03.61.01 ADAMH Board Provider Contracting
Attachment – 1
Fairfield County Alcohol, Drug Addiction, and Mental Health (ADAMH) Board
State Fiscal Year SFY 2019
Service Provider Contract Application Materials
July 1, 2018through June 30,2019
If your organization has received ADAMH funds in State Fiscal Year 2018, then we have some of the required documents already on file for you. Please note, however, that the application itself has been updated and changed. It is important to read the entire document thoroughly and ensure that all requested documents are submitted with this application. If you are a new applicant organization, please make sure that you are aware of the following: The ADAMH Board can only utilize funds toward organizations and services that are certified through Ohio Mental Health and Addiction Services. If you have applied for certification and are waiting for the next step in that process we can accept your application, but cannot release funds until we know that you have been approved.
This year we are especially interested in looking at projects which reflect specific outcomes. We are not expecting to fund “startup” costs or award much in the way of grant funding. (Although we do realize that some projects have to be funded this way). We consider those projects that have the ability to be billed through GOSH (Great Office System Helper)to be the most compatible with our goal in identifying “Who is getting What services(s) in What Program(s) at What Cost(s) to What Outcome.”
We will give additional attention to those programs which utilize Evidenced Based Practices to achieve their outcomes. A list of potential Evidenced Based Practices is on the ADAMH Board website ( (Note: All providers with ADAMH Funding for programs will be required to be Evidence Based with Fidelity and given deadlines to comply if this cannot be met by July 1, 2019.
We are interested in understanding not only what activities and services you plan to offer utilizing ADAMH Board funds, but what impact(s) you expect to achieve as a result of these activities and services. The Program Coordinator and Finance Director will be available on the following dates and times to discuss the applications and the process for the award of funding. You need to only attend one session.
Thursday, November 9, 20179:30 a.m. Board Office
Tuesday, November 14, 2017 1:30 p.m. Board Office
In submitting your application please make sure that you include a signed hard copy, an electronic copy, and that all assurances are signed and dated. You will need to also download a copy of the current OhioMHAS assurances and sign and date these, including them with your application. If you are applying to provide a service area in which you have not obtained OhioMHAS certification, you need to indicate on your application when you have applied for the certification and when you anticipate receiving said certification area. The application deadline isFriday, January 19, 2018, by 5:00 p.m.
Submit in Person to: Patricia Waits, Program Coordinator
ADAMH 108 W. Main Street Suite A
Lancaster, Ohio 43130
And Electronically to:
All Agencies must submit:
_____ Application(Answering questions on pages 4 through 8)
_____ Logic Model for Each Program for which you are Requesting Funds
_____ Current Agency Brochure (If we do not have the latest)
_____ Current list of Uncompensated Trustees
_____ Current 990
_____ Current Audit and Management Letter
_____ Copy of All Relevant Evidence of Insurance Coverage(If we do not have the latest)
_____ Annual Report
_____ Current Continuous Quality Improvement Plan
_____A Program Success Story for each program seeking funding (Page 14)
_____Signed ADAMH Board Assurances (Pages 9 thru13)
New Agencies must submit all of the above and also:
_____ Proof of certification or of application for certification by OhioMHAS in the area for which you are requesting funds
_____Proof that organization Is incorporated and authorized to do business within Ohio as a voluntary, not for profit organization, registered and reporting annually with the Ohio Attorney General as required by sections 109 and 1716 of the Ohio Revised Code
_____ProofofTax Exempt Status and
Policy and Procedures on Health and Safety
Clients Rights
Equal Opportunity/Civil Rights
Major and Unusual Incidents
- All Hazards Contingency Plan (what you will do as an agency to carry on if natural disaster occurs)
_____ Not on disbarment list for Ohio
- Organization Cover Sheet
Agency Name:
Address:
Phone: / Fax:
Website
Agency Director: / Email:
FY 2019 Proposed
(July 2018 – June 2019)
Total Agency Budget
ADAMH Requested Allocation
Percent of Total Agency Budget
CERTIFICATION: I certify that all statements and information contained in this Request for Funding are true and complete to the best of my knowledge and belief.
Agency Executive Director: / Agency Board President/Chair:
Signature: / Signature:
Date: / Date:
For Office Use Only: Date Received: ______Person Who Received Proposal: ______
II.Organization General Information
A.Please write a paragraph or two about your organization that may be used by the ADAMH Board in brochures and descriptions of providers.
B.Provide a current organizational chart.
(Please show all positions filled and vacant positions. Specify the number of staff necessary to meet the needs of the agency, including auxiliary staff.)
C.Special Areas of Expertise.
Staff Example / # clinicians
Trauma-Informed CBT for Children / 1
EMD-R for Adults / 2
D.Please provide a financial overview of the organization by providing:
1.Revenue Budget
2.Expense Budget
3.Operating Reserves
E.Management Information
If you have received ADAMH Board funding in the past please address any updates and/or changes, including upgrades in your systems.
