A: Service Provider Agreement DHHS (DSS-9)

Appendix A
DSS-9

Agreement Number ________________

SECTION I
Check Appropriate Box and Write Provider Number
Agency FID __________________	Individual Provider Social Security Number __________________________________
SECTION II
Provider Name ____________________________________________________________
Provider Street Address ____________________________________________________________
Mailing Address if Different from Location		___________________________ ___________________________
Business Telephone _____________________________		Home Telephone ___________________________
Appropriate Licensure ___________________________________________________________
Location of Service Provision if different than above ___________________________________________________________

Par. 1 This Agreement between the Nebraska Department of Health and Human Services (hereinafter the Department) and ____________________________, a service provider, governs the provision of the following service(s) checked below as defined in the Department of Health and Human Services Program Manual, Nebraska Administrative Code (NAC) Titles 465, 471, 473, 474, and 480. Appropriate checklist(s) marked "Provider Addendum (name of service)" and other appropriate additions to the agreement marked "Attachment (A,B, or C)" for contracted service is/are attached and by this reference are made part of this agreement as if included in the contract word for word and the provider agrees to abide by all regulations as outlined in the attachment(s).

Par. 2 Agreement Effective Date from ____________ through _____________.

Par. 3 Service(s) to be provided. (See corresponding service addendum.) DD = Developmental Disabilities

SECTION III

Terms of Agreement

Par. 1 If the provider violates or breaches any of the provisions of this Agreement, then this Agreement may be terminated immediately, at the election of the Department. If there are any damages arising from such violation or breach, legal remedies may be pursued to recover such damages. Any money due to the provider which accrued prior to such violation or breach may be offset against the damages.

Par. 2 Under the terms of this Agreement:

The service area staff will determine eligibility for services and authorize appropriate services for the individuals.
The service area staff will notify providers if the service(s) being provided for a specific client is to be terminated or changed before the end of the authorized period.
The Department will honor claims and make payments for services that were authorized and provided in accordance with the Department's policies and standards.

Par. 3 This Agreement may be terminated by either party at any time by giving at least thirty days advance written notice to the other party to allow for arrangements of alternate service provision for service clients. The notice requirement may be waived in case of emergencies such as illness, death, injury, or fire. Only such payments as have already accrued for services rendered prior to the effective date of termination shall be made to the provider upon such voluntary termination.

Par. 4 Subcontracting by an individual provider is not allowed under this Agreement.

DSS-9 Rev. 3/98 (05004)
(Previous version 4/96 should NOT be used)

Par. 5 Service(s) will be provided using the following unit rate(s) within the maximum number of units authorized by the service area staff on a case-by-case basis. This information applies to all services covered by this agreement except Personal Care Aide (see below), and Child Care.

Service Code	Service	Maximum Rate	Units

Medicaid Personal Care Aides are authorized as follows:
Procedure Code	Service	Rate
199814	Trained PCA*	______________
199811	Service - Untrained PCA	______________
* Attach documentation of trained status

SECTION IV

General Provider Standards
By signing this agreement, the service provider agrees to:

