Required_Documents.pdf

RFP SFGOV- 0000011781

ON DEMAND, NON-EMERGENCY AMBULANCE TRANSPORTATION SERVICES

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

ATTACHMENT “A”

CONTACT INFORMATION COVER SHEET

REQUESTS FOR PROPOSALS SFGOV-0000011781

ON DEMAND, NON-EMERGENCY AMBULANCE TRANSPORTATION SERVICES

*THIS FORM MUST BE COMPLETED AND SUBMITTED WITH YOUR TECHNICAL/WORK

PROPOSAL (Electronic File #1)*

LEGAL NAME OF COMPANY(PROPOSER): ________________________________________

BUSINESS ADDRESS: _________________________________________________________

FEDERAL EMPLOYEE IDENTIFICATION NUMBER: _________________________________

CALIFORNIA BUSINESS ENTITY NUMBER: _______________________________________

CITY SUPPLIER ID (if registered): ________________________________________________

TELEPHONE: _______________ CELL PHONE: _______________ FAX: ________________

CONTACT PERSON: ____________________ EMAIL ADDRESS: ______________________

A. I hereby certify that I have the authority to submit this Proposal to the City and County of San Francisco for the above listed individual or company. I certify that I have the authority to bind myself/this company in a contract should I be successful in my proposal.

PRINTED NAME AND TITLE

SIGNATURE AND DATE

B. The following information relates to the legal contractor listed above, whether an individual or a company. Place check marks as appropriate:

1. If successful, the contract language should refer to me/my company as:

An individual;

A partnership, Partners’ names: ____________________________________

A company;

A corporation, if a corporation, organized in the state of: _________________

RFP SFGOV-0000011781

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

C. Representation re Good standing, Licenses, Etc.

A representation that the Proposer is in good standing in the State of California and has all necessary licenses, permits, approvals and authorizations necessary in order to perform the Work and conduct the Candidate’s business. Please check the item below if you agree with this statement.

I hereby represent and certify that the above statement is true and correct.

D. Representation regarding City Contracting Requirements.

A representation that the Proposer is able and willing to comply with all the contracting requirements described in this RFP. Please check the items below if you agree with the statements.

I hereby represent and certify that the Proposer will comply with all contracting requirements, including the City’s Contract Terms, as described in this RFP. The City reserves the right to terminate negotiations with any candidate that does not execute the City’s Contract Terms.

I hereby represent and certify that the Proposer will comply with all requirements of the Business Associate Agreement (BAA) and any attestations and/or attachments as presented in Attachment G of this RFP. The City reserves the right to terminate negotiations with any candidate that does not execute or agree to the Business Associate Agreement.

I hereby represent and certify that the Proposer will comply with all San Francisco labor laws for City contractors. Should the Proposer seek exemptions, they will do so based on the list of allowable exemptions and will clearly indicate which exemptions they believe apply to them. Outside of the listed exemptions, no other conditions are permissible. The Proposer will also furnish supporting documents for their exemption request. All exemption requests must be submitted with the proposal.

1. Minimum Compensation Ordinance (MCO)

MCO Declaration completed

Exemption requested pursuant to Category _____ of OLSE’s List of Exemptions

2. Health Care Accountability Ordinance (HCAO)

HCAO Declaration completed

Exemption requested pursuant to Category _____ of OLSE’s List of Exemptions

3. Health Care Security Ordinance (HCSO)

4. Fair Chance Ordinance (FCO)

5. First Source Hiring Form (FSH)

FSH completed (proof included in Proposal)

FSH exception submitted to First Source (proof included in Proposal) https://www.sf.gov/sites/default/files/2024-03/MCO%202015%20List%20of%20Exemptions%20for%20the%20Minimum%20Compensation%20Ordinance-no%20mayor.pdf https://sf.gov/sites/default/files/2022-12/9494-HCAO%20List%20of%20Exemptions.pdf

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

E. ADDENDA ACKNOWLEDGMENT:

Acknowledgment of Receipt of any Addenda issued by the City for this RFP is required by including the acknowledgment with your proposal. Failure to acknowledge the Addenda issued may result in your proposal being deemed non-responsive.

In the space provided below, please acknowledge receipt of each Addenda:

Addendum(s) # _______________ is/are hereby acknowledged.

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

ATTACHMENT “B”

NON-COLLUSION AFFIDAVIT

REQUESTS FOR PROPOSALS SFGOV-0000011781

*THIS FORM MUST BE COMPLETED AND SUBMITTED WITH YOUR TECHNICAL/WORK

PROPOSAL (Electronic File #1)*

The undersigned, deposes and says that he or she is of

, the party making the foregoing Proposal. That the

Proposal is not made in the interests of, or on the behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the Proposal is genuine and not collusive or sham; that the Proposer has not directly or indirectly induced or solicited any other Proposer to put in a false or sham Proposal, and has not directly or indirectly colluded, conspired, connived, or agreed with any Proposer or anyone else to put in a sham

Proposal, or that anyone shall refrain from Proposing; that the Proposer has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the

Proposal price of the Proposer or any other Proposer, or to fix any overhead, profit, or cost element of the Proposal price, or of that of any other Proposer, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract;

that all statements contained in the Proposal are true; and, further, that the Proposer has not, directly or indirectly, submitted his or her Proposal price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereof, or paid, and will not pay, any fee to any corporation, partnership, company, association, organization, Proposal depository, or any other member or agent thereof to effectuate a collusive or sham Proposal.

