Application for Work Group Membership
The Health and Human Services Commission (HHSC) is seeking applications for the Mental Health Condition and Substance Use Disorder Parity Work Group (Work Group). The purpose of theWork Group is tostudy and make recommendations on increasing compliance, enforcement and oversight of state and federal laws concerning the availability of and terms and conditions of, benefits for mental health conditions and substance use disordersin accordance with House Bill (H.B.)10, 85th Legislature, Regular Session, 2017.
HHSC will use the information you provided and your resumé, if submitted,to decide if you are eligible to serve on this workgroup.
If a question does not apply to you, please enter “N/A.”
Important note: Mental Health Condition and Substance Use Disorder Parity Work Groupmembers will not be reimbursed to travel (including per diem and lodging) or attendWork Group Meetings.
HHSC will not consider an application received or postmarked after September 10, 2017.
SECTION 1
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Name:
Home Address:
City: State: TXZip: Phone:
Fax:Email:
Employment Information
Business/Organization:
Address:
City:State: TXZip: Phone:
Fax:Email:
Current Position Title:
Please indicate where you would like to receive further communications:
Work Email Home Email Work Address Home Address
Gender
MaleFemale
Race/Ethnicity
American Indian/Alaskan Native Asian/Pacific Islander
Black Hispanic
White Other
Presiding Officer
Are you interested in leading this workgroup as the presiding officer?
Yes No
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SECTION 2
Family members or persons with lived experience with mental illness, substance use, or co-occurring disorders may apply to be on this committee.Resumé is optional.
Please complete SECTION 2 if you are a family member or a person with a lived experience and have current or prior direct experience participating in services within Texas public behavioral health system. If not a family member or person with lived experience please skip to SECTION 3.
1. What do you want to achieve through participation on this workgroup that will increase compliance, enforcement and oversight of state and federal laws concerning benefits for mental health conditions and substance use disorders?
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2. Please tell us about your direct experience as an individual or family member in services in the publicly funded behavioral health system.
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3. Please list your personal or professional achievements, including current certifications, licensures, or activities that will inform contributions you can make on this work group.
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4. Describe your previous experience on advisory committees or workgroups (national, state, local, or organizational).
5. Have you ever been disciplined by any certification/licensing board/professional or civic organization, including the HHSC Inspector General?
No Yes
If yes, please explain:
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SECTION 3
Individual providers and organizations may apply to be on this work group. This includes providers, professional associations, non-profit organizations, managed care organizations, and other subject matter experts. Please attach a resumé.
Please Note:Member slots representing organizations will require an accompanying letter from that organization authorizing the representative to participate on the stakeholder group as an official representative. The authorizing letter should describe in what capacity the individual serves in the organization and why this individual was identified to represent the organization.
Please complete SECTION 3if you are applying for a provider position on this workgroup. Note: Individuals with lived experience who are also providers must complete SECTION 2 as well.
1. What does your organization want to achieve through participation on this workgroup that will improve services within the public behavioral health system?
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2. Describe policies or positions that the organization you represent has taken in regard to Mental Health and Substance Use Disorder Parity.
3. Describe your direct knowledge of the publicly funded behavioral health system in Texas as a provider or organization described above.
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If you have already completed Section 2 skip to Section 4
4. Please list your personal or professional achievements, including current certifications, licensures, or activities that will inform contributions you can make on this work group. Please attach a resumé.
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5. Describe your previous experience on advisory committees or workgroups (national, state, local, or organizational).
6. Have you ever been disciplined by any licensing board/professional or civic organization, including the HHSC Inspector General?
No Yes
If yes, please explain:
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SECTION 4(All applicants must complete this section.)
H.B. 10 explicitly requires one representative from each category listed below for the Mental Health Condition and Substance Use Disorder Parity Work Group. Please check the category you would like to apply for. You may select more than one category that applies to you.
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Medicaid and the child health plan program;
Texas Department of Insurance;
Medicaid managed care organization;
Commercial health benefit plan;
Mental health provider organization;
Physician;
Hospital;
Children's mental health provider;
Utilization review agent;
Independent review organization;
Substance use disorder provider or a professional with co-occurring mental health and substance use disorder expertise;
Mental health consumer;
Mental health consumer advocate;
Substance use disorder treatment consumer;
Substance use disorder treatment consumer advocate;
Family member of a mental health or substance use disorder treatment consumer; and
Ombudsman for behavioral health access to care.
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Please specify what area of expertise you would bring to the group.
Member Participation
Every member appointed to the Work Group must attend regularly and must participate inWorkGroup activities.
- Regular Work Group meetings will be held quarterly. The presiding officer may call additional Work Group meetings as necessary. Members must travel to Austin for these meetings. Each meeting may last several hours.
- Please note, travel expenses to Mental Health Condition and Substance Use Disorder Parity Work Group meetingsor any other activities are not reimbursed.
Do you believe you will be able to regularly participate in the Mental Health Condition and Substance Use Disorder Parity Work Group activities, if you are appointed?
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Yes No
If no, please explain:
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Miscellaneous Information
Do you have a personal or private interest in a matter pending before HHSC?("Personal or private interest" means you have a direct monetary interest in the matter or owe your loyalty to an entity involved, but does not include the member's engagement in a profession, trade, or occupation when the member's interest is the same as all others similarly engaged in the profession, trade, or occupation.)
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Yes No
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References
Please provide the names and contact information for two people who can tell us more about your qualifications to serve on the Work Group. References can include employers, clients, religious leaders, community leaders, advocates, friends, or others who know about your interest in and/or involvement with service delivery through Medicaid. If you are applying as a provider, include at least one client reference.
Reference #1
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Name:
Address:
City: State: Zip:
Daytime Phone:
Email:
Relationship (how this person knows you):
Reference #2
Name:
Address:
City: State: Zip:
Daytime Phone:
Email:
Relationship (how this person knows you):
Do you have prior justice involvement (excluding traffic violations)?
No Yes
If yes, please explain:
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All the information contained in this application is true and correct. I understand that the Mental Health Condition and Substance Use Disorder Parity Work Groupwill meet in Austin quarterly until September 1, 2021, at which time this Work Group will be abolished. If selected, I will make every effort to attend all Work Group meetings.
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Signature (typed name is acceptable) Date
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Please return this form and any supporting documentation to:
Email:
Attn: Karissa Sanchez
Mail:
Texas Health and Human Services Commission
4900 North Lamar Blvd., MC-1155
Austin, Texas 78751
Attn: Karissa Sanchez
Fax:
512-428-1970
Attn: Karissa Sanchez
If you have any questions about the application or the Mental Health Condition and Substance Use Disorder Parity Work Group, please contact Karissa Sanchezat512-487-3337or by email at .
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