Follow all applicable Nebraska Health and Human Services policies and procedures (Nebraska Administrative Code Titles 465, 471, 473, 474, and 480).
1. Bill only for services which are authorized and actually provided.
2. Submit billing documents after service is provided and within 90 days.
Accept payment as payment in full (payment from DHHS plus the client's obligation) and assure that the rate negotiated or charged does not exceed the amount charged to private payers.
Not provide services if s/he is the legally responsible relative (i.e., spouse of client or parent of minor child who is a client).
Not discriminate against any employee, applicant for employment, or program participate or applicant because of race, age, color, religion, sex, handicap, or national origin, in accordance with 45 CFR Parts 80, 84, 90; and 41 CFR Part 60.
Retain financial and statistical records for four years from date of service provision to support and document all claims.
Allow federal, state, or local offices responsible for program administration or audit to review service records, in accordance with 45 CFR 74.20-74.24; and 42 CFR 431.107. Inspections, reviews, and audits may be conducted on site.
Keep current any state or local license/certification required for service provision.
Provide services as an independent contractor, if the provider is an individual, recognizing that s/he is not an employee of the Department or of the State.
Agree and assure that any false claims (including claims submitted electronically), statement, documents, or concealment of material fact may be prosecuted under applicable state or federal laws (42 CFR 455.18).
Respect every client's right to confidentiality and safeguard confidential information.
Understand and accept responsibility for the client's safety and property.
Not transfer this agreement to any other entity or person.
Operate a drug free workplace.
Not use any federal funds received to influence agency or congressional staff.
Not engage in or have any ongoing history of criminal activity that may be harmful or may endanger individuals for whom s/he provides services. This may include a substantiated listing as a perpetrator on the child and/or adult central registries of abuse and neglect.
Allow Central Registry checks on himself/herself, family member if appropriate, or if an agency, agree to allow Department of Health and Human Services staff to review agency policies regarding hiring and reporting to ensure that appropriate procedures regarding abuse, neglect, and law violations are in place.
Have the knowledge, experience and/or skills necessary to perform the task(s).
Report changes to appropriate Department staff (e.g., no longer able/willing to provide service, changes in client function).
Agree and assure that any suspected abuse or neglect will be reported to law enforcement and/or appropriate Department staff.

I certify that I have read and understand the standards as stated and referenced above and agree to comply with all the terms of this Agreement.

SECTION V

____________________________________ ___________
Provider/Agency Representative Date

____________________________________ ___________
Parent or Legal Guardian Signature (if required) Date

____________________________________ ___________
Signature of Authorized Representative Date
Nebraska Department of Health and Human Services

A

B: Aged and Disabled Medicaid Waiver Plan of Services and Supports Nebraska Department of Health and Human Services (DSS-12AD)

Appendix B
DSS-12AD

Client's Name	Social Security Number	Page ______ of ______.
Services Coordinator		Date

SECTION 1: OUTCOMES
Assessment Section:	Desired Outcome:

SECTION 2: ACTION STEPS
Steps to be Taken	By Whom	Date	Progress

SIGNATURES (Optional)


Services Coordinator	Client	Other

DSS-12AD Rev. 6/98 (27004)
(Previous version 3/96 should be used first)

B

C: DHHS Assisted-Living Service Provider Addendum, HCB Waiver for Aged Persons, Adults or Children with Disabilities (MILTC-1AD)

Appendix C
Developing Goals in
Outcome Measurement

I reserve the right to discharge any resident whose personal care needs change for more than a temporary time period to a level beyond the service capability of this facility.

In instances where a person must be discharged from the facility, I agree to work with the Services Coordinator to allow time for alternative services arrangements to be made.

Signatures

I have read and understand the above statements and agree to meet them while providing Waiver Assisted Living Services.

Sign Here
Faculty Administrator Date

I have explained the above statements to this provider, and This Assisted Living Facility meets all of the standards to provide Waiver Assisted Living Service.

Sign Here
Waiver Representative Date

MILTC-22 Rev. 10/98 (57082)
(No previous version)

C

D: DHHS Assisted Living Service Provider Checklist HCB Waiver for Aged Persons, Adults or Children with Disabilities (MILTC-1AD)

Appendix D
Provider Authorization

E: Aged and Disabled Waiver Assisted Living Services Client Consent for Multiple Occupancy (MILTC-21)

Appendix E
Preprinted DSS-5N

Client Name __________________ Address__________________

Social Security Number _____________ __________________

I, __________________________desire to share an assisted living

unit with _______________________________________
(name/relationship).

I understand this is a voluntary choice. I may request to change this living
arrangement at any time and will notify the facility administrator and my
Services Coordinator of this decision.