Signature: ______________________________________________

Title: _____________________________________________

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

ATTACHMENT “C”

REFERENCES

REQUESTS FOR PROPOSALS SFGOV-0000011781

ON DEMAND, NON-EMERGENCY AMBULANCE TRANSPORTATION SERVICES

*THIS FORM MUST BE COMPLETED AND SUBMITTED WITH YOUR TECHNICAL/WORK

PROPOSAL (Electronic File #1)*

Reference 1 Firm that Provided Products/Services to Reference (Prime or Subcontractor’s Name):

Organization Name: Contact Name and Title:

Email: Phone Number:

Effective Date of Contract: Value of Contract:

Description of Products/Services Provided:

Reference 2 Firm that Provided Products/Services to Reference (Prime or Subcontractor’s Name):

Organization Name: Contact and Title:

Email: Phone Number:

Effective Date of Contract: Value of Contract:

Description of products/services provided:

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

Reference 3 Firm that Provided Products/Services to Reference (Prime or Subcontractor’s Name):

Organization Name: Contact and Title:

Email: Phone Number:

Effective Date of Contract: Value of Contract:

Description of products/services provided:

RFP SFGOV- 00000111781

FOR THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

ATTACHMENT “D”

12L COMPLIANCE

REQUESTS FOR PROPOSALS SFGOV-0000011781

ON DEMAND, NON-EMERGENCY AMBULANCE TRANSPORTATION SERVICES

*THIS FORM MUST BE COMPLETED AND SUBMITTED WITH YOUR TECHNICAL/WORK

PROPOSAL (Electronic File #1)*

Non-Profit Entities: If a Proposer is a non-profit entity that receives a cumulative total per year of at least $250,000 in City funds or City-administered funds and is a non-profit organization as defined in Chapter 12L of the S.F. Administrative Code, the Proposer must describe how Proposer will comply with Chapter 12L.

Failure to comply with the reporting requirements of Chapter 12L or material misrepresentation in Proposer’s Chapter 12L submissions shall be grounds for rejection of the Proposal and/or termination of any subsequent Agreement reached on the basis of the Proposal.

☐ This form is not applicable to my organization. My organization is a non-profit that does not receive a cumulative total per year of at least $250,000 in City funds or City-administered funds.

☐ This form is not applicable to my organization. My organization is not a non-profit.

Item #1: A statement describing its efforts to comply with the Chapter 12L provisions regarding public access to Proposer’s meetings and records.

Item #2: A summary and disposition of all complaints concerning the Proposer’s compliance with Chapter 12L that were filed with the City in the last two years and deemed by the City to be substantiated. If no such complaints were filed, the Proposer shall include a statement to that effect.

If you need more space for your explanation, please attach a separate document.

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11/01/2025

CITY AND COUNTY OF SAN FRANCISCO

CONTRACT MONITORING DIVISION

CHAPTER 14B

CMD ATTACHMENT 2

Architecture, Engineering, and Professional Services

FORM 2A: CMD CONTRACT PARTICIPATION FORM

Section 1: This form must be submitted with the proposal or the proposal may be deemed non-responsive and rejected. Proposer, each Joint Venture partner, Subconsultants, Vendors, and lower sub tiers must be listed on this form. The RFP/RFQ will state which LBE size category (e.g., Micro, Small, and/or SBA-LBE) can be used to meet the LBE sub participation requirement(s). All LBE Proposers/JVs with LBE participation must meet the LBE sub participation requirement(s). Any LBE Proposer/JV with LBE participation may not count its participation towards meeting the LBE sub participation requirement(s). Be sure to check the appropriate box for Rating Bonus under Section 2. If more space is needed for Section 1, attach additional copies of this form.

*Type: Identify if Prime (P), JV partner (J), Subconsultant (S), or Vendor (V)

TY

PE

Firm

Portion of Work

(Describe Scope(s) of

Work)

% of Work

Indicate LBE or Non-LBE. If LBE, Micro, Small, or

SBA.

% of LBE Subwork (Carry-Over from % OF

Work Column)

Micro Small SBA

Total % of Work: 100% Total LBE Sub Participation: % % %

I declare, under penalty of perjury under the laws of the State of California, that I am utilizing the above Consultants for the portions of work and amounts as reflected in the proposal for this Contract.

Owner/Authorized Representative (Signature): _____________________ Date: _________________________

Print Name and Title: _____________________________________________________________________________

** See CMD website: http://www.sfgov.org/cmd for each firm’s status

Contract No.:

Contract Title: LBE SUBPARTICIPATION REQUIREMENT(S)

Firm: Micro and Small-LBE Sub Requirement – ___%

Contact Person: Micro, Small, SBA-LBE Sub Requirement – ___%

Address: Micro-LBE Sub Requirement - ___%

City/ZIP: Small-LBE Sub Requirement – ___%

Phone, Email: SBA-LBE Sub Requirement – ___% http://www.sfgov.org/cmd

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Section 2. Rating Bonus

Check applicable boxes.

A. NO Rating Bonus Requested 0%

B. Contracts with an Estimated Cost in Excess of $400,000 and Less Than or Equal to $10,000,000. See instructions in Sections 2.01 and 2.02.

Micro or Small-LBE 10%

Joint Venture 7.5%

Joint Venture 5%

Joint Venture (Micro or Small-LBEs only) 10%

SBA-LBE 5%

C. Contracts with an Estimated Cost in Excess of the Delegated Purchasing Amount ($20,000 as of July 1, 2024) and Less Than or Equal to $10,000,000. The below rating bonuses DO NOT apply to Chapter 21 contracts and only apply to Chapter 6 contracts, including Chapter 6.40. See instructions in Section

2.01 for details. This Neighborhood/Zip Code LBE Program shall apply to projects located within the jurisdictional boundary of San Francisco. The program shall not apply to Job Order Contracts (JOC), As- Needed contracts, or other contracts where no specific project location is specified at the time of proposal. The RFP/RFQ will clearly state whether the Pilot Neighborhood/Zip Code LBE Program is applicable to the specific project. A Proposer may receive up to a maximum rating bonus of 13% depending on the particular application.

