RFR 253933 Refugee Health Assessment Program Application~1.docx

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 Rev 8

APPLICATION RESPONSE FORM, INSTRUCTIONS, AND CHECKLIST

For use with the M03/MM3 RFR

General Instructions:

1. See the RFR and COMMBUYS posting for complete procurement specifications.

2. All responses are to be submitted using the online submission tools available to Vendors registered in COMMBUYS. There is no charge to register in COMMBUYS. To Register go to www.COMMBUYS.com and click on the “Register” link on the front page.

Bidders are solely responsible to monitor COMMBUYS for Bid amendments, if any. Bidders may monitor the record by frequently checking the Amendment Section on the Summary screen for the BID in COMMBUYS.

3. All Bidders are advised to allow adequate time for submission by considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume. DPH is not responsible for delays encountered by Bidders or their agents, or for a Bidder’s local hardware failures, such as computers or related networks, associated with bid compilation or submission. Bids submitted via COMMBUYS are time stamped by the COMMBUYS system clock which is considered the official time of record.

Formatting Instructions:

This document was prepared using Microsoft Word’s forms feature. Complete the form on your computer using Microsoft Word.

1. Save this document file to your computer.

2. Enter your responses in the text box, moving between the text boxes using the tab key on your keyboard.

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5. Those with visual impairments may use an electronic text reader by unlocking the Application Response Form.

RFR #______

APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

RFR TITLE: Refugee Health Assessment Program

RFR # 253933

Organization Organization Name: [ ]

Address:

City: [ ] State: [ ] Zip: [ ]

Vendor Code: [ ]

CEO (Chief Executive Officer) First Name: [ ] Last Name: [ ]

FEIN: [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Organization Information

Is your agency pre-qualified to conduct business with the Commonwealth? |_| Yes |_| No

If so, which Massachusetts Department is your Principal Purchasing Agent (PPA): [ ]

Location of Proposed Service Program Name: [ ]

Program Address:

City: [ ] State: [ ] Zip: [ ]

RFR #253933

A note about the text boxes: Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in a text box.

QUESTIONS FOR RESPONSE

Enter your response in the text boxes using Microsoft Word. Applications with missed responses to any of the questions, including those without assigned points, will not be considered for review.

A note about the text boxes: Type or paste text into the gray areas. Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc., are counted as characters. The spell-check feature does not work in a text box.

1. Prior to entering into a contract with DPH, a bidder must demonstrate that it meets minimum administrative and fiscal standards established by the Executive Office of Health and Human Services (EOHHS) provider qualification policy. Potential bidder’s new to the state system must upload completed provider qualification application materials as part of the response to this RFR. See the Provider Qualification Folder (QUALIFICATION) for instructions and forms. Bidders with current human and social services contracts (MM3/M03) must have filed their Uniform Financial Statements and Independent Auditor's Report (UFR) with the Operational Services Division eFile system. Applications will not be reviewed unless this response is provided, even though no score is assigned.

|X| New provider – Uploaded requested documents to COMMBUYS.

|X| Existing provider – UFR on file at the OSD eFile website.

2. (a) Attach an organizational chart showing the proposed Refugee Health Assessment Program (RHAP) location within your agency.

|X| Organization Chart uploaded to COMMBUYS.

(b) Describe how the proposed program will link with the mission and programs described in your agency’s mission statement (text input limit 1,250 characters, approximately 200 words). (2 points).

Enter text here: text limit 1,250 characters

3. (a) Bidders are required to make a meaningful financial commitment (“SDP Commitment”) by partnering with one or more SDO-certified or recognized diverse business enterprises or non-profit organizations. Providers should aim to direct at least 1% of their Commonwealth contract revenue toward spending with SDP Partners. The Provider’s percentage of spending with SDP Partner(s) for the prior fiscal year can be seen as “PERCENT (%) OF POS SPEND” on the completed “SDP Plan Form for POS” for that fiscal year. (15 points).