F.Marketing and Outreach
Tell how you will promote ADAMH in the community. Note: The ADAMH Board logo is expected to be displayed on all materials. If display of logo is not feasible, the statement “funded by the Fairfield County ADAMH Board” can be used as an alternative. Continued funding is contingent upon adherence to this principle throughout the contract period.
G. Program Descriptions
In this section please address the following:(Note: This section is for new programs only. If you are requesting funding for a program that ADAMH has funded in the past year or longer, you do not need to complete sections 1,2,3,4 or 5. Start with section 6)
1. Describe the Need(s) for your project(s) or services (New Programs Only).Consider these questions as you address this section:
What problem(s) in the community will your project address? The language that you use to describe this program will be utilized in the agency specific language should you be funded.
Be specific about the positive behaviors you want to see strengthened and /or the negative behaviors you want to see changed.
Who is your target population?
Why did you choose these particular problems in Fairfield County? Why is this important?
Consider magnitude, trends, severity,and economic costs.
What factors in our community contribute to these problems? Consider factors specific to Fairfield County.
Are there efforts in the community that address these problems? If so,how well? If not, why not?
How does your project fit relative to other approaches in the county? Does your project add anything new or different?
Do you expect support from the community for your project? Why or Why not?
2.Define your Goals(New Programs Only):
This section may simply be one or two sentences.
What do you want to see changed in the long term?
Write goal statements that tie directly to your identified needs in section D1.
How do (or how does) your goal statement correspond with ADAMH Goals as stated in the Community Plan, Strategic Plan, or other ADAMH reference documents?
3.Specify your Outcomes(New Programs Only):
What specific changes do you anticipate will result from participation in your project?
Are you expecting changes at the individual, organizational, community, or policy level?
If individuals, then which individuals, and what about them- i.e. knowledge, attitudes, behaviors- do you expect to see change?
What will be the expected magnitude of these changes (e.g., at least 80% of participating consumers will report an improvement in their eating habits) (e.g., 50% of participants will recognize the difference between 5 myths about mental health and 5 true statements about mental health) (e.g., 75% of those participating in Medication Assisted Treatment reporting remaining off street drugs for 6 months or longer).
When do you anticipate seeing these changes?
Write your short-term objectives and tie them directly to your problem or need statement and the contributing factors that you identified earlier.
Write your long-term objectives
4. Outline your Program Activities (New Programs Only):
List the activities that comprise your project
How will these activities address those factors that contribute to the problem? How will the activities help you get to your goals and objectives? These are your theories of change.
Which of these activities are critical to the project’s success?
Which of these are short term activities?
Which are long term activities?
5. Identify people who will be responsible for ensuring that your project succeedsand who in the community will help support your project(New Programs Only):
Who is responsible for implementing your project(s)?
Who else, other than staff, wants your efforts to succeed?
Are there barriers or is there stigma attached to what you are trying to achieve and are there persons in the community that may oppose your efforts?
6. Process and Outcome Measures(All Programs)
How will you know your activities happened as planned?
Please list the activities and the process measure
Project Activity
/Process Measure
List the measures you will use to collect each kind of information.
How will you ensure that activities are being implemented reliably—as it was originally?
How will you measure program produced changes?
List your short-term outcome measures (theses should correspond with your short-term objectives)
List your long-term outcome measures (these should correspond with your long-term objectives)
You should now be able to develop your Logic Model (for each new project only) and include it with your application.
H.ADAMH Funded Services Budget
1. Programs which are Grant Based (not billed by Unit of Service)
a. Narrative: describe the specific project expenses for which ADAMH funds will be used.
b. Please provide a detailed program budget including administrative overhead, include detail on all programmatic line item costs including any non-administrative overhead applied to the cost of the program. Use the attached forms to do this.
c. If Fairfield ADAMH funds are used to pay for client participation in your program, please describe the eligibility requirements and cost for participation with Fairfield ADAMH funding.
d. Please provide a listing of all sources of reimbursement (revenue) for each program other than the ADAMH Board with estimates from each.
e. ADAMH Board may require grant requested programs be reimbursed on a per unit basis through GOSH (exceptions can be requested for Board consideration).
Note: If you are applying for grant funding-please use the Forms in this application specifically for that purpose.
f. All grant based funding will require quarterly reconciliations comparing total funds received to total costs of the program to ensure any funds paid in excess of total costs by the ADAMH Board will be returned and any shortfall in estimated revenues from other sources to cover costs will be paid by the ADAMH Board.
h. In preparing your budgets please be aware that according to OAC 5122:1301 Financial Requirements for Boards under Section (D), Subsection (4), item (e) Boards shall insure that payments to providers for services provided meet the following requirements (exceptions can be requested for Board considerations)
- Provider shall not bill the Board for a service rendered to persons that have Medicaid, Medicare, or private insurance coverage when the service is payable under such coverage (lack of staff credential to bill payer source does not qualify as no payer source or lack of coverage).