Prime Neighborhood/Zip Code LBE rating bonus:

Prime Neighborhood LBE (or a JV where the Neighborhood LBE JV partner(s)’ participation is at least 40%) 1%

OR

Prime Zip Code LBE (or a JV where the Prime Zip Code LBE JV partner(s)’ participation is at least 40%) 1.5%

Subconsulting Neighborhood/Zip Code LBE rating bonus:

Sub Neighborhood LBE 0.5%

OR

Sub Zip Code LBE 1.5%

D. Contracts in Excess of $10,000,000 and Less Than or Equal to $20,000,000. See instructions in Section 2.01.

Micro, Small, or SBA-LBE 2%

E. Mentor-Protégé Program Bid Discount/Rating Bonus. The Mentor Protégé rating bonus is not applicable to professional services contracts. However, for this CMD Attachment 2, the Mentor Protégé rating bonus/bid discount is applicable for Design-Build and/or CM/GC projects only. See instructions in Section 2.01.

Mentors of the Mentor-Protégé Program 1%

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Section 3. Proposer, Joint Venture Partners, Subconsultant, and Vendor Information

Provide information for each firm listed in Section 1 of this form. Firms which have previously worked on City contracts may already have a vendor number. Vendor numbers of LBE firms are located on the CMD LBE website at http://www.sfgov.org/cmd. Use additional sheets if necessary.

FIRM NAME: VENDOR #:

ADDRESS: FEDERAL ID #:

CITY, ST, ZIP: PHONE: EMAIL:

SERVICE:

CITY, ST, ZIP: PHONE: EMAIL:

http://www.sfgov.org/cmd

GENERAL SERVICES AGENCY

OFFICE OF LABOR STANDARDS ENFORCEMENT

PATRICK MULLIGAN, DIRECTOR

SF OFFICE OF LABOR STANDARDS ENFORCEMENT, CITY HALL ROOM 430 MCO/HCAO TEL (415) 554-7903 • FAX (415) 554-6291

1 DR. CARLTON B. GOODLETT PLACE • SAN FRANCISCO, CA 94102 WWW.SFGOV.ORG/OLSE

Minimum Compensation Ordinance (MCO) Declaration

What the Ordinance does. The Minimum Compensation Ordinance (MCO) became effective October 8, 2000, and was later amended by the Board of Supervisors, with an effective date for the amendments of October 14, 2007. The MCO requires City contractors and subcontractors to pay Covered Employees a minimum hourly wage and to provide 12 compensated and 10 uncompensated days off per year. The minimum wage rate may change from year to year and Contractor is obligated to keep informed of the then-current requirements.

The MCO applies only if you have at least $25,000 in cumulative annual business with a City department or departments and have more than 5 employees, including employees of any parent, subsidiaries and subcontractors.

The City may require contractors to submit reports on the number of employees affected by the MCO.

Effect on City contracting. For contracts and amendments signed on or after October 8, 2000 the MCO will have the following effect:

In each contract, the contractor will agree to abide by the MCO and to provide its employees the minimum benefits the MCO requires, and to require its subcontractors subject to MCO to do the same.

If a contractor does not agree to provide the MCO’s minimum benefits, the City will award a contract to that contractor only if the contractor has received an approved exemption or waiver under MCO from the Office of Labor Standards Enforcement (OLSE) through the contracting Department. The contract will not contain the agreement to abide by the MCO if there is an exemption or waiver on file.

What this form does. If you can assure the City now that, beginning with the first City contract or amendment you receive after October 8, 2000 and until further notice, you will provide the minimum benefit levels specified in the MCO to your covered employees, and will ensure that your subcontractors also subject to the MCO do the same, this will help the City’s contracting process.

If you cannot make this assurance now, please do not return this form.

For more information, (1) see our Website, including the complete text of the ordinance: www.sfgov.org/olse, (2) e-mail us at: MCO@sfgov.org, (3) Phone us at (415) 554-7903.

Where to Send this Form. Submit this form via San Francisco’s centralized vendor portal sfcitypartnersupport@sfgov.org or call the Supplier Support Desk at 415-944-2442, Ext 1

Declaration

In order to be a certified vendor with the City and County of San Francisco, this company will provide, if applicable, the minimum benefit levels specified in the MCO to our Covered Employees, and will ensure that our subcontractors also subject to the MCO do the same, until further notice. This company will give such notice as soon as possible.

I declare under penalty of perjury under the laws of the State of California that the above is true and correct.

Signature Date

Print Name Bidder/Supplier # - if known

Company Name Phone Federal Employer ID # mailto:MCO@sfgov.org https://sfcitypartner.sfgov.org/ mailto:sfcitypartnersupport@sfgov.org?Subject=Question%20to%20User%20Support

For more information, or to sign up for email updates on the MCO and HCAO, visit our website: SF.GOV/OLSE

San Francisco Labor Laws for City Contractors Effective July 1, 2025

(Revised: June 2025)

Minimum Compensation Ordinance (MCO) Wages and Paid Time Off (PTO)

For a company that has 5 employees or greater, anywhere in the world. Includes subcontractors.

Any employee who works on a City contract for services:

- For-profit rate is $21.54/hour as of 7/1/25

- Non-profit rate is $21.55/hour as of 7/1/25; $23.00/hour as of 1/1/26

- Public Entities rate is $22.00/hour as of 1/1/25; $23.00/hour as of 1/1/26

- 0.04615 hours of Paid Time Off (PTO) per hour worked (can be used as vacation or sick leave, and is vested and cashed out at termination)

- 0.03846 hours of Unpaid Time Off per hour worked – allowed without consequence

- Employee must sign a “Know Your Rights” form

- Posting Requirement

Contact the MCO unit: mco@sfgov.org and (415) 554-7903

Health Care Accountability Ordinance (HCAO)

For a company that has > 20 workers (for profit)/ > 50 workers (nonprofit), anywhere in the world – Includes subcontractors

Any employee who works at least 20 hours a week on a City contract for services:

- Either:

A) Offer a compliant health plan with no premium charge to the employee. See Minimum Standards

OR

B) Pay $7.50* per hour to SF General Hospital (not Healthy San Francisco and not a benefit to employees)

OR

C) Pay $7.50* per hour to covered employee. N/A to SFO and San Bruno Jail locations. Employee must live outside of SF and work on a City contract outside of SF. See HCAO for more details.