Multiple occupancy rates are computed at 80% of the single occupancy
rate. Multiple occupancy requires prior approval of DHHS and consent
form signed by the client and roommate. I have read and understand
the consent as stated above and agree to comply with the terms

______________________________________________________
Client/Guardian Date
______________________________________________________
Roommate/Guardian Date

MILTC-21 Rev. 10/98 (57091)
(No previous version)

E

F: DHHS Long Term Care Facility Turnaround Billing Document (MC-4)

Appendix F
Authorization Notice

F

G: DHHS Finance and Support Manual Home and Community-Based Services Assisted Living Rates Chart (480-000-210)

Appendix G
Assisted Living Rates Chart
480-000-210

The following are the Assisted Living Standard Rates for individuals qualified under the Aged and Disabled Medicaid Waiver.

The "Per Day Equivalents," as used in the table below, are calculated to cover the total of: (1) the Aged and Disabled Medicaid Waiver Assisted Living service component; and (2) a $485 per month room/board component.
* Medicaid does not pay for room and board. Each client is financially responsible for his/her own room and board with funds s/he receive from any of several sources such as Social Security benefits, Supplemental Security Income (BSI), retirement/pension, or an DHHS grant (Aid to the Aged, Blind or Disabled/AABD or State Supplemental). This amount must be prorated for clients whose "Prior Authorization for Assisted Living Waiver Service" is for a partial month.

**The client may have a "share of cost" or "spenddown" s/he must obligate before DHHS will assume financial responsibility for the service component. Waiver facilities receive a "Notice of Finding" from the Medicaid eligibility worker stating the client's share, if any.

Urban rates apply to facilities in Cass, Dakota, Douglas, Lancaster, Sarpy, and Washington counties.

Multiple occupancy requires:

prior approval by DHHS; and
consent forms signed by the residents. Multiple occupancy rates are computed at 80% of the single occupancy rate.

Rates for Assisted Living Facilities which receive funding from the Nebraska Health Care Trust Fund are computed at 95% of the corresponding Standard Rate.

Standard Rates

Rural	Level of Care	Urban
$1800	Single Occupancy	$2025
-$485*	Room & Board Paid by Client	-$485*
$1315**	Net Amount Due for Medicaid Waiver Assisted Living Service	$1540**
$43.23	Per Day Equivalent	$50.63

Rural	Level of Care	Urban
$1440	Multiple Occupancy (80%)	$1620
-$485*	Room & Board Paid by Client	-$485*
$955**	Net Amount Due for Medicaid Waiver Assisted Living Service	$1135**
$31.40	Per Day Equivalent	$37.32

G

H: DHHS Prior Authorization for Assisted Living Waiver Service (MC-9AD)

This authorization is void if client is ineligible for Medicaid.

To be completed by Service Coordinator

Client Name: _______________________________

Medicaid	___________________
Number:

Facility Name ____________________

Address ________________________

________________________________

Facility	___________________
Provider
Number:

Level

License No.

2801 MD

Diagnosis Code:

V719

Service Begin Date

Service End Date

(If applicable)

Waiver Payment Effective Date

complete even if it is the same as service begin date

Comments:

Check here if this is to amend an existing authorization for this client in this assisted living facility. If so, indicate change here, and forward copies to DHHS Central Office, the assisted living facility, and to the Medicaid eligibility worker.

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Signature of Service Coordinator _________________________________

Office Location _________________ Phone ___________ Date ________

MC-9AD Rev. 3/98 (37010)

H

Adult Day Care	Habilitative Day Care - DD	Independence Skills Man.
Adult Day Health	Homemaker	Nutrition Services
Assisted Living	Homemaker - DD	PERS
Child Care	Home Care/Chore	Personal Care Aid - Medicaid
Congregate Meals	Home Delivered Meals	Respite Care
Family Support	Home Modifications DD	Transportation

