from doing business with Maryland

● Determination regarding No Conflicts of Interest

● Review of Single Audits

● Review for Debarment, Suspension, or any Exclusion from doing business with the Federal Government

SECTION IV. INCORPORATION BY REFERENCE

Both parties hereby agree that the documents described below, if any, are hereby incorporated into and made an integral part of this Agreement: (Type "None", if none)

Exact Title of Document(s)

Number of Pages

Conditions of Award- Attachment A

Federal Funds- Attachment B

Debarment Affirmation- Attachment C

Certification Regarding Tobacco Smoke- Attachment D

Certification Regarding Lobby- Attachment E

W orkplan Template - Attachment C

RFA Checklist – Attachment B 1

ATTACHMENT A

CONDITIONS OF AWARD

Maryland Department of Health (MDH)

<Enter Department Here> <Enter Federal Awarding Agency Here>

<Enter Name of Federal Award and Grant Number Here>

Period of Performance: <Enter From and To Dates Here>

Important Dates:

<Enter Date Here>: Quarterly progress report <Enter Date Here>: All funds obligated <Enter Date Here>: All funds must be spent <Enter Date Here>: Final progress and fiscal report due to MDH

The grantee/sub-grantee/sub-recipient (circle one), shall comply with these conditions. Consequences for failure to comply with these conditions may include: a point reduction in score for future competitive and non-competitive applications, a reduction of overall award, audit exceptions and/or reduction in future awards.

Program Requirements:

1. The grantee/sub-grantee/sub-recipient, <Enter Grantee Name Here > agrees to comply with MDH guidelines and initiatives with regards to their expenditures/purchases.

2. When procuring equipment, the recipient must comply with the procurement standards at 45 CFR Part 92.36 and 45 CFR 74.40 through 74.48, including 74.45, which requires the performance and documentation of some form of cost or price analysis with every procurement action.

3. The grantee/sub-grantee/sub-recipient, will perform activities that coordinate, integrate, prioritize and sustain improvements in public health emergency preparedness.

4. The grantee/sub-grantee/sub-recipient, shall cite < Enter Name of Federal Award > and the MDH <Enter Department Here> as a funding source when publishing or presenting data or programs partially or fully funded by MDH grants.

5. The grantee/sub-grantee/sub-recipient, should inform the MDH <Enter Department Here> as a courtesy when a presentation or publication is made public that involves programs or data partially or fully funded by MDH, and any federal grants. All reports, data, software, or presentations generated from federal funded projects must be made available to MDH for review and comment prior to release or distribution.

Fiscal Requirements:

1. The grantee/sub-grantee/sub-recipient, shall not use <Enter Name of Federal Award> to:

a. Support the costs of operating clinical trials of investigational agents, equipment or treatments;

b. Make payments directly to recipients of services, except for reimbursement of reasonable and allowable out-of-pocket expenses associated with consumer participation in State or consortia activities;

c. Support legal services;

d. Provide direct maintenance expenses of privately owned vehicles or any other costs associated with a vehicle, such as lease or loan payments, vehicle insurance, or license registration fees;

e. Purchase or improve land, or to purchase, construct, or make permanent improvements to any building, except for minor remodeling;

f. Pay property taxes;

g. Fund capital improvement projects;

h. Supplant personnel costs and/or other activities.

i. Prepare, distribute, or use of any material (publicity/propaganda) or to pay the salary or expenses of grants, contract recipients, or agents that aim to support or defeat the enactment of legislation, regulation, administrative action, or executive order proposed or pending before a legislative body.

2. The grantee/sub-grantee/sub-recipient will comply with all MDH and federal fiscal requirements for timely submission of detailed budgets and budget modifications, including monthly invoice requirements.

3. The grantee/sub-grantee/sub-recipient will return any unspent and unobligated funds to MDH and provide the necessary supporting documentation.