Bidders can

· upload a copy of the SDP Plans most recently filed through the Uniform Financial Reporting (UFR) system

· upload an updated SDP Plan using the SDP Form for POS found in the attachment section on COMMBUYS

· if a new provider complete the SDP Plan for POS and upload with your response

Contractors seeking assistance in the development of their SDP Plans or identification of potential SDP Partners may visit the SDP webpage, www.mass.gov/sdp, or contact the SDP Help Desk at sdp@mass.gov

|_| SDP plan form for POS uploaded to COMMBUYS

(b) Describe how your organization's current or planned operations support racial/health equity. (10 points).

Enter text here: text limit 1,250 characters

4. Provide an abstract and describe the proposed Refugee Health Assessment Program at your site, including systems and methods that will be used to manage and deliver services to eligible individuals. Your response should outline services to a new patient to delineate proposed operations and describe your workflow(s). We suggest starting with a Resettlement Agency faxing an appointment request for a newly arrived refugee, continuing through the two health assessment visits, referrals, and reporting to DPH. Do not include a description of the clinical protocols; your capacity and agreement to adhere to the clinical protocols are affirmed through signing the program assurances. (text input limit 1,875 characters, approximately 300 words). (17 points).

Enter text here; text limit 1,875 characters

5. (a) Provide a percentage breakdown by job category and race/ethnicity of your agency’s staff on the Agency Staff Demographics Table available in the COMMBUYS Bid Attachment Section. Please enter percentages as whole numbers (e.g., 2.3% = 2%). (3 points).

|_| Agency Staff Demographics Table uploaded to COMMBUYS.

(b) Describe the population your agency serves across all programs regarding its racial, ethnic, linguistic, cultural, gender, and age characteristics. What neighborhood(s) or town(s) does your agency serve? (text input limit 2,500 characters, approximately 400 words). (3 points).

Enter text here; text limit 2,500 characters

6. The Department expects health and human service providers and residents to collaborate to identify local and regional health priorities, design community-based prevention plans, and track success in achieving healthier communities through internal and external collaborations and participation in a local Coalition that meets the minimum requirements established in the 2015 DPH Coalition Principles and Guidelines.

https://www.mass.gov/service-details/healthy-communities-and-community-engagement-capacity-building.

Describe how internal and external collaborations have and will enhance your ability to target, plan, provide, and evaluate the proposed program. Note how these collaborations will directly benefit the priority population, promote efficiency, and/or improve effectiveness. (text input limit 2,500 characters, approximately 400 words). (3 points).

7. If the submitted proposal contains subcontracts, name the proposed subcontractors. Describe how the subcontracts will function, including descriptions of responsible parties and structures for operation and accountability. All subcontracts are subject to DPH approval. If you propose using subcontractors, complete the Direct Care Proposed Subcontractor Identification List in the COMMBUYS Bid Attachment Section. (text input limit 2,500 characters, approximately 400 words).

|_| Proposed Subcontractor Identification List uploaded to COMMBUYS (if applicable).

8. Federal standards direct agencies to deliver effective, understandable, and respectful care that is provided in a manner compatible with a client’s cultural health beliefs and practices and preferred language. Please describe your program’s strategies for delivering culturally competent and linguistically appropriate services (CLAS). Please see the attachment for the Cultural and Linguistic Appropriate Services Standards and Guidelines available in the COMMBUYS Bid Attachment Section for assistance in developing strategies to provide CLAS standards of care. Bidders must submit a separate CLAS Self-Assessment upon signing a contract with DPH. CLAS Self-Assessment is available here: https://www.mass.gov/lists/making-clas-happen-six-areas-for-action#self-assessment-tool- (text input limit 2,500 characters, approximately 400 words). (4 points).

9. Describe how RHAP services are organized, specifically if appointments will be in blocks or sessions (e.g., refugee clinic) or integrated into provider schedules. Detail your capacity regarding the number of pediatric and adult RHAP appointments per month (# of new/visit first-appointment, and # of follow-up/visit second-appointment). Describe your capacity to provide services to families that include children, adolescents, and adults. It is not uncommon for large families to be resettled. (text input limit 2,500 characters, approximately 400 words). (7 points).