SECTION 1 Provider Identification
Provider Name									FID Number
SECTION 2 General Provider Standards
I certify that I/my agency will: Meet all general provider standards in the Title 480 NAC, Chapter 5. .................. Bill according to procedures explained by the service area representative. ................ Assure that any suspected abuse or neglect will be reported to law enforcement and/or appropriate DHHS staff.................									Please Check Yes No
SECTION 3 Facility Standards
I certify that my facility will provide: A private room with bath consisting of a toilet and sink, for each waiver client. .......... The following standards also apply to Assisted Living facilities who also provide nursing facility care If my facility received funding through the Nebraska Health Infrastructure Fund Act, a tub or shower will also be provided in the waiver client's private room. ...................................... A separate location (e.g., wing or section of the building). .... A separate dining and common areas. ...........
SECTION 4 Service Components Standards
I certify that I/my staff will make available and provide each of the following services components as identified in the client specific plan of services and supports and as agreed upon in the Resident Service Agreement: Adult Day Care/Socialization Activities: Structured social, habilitative and health activities geared for the needs of the client. .. Escort Services: Accompanying or personally assisting a client who is unable to travel or wait alone. This may include assistance to and from a vehicle and/or place of local destination. This may also include providing or making arrangements for supervision and support to the client while away from the assisted living facility, as determined on an individual basis and specified in the Resident Service Agreement. ........ Essential Shopping: Obtaining clothing and personal care items for the client, when the client is unable to do so for him/herself. This does not include financing the purchase of clothing and personal care items. ..... Health Maintenance Activities: Non-complex interventions which can safely be performed according to exact directions, which do not required alterations of standard procedures and for which the results and client's responses are predictable. Need for health maintenance activities is determined on an individual basis. ............. Housekeeping Activities: Cleaning of public areas as well as the client's private residence, such as dusting, vacuuming, cleaning floors, cleaning of the bathroom and making and changing of the bed. Bed linens will be changed as soiled but at least weekly. Clean bath linens shall be made available daily. .... Laundry Services: Washing, drying, folding and returning client's clothing to his/her room. Dry cleaning is the responsibility of the client, but the facility will assist the client in arranging for this service if needed. ...............
MILTC-1-AD Rev. 4/98 (62001) (No previous version)

SECTION 4 (cont.) Service Components Standards
Meal Service: Three meals per day, seven days per week, as well as access to between meal snacks. Each meal must consist of a variety of properly prepared foods containing at least one-third of the Minimum Daily Nutritional Requirements for adults and take into account cultural, personal preference for food served. Meals will be delivered to a client's room for those experiencing temporary illness. ...... Medication Assistance: Assistance with administration of prescriptions and nonprescription medications. ..... Personal Care Services: Assistance with ADLs (e.g., transferring, dressing, eating, bathing, toileting, and bladder and bowel continence). The facility shall also provide assistance with eating. Assistance with eating includes opening packages, cutting food, adding condiments, and other activities which the client is unable to do for him/herself in preparing to eat food. If the client is unable to eat independently, the facility shall feed the client or shall assure other arrangements are made for this care. Personal care shall be provided in a manner in which the individual maintains as much independence and privacy as possible. The amount and degree of personal care services is determined on an individual basis. ........... Transportation Services: Transporting or making arrangements for transporting a client to and from local community resources identified during client assessment and included in the Plan of Services and Supports as directly contributing to the ability of the individual to remain in an assisted living facility. .....	Please Check Yes No
SECTION 5 Record Keeping
I certify that: Records will be maintained for four years as required in 480 NAC 5-011.. A file will be maintained on each client including: The Resident Services Agreement;.................... The Individualized Plan of Services and Supports; and.... Phone number of client's choice of physician and emergency contact person. ................... Client agreement to a multiple occupancy living arrangement. ......
SECTION 6 Comments

SECTION 7 Signatures and Dates
I have read and understand the above standards as explained by the service area representative. I certify that I and my employees will meet all the above standards while providing Waiver Assisted Living Service. I agree to allow Central Registry and law enforcement checks on myself and my employees. Sign Here _________________________________________________ Agency Representative Date I have explained the above standards to this provider, and this Assisted Living Facility meets all of the standards to provide waiver Assisted Living Service. Sign Here _________________________________________________ Health and Human Services Representative Date

Appendices