- Employee must sign a “Know Your Rights” form

* Rate changes every July 1

Contact the MCO unit: hcao@sfgov.org and (415) 554-7903 mailto:mco@sfgov.org mailto:hcao@sfgov.org

For more information, or to sign up for email updates on the MCO and HCAO, visit our website: SF.GOV/OLSE

Health Care Security Ordinance (HCSO) Any employee who works an average of 8 hours a week in the City of San Francisco (whether or not on a City contract) and is not covered by the HCAO:

- As of 1/1/2025, spend $2.56* or $3.85* (depending on your size) per hour on their health care (e.g. health insurance, or a contribution to Healthy San Francisco)

- Employee can only waive their rights:

o By signing an official HCSO voluntary waiver, and o If they show they have insurance through another employer

- Posting Requirement

* Rate changes every January 1st

Contact the HCSO unit: hcso@sfgov.org and (415) 554-7892

Office of Labor Standards and Enforcement (OLSE) City Hall Room, 430

1 Dr. Carlton B. Goodlett Place San Francisco, CA 94102

Fair Chance Ordinance (FCO) Hiring Process

- You may not ask about criminal background in a job application or at the start of the hiring process

- Job announcements must include language specified by the law

- You may inquire into criminal background after an interview or once a conditional offer has been made

- If you intend to consider criminal background in your hiring decision, you must give the applicant the opportunity to provide evidence of rehabilitation or mitigating circumstances

- Posting Requirement

Contact the FCO unit: fco@sfgov.org and (415) 554-5192 mailto:hcso@sfgov.org mailto:fco@sfgov.org

Please Post Where Employees Can Read It Easily

NOTICE TO EMPLOYEES – JULY 1, 2025

Minimum Compensation Ordinance

This employer is a contractor with the City and County of San Francisco. This contract agreement is subject to the Minimum Compensation Ordinance (MCO). If under this contract agreement you perform any work funded under an applicable contract, you must be provided no less than the Minimum Compensation outlined below.

THESE ARE YOUR RIGHTS . . .

1. Minimum Hourly Compensation:

For contracts entered into or amended on or after October 14, 2007

• For-Profit Rate is $21.54/hour effective 7/1/25

• Non-profits is $21.55/hour effective 7/1/25; $23.00/hour effective 1/1/26

• Public Entities is $22.50/hour effective 7/1/25; $23.00/hour effective 1/1/26

• Rates subject to change; your employer must pay the then-current rate posted on the

OLSE web site: https://sf.gov/information/understanding-minimum-compensation-ordinance

For contracts entered into prior to October 14, 2007

• For work performed within the City Of S.F.: SF Minimum Wage ($19.18/hour effective 7/1/25)

• For work performed outside of S.F.: $16.50/hour

2. Paid Days Off:

• 12 paid days off per year for vacation, sick leave, or personal necessity

• The paid days off for part-time employees are prorated based on hours worked

3. Unpaid Days Off:

• 10 unpaid days off per year

• Unpaid days off for part-time employees are prorated based on hours worked

IF YOU BELIEVE YOUR RIGHTS ARE BEING VIOLATED CONTACT THE

OFFICE OF LABOR STANDARDS ENFORCEMENT AT (415) 554-7903.

Office of Labor Standards Enforcement (OLSE)

City Hall, Room 430 1 Dr. Carlton B. Goodlett Place

San Francisco, CA 94102 https://sf.gov/information/understanding-minimum-compensation-ordinance

Revised 6/2025 https://sf.gov/information/understanding-minimum-compensation-ordinance https://sf.gov/information/understanding-minimum-compensation-ordinance

SF OFFICE OF LABOR STANDARDS ENFORCEMENT, CITY HALL ROOM 430 TEL (415) 554-6235 • FAX (415) 554-6291

1 DR. CARLTON B. GOODLETT PLACE • SAN FRANCISCO, CA 94102 WWW.SF.GOV/OLSE

KNOW YOUR RIGHTS – JULY 1, 2025

This notice is intended to inform you of your rights under the Minimum Compensation Ordinance (MCO). The MCO requires your employer to provide a prescribed minimum level of compensation be paid to employees of (1) contractors and their subcontractors providing services to the City and County; (2) public entities whose boundaries are coterminous with the City and County who have city contracts; and, (3) tenants and subtenants on Airport property and their subcontractors. The Office of Labor Standards Enforcement (OLSE) is charged with enforcing the MCO. You will be asked to sign this document after you have reviewed the following information. Do not sign this document unless you fully understand your rights under this law.

THE MCO REQUIREMENTS

1. Minimum Hourly Wage

• For-Profit Rate is $21.54/hour effective 7/1/25

• Non-profits is $21.55/hour effective 7/1/25; $23.00/hour effective 1/1/26

• Public Entities rate is $22.50/hour effective 7/1/25; $23.00/hour effective 1/1/26

• For contracts entered into prior to October 14, 2007, the rate for work performed within the City of S.F.

is the San Francisco minimum wage ($19.18/hour effective July 1, 2025). The rate for work performed outside of S.F. is $16.50/hour.

• Rates are subject to change. Your employer is obligated to keep informed of the requirements and to notify employees in writing of any adjustment to the MCO wage.