10. Describe the clinical and administrative team that will provide RHAP services in accordance with established protocols. Provide details for the lead individual in each of four roles in refugee health assessment: the Lead Clinician, the overall program Coordinator, the Liaison to Resettlement Agencies, and the Billing Lead. The requested details include the name and title, their role in the agency, and [in brief] their experience in providing refugee health assessments. The table format below may be used. (CVs for persons in these four roles will be submitted in appendices.)

In the context of where these individuals fit within your organizational structure, describe your processes or plan for facilitating regular and timely communication among clinical, administrative, and billing staff to ensure effective service delivery and address issues that may arise. A workflow diagram that includes all information requested in the table below can be submitted to illustrate these processes and replace the table/long-form text response. Include a description of a communication plan with Resettlement Agencies regarding services. Detail the number and type of clinicians who will provide Refugee Health Assessment Program services. (text input limit 2,500 characters, approximately 400 words). (4 points).

Role:

Name

Lead Clinician:

Program Coordinator:

Liaison to Resettlement:

Billing Lead:

11. Describe your surge response plan and operational mechanisms designed to prepare for and accommodate rapid, increased demand for health assessments. (text input limit 1,250 characters, approximately 200 words) services. (4 points).

Enter text here; text limit 1,250 characters

12. The RHAP protocol includes many elements that require laboratory procedures. Please describe the laboratory capacity of your site relative to the range of RHAP requirements. List all tests and laboratory procedures conducted on-site. If all or part of your laboratory testing is done at an off-site facility, please list each external laboratory, describe the contractual arrangement, including mechanisms to prevent patient billing and document which test will be performed at each facility. (text input limit 2,500 characters, approximately 400 words). (4 points)

13. Describe your capacity to provide primary care for health assessment patients, both pediatric and adult, who are interested in continuing care at your site. Additionally, outline the referral process for refugees seeking care elsewhere for primary care and explain how to share health assessment information with the alternative provider. (text input limit 1,250 characters, approximately 200 words). (4 points)

14. Detail your agency's capacity to directly provide specialty care and supplemental services such as clinical case management, mental health, infectious disease follow-up, dental health, social services, WIC, or transportation. If your organization holds other contracts with DPH for these services, please list and describe those contracts here. Also, the referral systems and networks should be defined if these services are unavailable in-house. Note whether your proposed site has or will have a designated civil surgeon. (text input limit 2,500 characters, approximately 400 words). (4 points).

15. Describe your capacity for pre-arrival consultation with Resettlement Agencies around care coordination for those refugees with known significant medical conditions. Describe your pre-arrival consultation plan for ensuring early access to care for such patients. (text input limit 1,250 characters, approximately 200 words). (3 points).

16. Indicate if you have a 340B Pharmacy or are affiliated with the 340B Drug Pricing Program. Describe your process for utilizing 340B pharmacies and pricing for refugees who require pharmaceuticals, whether covered by RHAP reimbursement or not. (text input limit 2,500 characters, approximately 400 words). (4 points).

17. Agencies will seek third-party reimbursement where possible and appropriate, as it is a key source of budget offset revenue. However, clients should never be turned away for inability to pay for services or because they are “out of network.” Provide details about how your current billing system safeguards against double billing, maximizes billing of patients' insurance, and ensures that patients are not billed for medical services. Additionally, describe your registration and coding system for identifying RHAP patients and ensuring that RHAP services are not billed to refugees. (text input limit 2,500 characters, approximately 400 words). (4 points).

18. Program Budget: The payment model for RHAP has transitioned to cost reimbursement. Provide an annual line-item budget using the Program Budget form found in the COMMBUYS Bid Attachment Section. Use the Purchase of Service Titles - UFR Titles: www.mass.gov/anf/docs/osd/forms/attachmts/postitles.doc, for a list of position codes for the form.

|_| Program Budget form is attached.

Provide a program budget justification narrative, reflecting each line in the Program Budget form. Demonstrate how each budget item supports the overall program. (text input limit 6,000 characters, approximately one page). (5 points).