- Provider shall not bill the Board for the unpaid portion of any claim paid by Medicare, Medicaid, or other insurance providers any portion of a claim billed to another coverage that is not paid under such coverage forany reason (including maxing out plan limit or denial as not medically necessary).
- If a dually eligible (Medicaid/Medicare) client receives a Medicare-reimbursable service that is not permitted to be billed to Medicare (such as when delivered by an LPCC), the practitioner should bill Medicaid directly for the service.
- Board expectation concerning Commercial Insurance. When an agency is not on a panel for a client, the agency will contact the insurance company and see if they will pay out of network. If they will payout of network, the agency will provide services that the insurance will pay for. Services not covered under the plan will be billed to the board, like case management. If the insurance company will not pay out of network for the client, then the agency will refer elsewhere for services, preferably to an agency that does accept the insurance of the client.
III.Agency Certification (Page 1 of 5)
You may copy and paste information from Organization Coversheet into the below section.Agency Name:
Address:
Phone: / Fax:
Website:
Agency Director: / E-mail:
I certify that the agency named above:
1. Agency Legal Status. Is incorporated and authorized to do business within Ohio as a voluntary, not for profit organization, registered and reporting annually with the Ohio Attorney General as required by sections 109 and 1716 of the Ohio Revised Code. Attach a current copy of Verification of Registration if a new applicant or if there are changes in current provider information
2. Services Provided. Is engaged in the delivery of voluntary educational health and human services and provides funds, programs or services directed at one or more of the common human needs as defined under Section IV (C). Please attach agency brochure or summary of services.
3. Tax Exempt Status. Has current status as tax exempt agency under 26 U.S.C. 501(c)(3) and is eligible to receive tax deductible contributions under 26 U.S.C. 170, the Internal Revenue Code and applicable laws of the state of Ohio. Please send copy of most recent 501 (c)(3) including authorization of name change if a new applicant or if there are changes in current provider information
4. Uncompensated Trustees. Is directed by active boards of trustees who serve without compensation. Please send list of board members with e-mail addresses (for purposes of Board information distribution) and term dates with acknowledgement that majority serve without compensation. Please include list of meeting dates, times and places.
5. Financial Standards. At a minimum, adopts and employs the Standards of Accounting and Financial Reporting for Voluntary Health and Welfare Organizations, and makes available to the general public an annual external audit by an independent public accountant or, in the case of those agencies with annual budgets less than $100,000, makes available to the public a copy of IRS Form 990. The agency will show that it has financial viability through its ability to generate sufficient Operating Income to meet Operating payments, debt commitments, and to allow for growth while maintaining service levels. Please send most recent Form 990 and AUDIT including a copy of the Management Letter (must be same time periods to include June 30, 2017). Please make certain that the copy of the IRS Form 990 has an Officer’s Signature on page 6.
6. Civil Rights and Equal Opportunity. Has stated policies on non-discrimination and complies with all the requirements of state and federal laws and regulations on non-discrimination and equal opportunity with respect to clients, officers, employees and volunteers. Please attach a copy of policy/procedure if a new applicant or if there are changes in current provider information
7. Client Rights and Grievances. Has in place a client rights and grievances policy/procedure. Please attach a copy of the agency’s client rights and grievances policy/procedureif a new applicant or if there are changes in current provider information
8. Major Unusual Incidents. Has in place a major unusual incidents policy/procedure to address out of the ordinary and/or client-related rare events. (to include client abuse/neglect).Please attach a copy of the agency’s major unusual incident policy/procedure if a new applicant or if there are changes in current provider information
9. Continuous Quality Improvement. Has in place a continuous quality improvement plan. Please attach a copy of the agency’s continuous quality improvement planif a new applicant or if there are changes in current provider information
10. Liability Insurance Coverage.
Has in place liability insurance in at least the following amounts, updated to reflect SFY 2015 changes:
12.1 General Liability
The Provider shall carry comprehensive general liability insurance in an amount of at least $1,000,000 per occurrence with an annual aggregate limit of at least $3,000,000.
12.2 Professional Liability
The Provider shall carry professional liability insurance providing single limit coverage in an amount of at least $1,000,000 per occurrence with an annual aggregate limit of at least $3,000,000.
12.3 Abuse/Molestation
The Provider shall carry Abuse/Molestation coverage providing single limit coverage in an amount of at least $1,000,000 per Occurrence with an annual single limit of at least $1,000,000.
12.4Employers’ Liability
The Provider shall carry employers’ liability insurance in a minimum amount of $500,000.
12.5Automobile
The Provider shall insure that there is automobile liability insurance for passenger vehicles for all such vehicles used to transport clients, whether such vehicles are owned by the Provider or its agents or employees with combined single Liability limits of at least $1,000,000. Hired and non-Owned Auto Liability coverage should be included in the Auto coverage form.