2. Paid Days Off

• 12 paid days off per year for vacation, sick leave or personal necessity

• The paid days off for part-time employees are prorated based on hours worked

3. Unpaid Days Off

• 10 unpaid days off per year

• Temporary and casual employees are not eligible for unpaid time off

RETALIATION PROHIBITED

Your employer may not retaliate against you or any other employee for trying to learn more about the MCO or exercising your rights under the law. If you believe that you have been discriminated or retaliated against for inquiring about or exercising your rights under the MCO, contact the OLSE at (415) 554-7903 to file a MCO complaint.

Do not sign this document unless you fully understand your rights under this law. If you have any questions about your employer’s responsibilities or your rights under this Ordinance, contact the OLSE at (415) 554-7903 or visit https://sf.gov/information/understanding-minimum-compensation-ordinance for more information about this law.

Print Name of Employee:

Signature of Employee: Date:

Para asistencia en Español, llame al (415) 554-7903

需要中文幫助﹐請電 (415) 554-7903

For a complete copy of the Minimum Compensation Ordinance, visit https://sf.gov/information/understanding-minimum-compensation-ordinance.

https://sf.gov/information/understanding-minimum-compensation-ordinance

Revised 5/28/2025

Health Care Accountability Ordinance agreement is subject to the Health Care Accountability Ordinance (HCAO). The HCAO requires your employer to provide health plan benefits to covered employees, make payments to the City for use by the Department of Public Health (DPH), or, under limited circumstances, make payments directly to employees. If you work at least 20 hours per week on a City contract, you are a covered employee and your employer must choose one of the following options:

1. PROVIDE YOU WITH A HEALTH PLAN THAT MEETS THE MINIMUM

STANDARDS OUTLINED BY THE DIRECTOR OF PUBLIC HEALTH

• Your employer cannot require you to contribute any amount towards the premiums for health plan coverage for yourself.

• Coverage must begin no later than the first of the month that begins after 30 days from the start of employment on a covered contract.

2. PAY $7.50 PER HOUR WORKED TO THE CITY & COUNTY OF SAN FRANCISCO

• If you live within the City and County of San Francisco or work on a City contract within the

City, the San Francisco Airport, or the San Bruno Jail, and your employer does not provide a health plan that meets the Minimum Standards, your employer must pay $7.50/hour for every hour you work (up to 40 hours a week) to the City and County of San Francisco.

3. PAY AN ADDITIONAL $7.50 PER HOUR WORKED TO THE EMPLOYEE

• If you live outside the City and County of San Francisco and work on a City contract located outside of the City, and not at the San Francisco Airport or at the San Bruno Jail and your employer does not provide a health plan that meets the Minimum Standards, your employer must pay you an additional $7.50/hour for every hour you work (up to 40 hours a week) to enable you to obtain health insurance coverage.

1 Dr. Carlton B. Goodlett Place San Francisco, CA 94102 https://sf.gov/information/understand-health-care-accountability-ordinance

SF OFFICE OF LABOR STANDARDS ENFORCEMENT, CITY HALL ROOM 430 TEL (415) 554-6235 • FAX (415) 554-6291

1 DR. CARLTON B. GOODLETT PLACE • SAN FRANCISCO, CA 94102 WWW.SF.GOV/OLSE

Revised 5/28/2025

This notice is intended to inform you of your rights under the Health Care Accountability Ordinance (HCAO). The HCAO requires your employer to provide health insurance to you. Your employer can do this by enrolling you in a health plan, by making payments to the City, or, under limited circumstances, by making payments directly to you.

The Office of Labor Standards Enforcement (OLSE) is charged with enforcing this Ordinance. You will be asked to sign this document after you have reviewed the following information. Do not sign this document unless you fully understand your rights under this law.

THE HCAO COMPONENTS

I. If you live in San Francisco (regardless of where you work) or if you work in San Francisco, at the San Francisco Airport, or at the San Bruno Jail, your employer must:

A. Offer you health coverage that meets the Minimum Standards starting on the first day of the month following 30 calendar days after your first day of work*; OR

B. For each month in which you averaged at least 20 hours of work per week, pay the City $7.50 per hour for each hour you work, up to 40 hours or $300 per week.

II. If you do not live in San Francisco and do not work in San Francisco, at the San Francisco Airport, or at the San Bruno Jail, your employer must:

A. Offer you health coverage that meets the Minimum Standards starting on the first day of the month following 30 calendar days after your first day of work*; OR

B. For each month in which you averaged at least 20 hours of work per week, pay you $7.50 per hour for each hour you work, up to 40 hours or $300 per week, so that you can obtain health insurance coverage on your own.

*Note that your employer must offer at least one plan that does not require you to contribute any amount towards the cost of premiums for health plan coverage for yourself.

EXEMPTIONS FROM COVERAGE

Certain categories of employees, including but not limited to students, trainees, and employees of employers subject to Prevailing Wage requirements, are exempt under the HCAO. For more information, go to https://sf.gov/information/understand-health-care-accountability-ordinance or call (415) 554-7903.

VOLUNTARY WAIVER OF COVERAGE

Employees may refuse health coverage offered by an employer if the employee signs the Voluntary Waiver Form.

Employees may revoke this voluntary waiver at any time.

RETALIATION PROHIBITED

Your employer may not retaliate against you or any other employee for trying to learn more about the HCAO or exercising your rights under the law. If you believe that you have been discriminated or retaliated against for inquiring about or exercising your rights under the HCAO, contact the OLSE at (415) 554-7903 to file an HCAO complaint.

Do not sign this document unless you fully understand your rights under this law. If you have any questions about your employer’s responsibilities or your rights under this Ordinance, contact the OLSE at (415) 554-7903 or visit https://sf.gov/information/understand-health-care-accountability-ordinance for more information about this law.