Enter text here; text limit 6,000 characters

APPLICATION RESPONSE SUBMISSION PAGE

Organization

CERTIFICATION OF ASSURANCE OF COMPLIANCE:

ADA/ 504 and NON-DISCRIMINATION BASED ON DISABILITY

All MDPH- funded projects must certify that the Applicant Organization will comply with all state and federal requirements regarding equal employment opportunity, nondiscrimination and civil rights for persons with disabilities. The Applicant must complete a Certification of Assurance of Compliance-ADA/504/Non-Discrimination based on Disability. By signing, the Applicant formally notifies MDPH that the Applicant is in compliance and shall maintain compliance with all applicable requirements.

· I , certify, that the Applicant is in compliance and shall maintain compliance with all applicable federal and state laws protecting the rights of persons with disabilities, including but not limited to the Americans with Disabilities Act (“ADA”), 42 12131-12134; Section 504 (“504”) of the Rehabilitation Act of 1973, 29U.S.C. §§ U.S.C. § 794; Article CXIV of the Massachusetts Constitution; and Chapter 6, §§ 185-87; Chapter 93, § 103; Chapter 151B; and Chapter 272, §§ 92, 98, and 98A of the Massachusetts General Laws.

· I understand that federal and state laws prohibit discrimination in public accommodations and employment based solely on disability. I recognize that to make goods, services, facilities, privileges, advantages, or accommodations readily accessible to and usable by persons with disabilities, the Applicant, under the ADA, must:

· remove architectural and communication barriers in existing facilities, when readily achievable and, if not readily achievable, must use alternative methods;

· purchase accessible equipment or modify equipment;

· modify polices and practices; and

· furnish appropriate auxiliary aids and services where necessary to ensure effective communication.

I recognize that Section 504 of the Rehabilitation Act requires recipients of federal funds (either directly or through contracting with a governmental entity receiving federal funds) to make their programs, services, and activities, when viewed in their entirety, accessible to qualified and/or eligible people with disabilities. I understand that reasonable accommodation is required in both program services and employment, except where to do so would cause an undue hardship or burden. I also understand that the Massachusetts Constitution Article CXIV provides that no otherwise qualified individual shall, solely by reason of disability, be excluded from the participation in, denied the benefits of, or be subject to discrimination under any program or activity within the Commonwealth.

· I agree the Applicant shall cooperate in any compliance review and to provide reasonable access to the premises of all places of business and employment and to records, files, information, and employees therein for reviewing compliance with Section 504, the ADA, the Massachusetts Constitution, other applicable state and federal laws, and this Contractual Agreement.

· I agree that any violation of the specific provisions and terms of this Assurance and/or Corrective Action Plan and/or Special Contract Conditions required herein or Section 504 or the ADA, shall be deemed a breach of a material provision of the Contract between the Department and the Contractor. Such a breach shall be grounds for cancellation, termination, or suspension, in whole or in part, of this Contract by the Department.

I affirm that I will comply with the requirements of this Request for Response and with the terms of this proposal.

Authorized Signatory:

First Name: [ ] Last Name: [ ]

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf and is agreeing all affirmations listed above.

CHECKLIST OF ATTACHMENTS TO THE APPLICATION RESPONSE FORM

All documents listed below must be submitted via COMMBUYS in order for your response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart.

Assign when creating documents

Scanned documents will be accepted. All scanned documents must be scanned in such a way that they can be read on a computer monitor and printed on 81/2” x 11” paper, unless otherwise specified. Attachments must be uploaded individually and cannot be combined in a zipped file.

Addendums or uploads not specifically requested in this document, the RFR or on the COMMBUYS Bid Solicitation will not be reviewed.

APPLICATION INSTRUCTIONS

1. Save, read and review the completed Application Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proof read text; spell-check does not work in the text boxes.

2. Upload in COMMBUYS the Application Response Form with the attachments according to the application Checklist.

3. Confirm that “No Charge” is checked or a dollar amount entered in the Unit Cost field on the Item screen in COMMBUYS. The “No Charge” selection will not be construed by the Purchaser to mean an offer to provide service or products at no charge.

4. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes) image1.png