Client Services

Fee for Service

RIDER A

SPECIFICATIONS OF WORK TO BE PERFORMED

  1. TABLE OF CONTENTS
  1. DEFINITIONS

BASICACRONYMS
(Commonly-known acronyms and Government Agency abbreviations)
Abbreviation / Abbreviated term

A.[Defined Term: Definition of defined term.]

B.

C.

  1. INTRODUCTION/OVERVIEW

The purpose of this Agreement is [… Add 3-5 sentences regarding the overall purpose of the service, andstate who the target population is.

The Provider shall [… Add 2-3 sentences stating the Provider’s overall role in this Agreement.]

  1. DELIVERABLES

The Provider shall perform all services and maintain all standards and requirements for services provided under this Agreement in accordance with the below: [If the Agreement is for multiple types of services, then replicate the subsections for each service.]

A.Facility Standards, Facility Operational Requirements, and Facility/Program Licensing

  1. [Ex: Provide…]
  1. [Ex: Comply with…]
  1. [Ex: Ensure that…]

B.Provider Staffing: Position Types, Qualification, and Hiring/Retention Standards

  1. [Ex: Provide…]
  1. [Ex: Comply with…]
  1. [Ex: Ensure that…]

C.Client Services Eligibility: Clinical/Income/Demographic Requirements to Receive Client Services and Provider Process for Eligibility Determination and Provider Methods for Provider Intake/Outreach

  1. [Ex: Provide…]
  1. [Ex: Comply with…]
  1. [Ex: Ensure that…]

D.Client Coverage Screening and Billing Methods: MaineCare and Private Health Insurance

1.Ensure that before being provided with services under this Agreement, it shall be determined whether or not each individual possesses either private health insurance or is a MaineCare Member. If it is determined that the individual:

  1. Is a MaineCare Member, bill for all services provided which MaineCare will reimburse for;
  2. Is a MaineCare Member with a Medically Needy Deductible, bill the Department for all servicesprovided until the Medically Needy Deductible is met. Once the Medically Needy Deductible has been met then MaineCare shall be billed for all servicesprovided which MaineCare will reimburse for;
  3. Has private health insurance, bill the individual’s health insurance carrier for all portions of all servicesprovided which the carrier will reimburse for, with the remaining portions being billed to the Department; or,
  4. Is neither a MaineCare Member nor has private health insurance, bill the Department according to Rider B of this Agreement.

2.If an individual receives services under this Agreement that are eligible for MaineCare coverage and after receiving the services the individual becomes a MaineCare member,obtain retroactive MaineCare coverage and reimbursement for the services provided and credit any such retroactive reimbursements to the Agreement funds, according to 10-144 C.M.R. ch. 332, Part 2, § 13.4.

3.ManageAgreement funds so that individuals receiving services under this Agreement are not prematurely discharged when the clinical need for the service is still present.

4.Provide assistance to each individual who is found not to have Mainecare and is receiving services under this Agreement in applying for MaineCare benefits within fourteen (14) days of the date such services are initiated.

E.Client Services to be Provided to Qualified Clients

  1. [Ex: Provide…]
  1. [Ex: Comply with…]
  1. [Ex: Ensure that…]

F.Administrative Services Related to the Provision of Client Services: Recordkeeping, Data Collection/Management, and Supportive Documentation

  1. [Ex: Provide…]
  1. [Ex: Comply with…]

i.

  1. [Ex: Ensure that…]
  1. PERFORMANCE MEASURES

In performing all services under this Agreement, the Provider shall achieve all Performance Measures listed within the Mandatory Performance Measures table directly below. Failure to achieve such Performance Measures may result in the Department withholding Agreement payment(s) to the Provider, at the discretion of the Department. The Provider shall provide additional Supportive Documentation as indicated within the table, for Department validation of the summary data submitted within the Performance Measures Report.

PROVIDER MANDATORY PERFORMANCE MEASURES
Performance Measure Letter: / Performance Measure / Assessment Cycle / Supportive Documentation

In performing all services under this Agreement, the Provider shall make every attempt to achieve all Performance Measures listed within the Department’s Internal Performance Measures table directly below. Failure to meet such standards and requirements may result in the Department completely terminating the services/program provided under this Agreement or substantially altering the methods/approach/structure of providing the services/program provided under this Agreement. Data to support Department assessment of the below-listed Performance Measures shall be submitted by the Provider to the Department or viathird-party data source, as indicated within the Performance Measure Data Source column of the table. The Provider may also be required to provide additional Supportive Documentation as indicated within the table, for Department validation of the summary data submitted within the Performance Measures Report.

DEPARTMENT PROGRAM/SERVICE PERFORMANCE MEASURES
Performance Measure Letter: / Performance Measure / Performance Measure Data Source / Supportive Documentation
Office Goal/Initiative:
Office Goal/Initiative:
Office Goal/Initiative:
  1. REPORTS

A.Required Reports

The Provider shall track and record all data/information necessary to complete the reports listed in the table below:

Name of Report or On-Site Visit: / Description or Appendix #:
Agreement Closeout Report / Located at:

*The original copy of the Final Agreement Closeout Report along with a check payable to Treasurer, State of Maine for any surplus balance must be sent to: DHHS Service Center, 221 State Street SHS#11, 3rd Floor – SSC-ACR, Augusta, ME 04333-0011.

B.Reporting Schedule for Above listed Required Reports

The Provider shall submit all of the reports listed in the table below to the Department in accordance with the deadlines established within the table:

Name of Report or On-Site Visit: / Period Captured by Report or on-site visit: (“Each year/quarter/month/week”) / Due Date: (“# days after each year/quarter/month/week”)
Agreement Closeout Report / Entire Agreement period / Sixty (60) days following the close of the Agreement period.

The Provider understands that the reports are due within the timeframes established and that the Department will not make subsequent payment installments under this Agreement until such reports are received, reviewed and accepted.

The Provider further agrees to submit such other data and reports as may be requested by the Agreement Administrator. The Provider shall submit all data and reports to the Department in accordance with Section 6 of Rider B of this Agreement.

Rider A, Page 1Version DHHS 2018.FFS.1