Name of Employee Date

Signature of Employee

Para asistencia en Español, llame al 554-7903 需要中文幫助﹐請電 554-7903

NOTE: For a complete copy of the Health Care Accountability Ordinance or the Minimum Standards, visit https://sf.gov/information/understand-health-care-accountability-ordinance https://sf.gov/information/understand-health-care-accountability-ordinance

Last Updated: October 2024 1 of 2

City and County of San Francisco London N. Breed

Mayor

San Francisco Department of Public Health Grant Colfax, MD

Director of Health

San Francisco Health Care Accountability Ordinance (HCAO) Minimum Standards – Effective January 1, 2025

The following minimum standards are effective January 1, 2025. Health plans deemed compliant with the HCAO must either:

(1) Meet all 16 minimum standards as described below, OR

(2) Be a gold- and platinum-level plan written in California (or actuarial value of at least 76%), where:

A. the employer covers 100 percent of both the plan premium and medical services deducible.

Employers may use any health savings/reimbursement product that supports coverage of the medical deductible; and

B. the plan covers all required covered services minimum standards (5, 8-16).

Note that the requirements under the HCAO are distinct from the Healthy Airport Ordinance (HAO). More information on the HAO can be found here: sf.gov/information/understanding-healthy-airport-ordinance

Benefit Requirement Minimum Standard

1. Premium

Contribution Employer pays 100 percent.

2. Annual OOP Maximum

In-Network:

• Employer must cover in-network out-of-pocket expenses up to 50 percent of plan’s annual out-of-pocket maximum. These expenses must be covered on a first-dollar basis.

• Employers may use any health savings or reimbursement product that supports compliance with this minimum standard.

• OOP Maximum must include all types of cost-sharing (deductible, copays, coinsurance, etc.).

• The plan’s out of pocket maximum cannot exceed the Federal out-of-pocket limit for a self-only coverage plan during the plan’s effective date.

In 2025, the limit is $9,200.

Out-of-Network: Not specified.

3. Medical Deductible • In-Network: $3,000 maximum.

• Out-of-Network: Not specified.

4. Prescription Drug Deductible

• In-Network: $400 maximum.

• Out-of-Network: Not specified.

5. Prescription Drug Coverage

• Plan must provide drug coverage, including coverage of brand-name drugs.

6. Coinsurance Percentages

• In-Network: 55 percent/ 45 percent.

• Out-of-Network: 50 percent/50 percent.

Last Updated: October 2024 2 of 2

Benefit Requirement Minimum Standard

7. Copayment for

Primary Care Provider Visits

• In-Network: $65 per visit. When coinsurance is applied See Benefit Requirement #6.

• Out-of-Network: Not specified.

8. Preventive & Wellness Services

• In-Network: Provided at no cost, per ACA rules.

• Out-of-Network: Subject to the plan’s out-of-network fee requirements.

These services are standardized by federal ACA rules at no charge to the member. The California EHB Benchmark Plan outlines the types of preventive services that are required.

9. Pre/Post-Natal Care • In-Network: Scheduled prenatal exams and first postpartum follow-up consult is covered without charge, per ACA rules.

• Out-of-Network: Subject to the plan’s out-of-network fee requirements.

These services are standardized by federal ACA rules at no charge to the member. The California EHB Benchmark Plan outlines the types of pre- and post-natal services that are required.

10. Ambulatory Patient Services (Outpatient Care)

• When coinsurance is applied See Benefit Requirement #6.

• When copayments are applied for these services:

o Primary Care Provider: See Benefit Requirement #7.

o Specialty visits: Not specified.

11. Hospitalization • When coinsurance is applied See Benefit Requirement #6.

• When copayments are applied for these services: Not specified.

12. Mental Health & Substance Use Disorder Services, including Behavioral Health

• When coinsurance is applied See Benefit Requirement #6.

• When copayments are applied for these services: Not specified.

13. Rehabilitative & Habilitative Services

• When coinsurance is applied See Benefit Requirement #6.

• When copayments are applied for these services: Not specified.

14. Laboratory Services • When coinsurance is applied See Benefit Requirement #6.

• When copayments are applied for these services: Not specified.

15. Emergency Room Services & Ambulance

• Limited to treatment of medical emergencies. The in-network deductible, copayment, and coinsurance also apply to emergency services received from an out-of-network provider.

16. Other Services • The full set of covered benefits is defined by the California EHB Benchmark plan.

London N. Breed

Mayor

San Francisco Department of Public Health Grant Colfax, MD

Director of Health

Office of Policy and Planning

2025-2026 Healthcare Accountability Ordinance (HCAO) Minimum Standards:

Frequently Asked Questions and Common Clarifications

1) Does the HCAO require that coverage be offered for the individual employee and their dependent(s)?

No, the HCAO only requires that medical insurance be offered to the individual worker.

2) Since an employer only has to offer one (1) compliant plan, do other additional plans have to be HCAO compliant?

A covered employer is only required to offer one (1) compliant plan at no charge to the employee. If they choose to offer additional plans, these plans do not have to meet all the minimum standards, and they can be administered as the employer so chooses.

For example, after offering the compliant plan at no charge, the employer can also:

• offer a plan with different benefits that do not meet the minimum standards; or

• offer a plan that requires an employee premium contribution

3) If an employer pays the HCAO fee instead of offering a compliant plan, does that count as insurance?

Does the employee benefit directly from the fee payment?

Paying the HCAO fee does not count as insurance, and where an employer needs to pay the fee depends on the location of where the employee’s work is performed:

• If the employee performs works on a City contract within the City, the San Francisco Airport, or the San Bruno Jail, the fee is paid to the Department of Public Health. These payments are not a benefit to employees and the fees paid are to meet the HCAO compliance’s requirement if the employee does not offer a HCAO complaint health plan to the covered employee.

• If the employee performs work on a City contract outside the City and County of San Francisco, the fee is paid to the employee. These payments to the employee are a direct benefit to the employee.

Contact the Office of Labor Standards Enforcement (OLSE) at hcao@sfgov.org for more questions about the fee, best practices on implementation of the above, and how to make a payment instead of offering a compliant plan.

4) Does it matter if our plan is self-funded vs fully-funded as it relates to the HCAO minimum standards?