Audits:

The grantee/sub-grantee/sub-recipient shall submit audits in accordance with Federal OMB 2 CFR 200, Subpart F - Audit Requirements. An electronic copy of all audits (2 CFR 200 Subpart F, as well as independent auditors) performed against federal funding should be forwarded to the Department for review.

Site Visits and Surveys:

1. As requested, the grantee/sub-grantee/sub-recipient shall participate fully in the MDH <Enter Department Here> Quality Improvement and Technical Assistance activities, which may include, but are not limited to:

a. Comprehensive site visits at the Department’s request within the project period;

b. Interviews of staff, review of fiscal and program records, monitoring, risk assessment, review of inventory purchased against federal funding, interviews with administrators, and observation of program activities/facility.

Equipment Inventory Requirements:

Equipment purchased with federal funds may be recalled or requested to support local, regional and/or statewide emergency response efforts and must be cataloged for future reference and review. Cataloging of equipment should be updated and maintained throughout the project period.

Risk Assessment:

The grantee/sub-grantee/sub-recipient shall be required to participate in an MDH Risk Assessment in accordance with Federal OMB 2 CFR §200.205 (b) thru (d), §200.207, and §200.331 (b) thru (h). As part of this requirement, sub- recipients will be monitored based on a risk level of High, Medium or Low. Each risk level imposes certain monitoring requirements set by the MDH Office of the Inspector General in accordance with the above federal guidelines.

ATTACHMENT B

FEDERAL FUNDS

A Summary of Certain Federal Fund Requirements and Restrictions

[Details of particular laws, which may levy a penalty for noncompliance, are available from the Maryland Department of Health.]

1. Form and rule enclosed: 18 U.S.C. 1913 and section 1352 of P.L. 101-121 require that all prospective and present subgrantees (this includes all levels of funding) who receive more than $100,000 in federal funds must submit the form “Certification Against Lobbying”. It assures, generally, that recipients will not lobby federal entities with federal funds, and that, as is required, they will disclose other lobbying on form SF- LLL.

2. Form and instructions enclosed: “Form LLL, Disclosure of Lobbying Activities” must be submitted by those receiving more than $100,000 in federal funds, to disclose any lobbying of federal entities (a) with profits from federal contracts or (b) funded with nonfederal funds.

3. Form and summary of Act enclosed: Sub-recipients of federal funds on any level must complete a “Certification Regarding Environmental Tobacco Smoke,” required by Public Law 103-227, the Pro-Children Act of 1994. Such law prohibits smoking in any portion of any indoor facility owned or leased or contracted for regular provision of health, day care, early childhood development, and education or library services for children under the age of 18. Such language must be included in the conditions of award (they are included in the certification, which may be part of such conditions.) This does not apply to those solely receiving Medicaid or Medicare, or facilities where WIC coupons are redeemed.

4. In addition, federal law requires that:

a) OMB 2 CFR 200, Subpart F, Audit Requirements requires that grantees (both recipients and sub-recipients) which expend a total of $750,000 or more in federal assistance shall have a single or program-specific audit conducted for that year in accordance with the provisions of the Single Audit Act of 1984, P.L. 98-502, and the Single Audit Act Amendments of 1996, P.L. 104-

156. and the Office of Management and Budget (OBM) 2 CFR 200, Subpart F.

b) All sub-recipients of federal funds comply with Sections 503 and 504 of the Rehabilitation Act of 1973, the conditions of which are summarized in item (C).

c) Recipients of $10,000 or more (on any level) must include in their contract language the requirements of Sections 503 (language specified) and 504 referenced in item (B).

Section 503 of the Rehabilitation Act of 1973, as amended, requires recipients to take affirmative action to employ and advance in employment qualified disabled people. An affirmative action program must be prepared and maintained by all contractors with 50 or more employees and one or more federal contracts of $50,000 or more.

This clause must appear in subcontracts of $10,000 or more:

i. The contractor will not discriminate against any employee or applicant for employment because of physical or mental handicap in regard to any position for which the employee or applicant for employment is qualified.