No, it does not.

5) How do I calculate the actuarial value of a plan?

Employers can request that your broker provide the actuarial value of the plan in question, or you can also use the CMS Actuarial Value Calculator (AV Calculator), which is designed to give an estimate of the actuarial value for a given plan design. Please ensure you use the calculator of the corresponding year you’re seeking compliance for (i.e., 2025 AV Calculator is used to calculate the AV of a 2025 health plan).

Updated August 2024 2 of 4

Services Covered

6) If our plan is written out of another state, what can we do to comply with the coverage requirements under standard 16 regarding the CA benchmark plan?

Employers can get a rider for the services not currently covered or get a plan written in CA.

7) Are quantity limits allowed on services that are in the CA benchmark plan?

Please refer to the CA benchmark plan for allowable quantitative limitations on services. For example, bariatric services cannot have quantitative limitations as specified under the CA Benchmark Plan: Link

8) Does an employer need to offer pediatric vision and dental coverage as part of the HCAO?

Given that the HCAO only requires adult coverage, plans do not need to include these benefits.

9) Are adult vision exams required? They are part of the benchmark plan but are not EHBs, so wanted to double check.

Routine eye exams for adults must be covered. Under the HCAO and HAO, plans must provide the full set of covered benefits defined by the California EHB Benchmark plan, and routine eye exams are a covered service.

10) What weight loss drugs must be covered by HCAO compliant health plans?

Under the HCAO Minimum Standard #16, compliant plans must cover all services and Rx drugs listed in the CA EHB Plan. The plan, on pp.9-13 of the CA EHB plan link, specifies which Rx's must be covered.

If your plan covers the listed # of Rx in the category/class in the table, then it complies with Rx requirements.

The weight loss programs and interventions referenced by EHB plans (and CMS) are grounded in the US Preventive Services Task Force, and generally more in the context of behavioral interventions. They are intentionally general and defer to the medical provider and their relationship with the patient to prescribe based on their clinical expertise. It does not require coverage of certain Rx drugs

Healthcare Accountability Ordinance (HCAO) vs. Healthcare Airport Ordinance (HAO)

11) How do I know if I have to comply with the HCAO or HAO?

The requirements under the HCAO are distinct from the Healthy Airport Ordinance (HAO). The HAO applies to employers at SFO with employees covered under the SFO Quality Standards Program (QSP).

More information on the HAO can be found here: sf.gov/information/understanding-healthy-airport-ordinance. For more info about whether your employees covered under the SFO QSP, contact 650-821- 1103; qsp@flysfo.com.

If you are required to comply with the HAO requirements, you do not need to comply with the HCAO minimum standards.

Updated August 2024 3 of 4

12) Does the HAO plan supersede the HCAO? If a company has QSP and non-QSP employees, can they offer only the HAO compliant plan?

The HAO does not supersede the HCAO. If there are non-QSP employees that fall under the HCAO, then they would need to be offered an HCAO compliant plan. In many cases, HAO compliant plans comply with the HCAO minimum standards, but employers should still review plans for HCAO compliance in this circumstance.

HCAO Compliance Timeline

13) If our health insurance policy does not end until after the revised minimum standards become effective for 2025, will we be considered out of compliance?

No – the employer’s plan would still be compliant. A plan year that overlaps with the revised standards effective January 1, 2025 (i.e. plan year was July 1, 2024 to June 30, 2025), would only need to comply with the standards that were effective January 1, 2024. Any subsequent contract effective on or after January 1, 2025 will need to comply with the revised standards.

Common Clarifications about specific Minimum Standards Minimum Standard Clarification

1. Premium Contribution Employer pays 100% of the premium contribution.

• Refers only to individual medical coverage and not vision/dental.

• No money may come out of an employee’s paycheck to pay the premium contribution.

• Employer is only required to offer at least 1 HCAO compliant health plan for which the employer must pay 100% of the premium contribution for the covered employee.

• Employer has the discretion to offer any additional health plans for which there can be an option for employees to contribute to their premiums.

2. Annual Out-of-Pocket Maximum

In-Network:

• Employer must cover in-network out-of-pocket expenses up to 50 percent of plan’s annual out-of-pocket maximum. These expenses must be covered on a first-dollar basis.

• OOP Maximum must include all types of cost-sharing (deductible, copays, coinsurance, etc.).

• The plan’s out of pocket maximum cannot exceed the Federal out-of-pocket limit for a self-only coverage plan during the plan’s effective date. In 2025, the limit is $9,200.

Out-of-Network: Not specified.

• If a HRA or HSA is utilized to cover the employee’s in-network out-of-pocket expenses, there is no need to pre-fund the full out-of-pocket expenses amount.

• Employer may use a third-party administrator or other appropriate option to manage reimbursement of employees’ medical expenditures that count towards the in-network out-of-pocket expenses as long as employees’ protected health information remain private and confidential in accordance with state and federal laws.

• Employers are encouraged to discuss the optimal reimbursement mechanism with their benefits administrator.

While not required, employers are strongly encouraged to provide an employer-funded mechanism, such as a pre-funded debit card, to beneficiaries to cover out-of-pocket expenses (e.g.

copays) upfront.

• Example of how standard would be applied to a health plan: If a plan’s annual out-of-pocket maximum for in-network services is $8,000, then the employer must cover the initial $4,000 of the employees in-network health expenses that count towards the OOP Maximum.

Updated August 2024 4 of 4

Minimum Standard Clarification

Medical Deductible

• In-Network: $3,000 maximum.

• Out-of-Network: Not specified.

• The $3,000 maximum limit is for an individual deductible.

• A plan can have combined medical and prescription drug deductible. In this situation, the $3,000 maximum would still apply to the combined deductible amount as long as the medical and prescription costs count toward the one total deductible.

16. Other Services The full set of covered benefits is defined by the California EHB Benchmark plan.

• Although all gold- and platinum-tier health plans are considered automatically compliant under the HCAO Minimum Standards, they must still offer coverage for the full set of covered benefits as defined by the California EHB Benchmark plan.

• Health plans offered by out-of-state contractors doing business with or in the City and County of San Francisco must provide coverage for the services covered by the California EHB Benchmark plan.

For more information tinyurl.com/sfhcao sf.gov/information/understand-health-care-accountability-ordinance

(628) 271-7517

SF OFFICE OF LABOR STANDARDS ENFORCEMENT, CITY HALL ROOM 430 MCO/HCAO TEL (415) 554-7903 • FAX (415) 554-6291

1 DR. CARLTON B. GOODLETT PLACE • SAN FRANCISCO, CA 94102 WWW.SFGOV.ORG/OLSE

Health Care Accountability Ordinance (HCAO) Declaration

What the Ordinance Requires. The Health Care Accountability Ordinance (HCAO), which became effective July 1, 2001, requires Contractors that provide services to the City or enter into certain leases with the City, and certain Subcontractors, Subtenants and parties providing services to Tenants and Subtenants on City property, to provide health plan benefits to Covered Employees, or make payments to the City for use by the Department of Public Health (DPH), or, under limited circumstances, make payments directly to Employees.

The HCAO applies only to Contractors with at least $25,000 ($50,000 for non-profit organizations) in cumulative annual business with a City department(s) and have more than 20 Employees (50 Employees for non-profit organizations) including Employees of any parent or subsidiaries.

The City may require Contractors to submit reports on the number of Employees affected by the HCAO.

Effect on City Contracting. For contracts and amendments signed on or after July 1, 2001, the HCAO requires the following:

Each contract must include terms ensuring that the Contractor will agree to abide by the HCAO and either to provide its employees with health plan benefits meeting the Minimum Standards set forth by the Director of Health or to make the payments required by the HCAO;

All City Contractors must agree to comply with the requirements of the HCAO unless the Contracting Department has obtained an approved exemption or waiver under the HCAO from the Office of Labor Standards (OLSE).

Contractors must require any Subcontractors subject to the HCAO to comply with the HCAO:

The Purpose of This Declaration. By submitting this declaration, you are providing assurances to the City that, beginning with the first City contract or amendment you receive after July 1, 2001 and until further notice, you will either provide the health plan benefits meeting the Minimum Standards to your covered employees or make the payments required by the HCAO, and will ensure that your Subcontractors also abide by these requirements. If you cannot provide this assurance, do not return this form.

To obtain more information regarding the HCAO, Visit our website, which includes links to the complete text of the HCAO, at www.sfgov.org/olse/hcao; send an e-mail to HCAO@sfgov.org; or call (415) 554-7903.

Where to Send this Form. Submit this form via San Francisco’s centralized vendor portal sfcitypartnersupport@sfgov.org or call the Supplier Support Desk at 415-944-2442, Ext 1

Declaration

In order to be a certified vendor with the City and County of San Francisco, the company named below will either provide, if applicable, health benefits specified in the HCAO to our covered employees or make the payments required by the HCAO, and will ensure that our subcontractors that are subject to the HCAO also comply with these requirements, until further notice. The company named below will provide such notice as soon as possible.

I declare under penalty of perjury under the laws of the State of California that the above is true and correct.

Signature Date

Print Name Bidder/Supplier # - if known

Company Name Phone Federal Employer ID # http://www.sfgov.org/olse/hcao mailto:HCAO@sfgov.org https://sfcitypartner.sfgov.org/ mailto:sfcitypartnersupport@sfgov.org?Subject=Question%20to%20User%20Support

For more information, or to sign up for email updates on the MCO and HCAO, visit our website: SF.GOV/OLSE

San Francisco Labor Laws for City Contractors Effective July 1, 2025

(Revised: June 2025)

Wages and Paid Time Off (PTO)

For a company that has 5 employees or greater, anywhere in the world. Includes subcontractors.

Any employee who works on a City contract for services:

- For-profit rate is $21.54/hour as of 7/1/25

- Non-profit rate is $21.55/hour as of 7/1/25; $23.00/hour as of 1/1/26

- Public Entities rate is $22.00/hour as of 1/1/25; $23.00/hour as of 1/1/26

- 0.04615 hours of Paid Time Off (PTO) per hour worked (can be used as vacation or sick leave, and is vested and cashed out at termination)

- 0.03846 hours of Unpaid Time Off per hour worked – allowed without consequence

- Employee must sign a “Know Your Rights” form

Contact the MCO unit: mco@sfgov.org and (415) 554-7903

For a company that has > 20 workers (for profit)/ > 50 workers (nonprofit), anywhere in the world – Includes subcontractors

Any employee who works at least 20 hours a week on a City contract for services:

- Either:

A) Offer a compliant health plan with no premium charge to the employee. See Minimum Standards

OR

B) Pay $7.50* per hour to SF General Hospital (not Healthy San Francisco and not a benefit to employees)

OR

C) Pay $7.50* per hour to covered employee. N/A to SFO and San Bruno Jail locations. Employee must live outside of SF and work on a City contract outside of SF. See HCAO for more details.

- Employee must sign a “Know Your Rights” form

* Rate changes every July 1

Contact the MCO unit: hcao@sfgov.org and (415) 554-7903 mailto:mco@sfgov.org mailto:hcao@sfgov.org

For more information, or to sign up for email updates on the MCO and HCAO, visit our website: SF.GOV/OLSE

Health Care Security Ordinance (HCSO) Any employee who works an average of 8 hours a week in the City of San Francisco (whether or not on a City contract) and is not covered by the HCAO:

- As of 1/1/2025, spend $2.56* or $3.85* (depending on your size) per hour on their health care (e.g. health insurance, or a contribution to Healthy San Francisco)

- Employee can only waive…