Attachment F. EVIDENCE-BASED REQUIREMENT – Description of the supporting evidence or evidence-producing strategy related the project selection, design, and implementation.
Attachment F. DSHS ASSURANCES AND CERTIFICATIONS Note: It is not required that the respondent return the DSHS Assurances and Certifications with the OE. Some of these Assurances and Certifications may not be applicable to your project. If you have questions, contact the contact person named in this OE. These assurances and certifications will remain in effect throughout the project period of this solicitation and the term of any contract between respondent and DSHS. As the duly authorized representative of the respondent, my signature on FORM A: FACE PAGE certifies that the respondent –
Attachment F. Attestation
Attachment F. Designation of Confidential, Trade Secret & Proprietary Information. Must be completed, signed/dated and submitted in ProcureAZ.
Attachment F. The Recipient must maintain current county emergency management and other contacts through the Division’s SharePoint including County Director and Alternate contacts, State Mutual Aid Agreement contacts, and many more; • Attachment F - Maintain site data in SharePoint including location and attribute information for all fire stations, law enforcement, emergency medical services, emergency operations center(s) and call centers; • Attachment F - Maintain site data in WebEOC including location and attribute information for all pre-identified sites for County Staging Areas (CSAs) and County Points of Distribution (PODs); • Attachment G - Complete the Hurricane Shelter Retrofit items A-G in the worksheet provided no later than March 31, 2021 and upload into WebEOC. Reporting Requirements: Quarter 1 Quarter 2 Quarter 3 Quarter 4 N/A N/A Deliverables Due Submit – Updates Only
Attachment F. Third Revised and Restated Table 1: PHP Time/Distance Standards Reference Number Service Type Urban Standard Rural Standard 1 Primary Care ≥ 2 providers within 30 minutes or 10 miles for at least 95% of Members ≥ 2 providers within 30 minutes or 30 miles for atleast 95% of Members 2 Specialty Care ≥ 2 providers (per specialty type) within 30 minutes or 15 miles for at least 95% of Members ≥ 2 providers (per specialty type) within 60 minutes or 60 miles for at least 95% of Members 3 Hospitals* ≥ 1 hospitals within 30 minutes or 15 miles for at least 95% of Members ≥ 1 hospitals within 30 minutes or 30 miles for at least 95% of Members 4 Pharmacies* ≥ 2 pharmacies within 30 minutes or 10 miles for at least 95% of Members ≥ 2 pharmacies within 30 minutes or 30 miles for at least 95% of Members 5 Obstetrics1 ≥ 2 providers within 30 minutes or 10 miles for at least 95% of Members ≥ 2 providers within 30 minutes or 30 miles for at least 95% of Members 6 Occupational, Physical, or SpeechTherapists* ≥ 2 providers (of each provider type) within 30 minutes or 10 miles for at least 95% of Members ≥ 2 providers (of each provider type) within 30 minutes or 30 miles for at least 95% of Members 7 Outpatient Behavioral HealthServices • ≥ 2 providers of each outpatient behavioral health service within 30 minutes or 30 miles ofresidence for at least 95% of Members • Research-based behavioral health treatment for Autism Spectrum Disorder (ASD): Not subject to standard • ≥ 2 providers of each outpatient behavioral health service within 45 minutes or 45 miles ofresidence for at least 95% of Members • Research-based behavioral health treatment for Autism Spectrum Disorder (ASD): Notsubject to standard 8 Location-Based Services (BehavioralHealth) ≥ 2 providers of each service within 30 minutes or 30 miles of residence for at least 95% of Members ≥ 2 providers of each service within 45 minutes or 45 miles of residence for at least 95% of Members 9 Crisis Services (Behavioral Health) ≥ 1 provider of each crisis service within each PHP Region 10 Inpatient Behavioral Health Services ≥ 1 provider of each inpatient BH service within each PHP Region 11 Partial Hospitalization (Behavioral Health) ≥ 1 provider of partial hospitalization within 30 minutes or 30 miles for at least 95% of Members ≥ 1 provider of specialized services partial hospitalization within 60 minutes or 60 miles for atleast 95% of Members 12 All State Plan LTSS (except nursing facilities)* PHP must have at least 2 LT...
Attachment F. DETAILED RATE REVIEW METHODOLOGY In the event that either County or Contractor requests a Detailed Rate Review, as provided for in Section 12.05, the Detailed Rate Review shall be based on evidence or data presented by County or Contractor contained within the compiled or audited financial statements for the preceding complete Calendar Year for the required franchise services. The Party that requests the Detailed Rate Review shall be responsible for the associated costs of providing any additional Annual Audited Financial Statements or Trienniel Audited Financial Statement, if any, that may be required to complete the Detailed Rate Review.
Attachment F. Contractor agrees to utilize one consistent pricing source for determining average wholesale price (AWP) information for use in claims pricing and to disclose its source in the contract with the County. If the Contractor decides to change its pricing source, it agrees to (1) provide the County with at least 90 days notice of the change and (2) provide the County with written validation that the change in pricing source is economically neutral or beneficial to the County. Contractor will provide validation noted above to the County at least 75 days prior to the change. Contractor agrees that when AWP-based pricing is replaced in the market it will (1) provide the County with at least 90 days notice of the new pricing methodology; (2) guarantee that any changes in pricing source/index result in economic equivalence or improvements to the County; (3) provide the County with an externally audited illustration of the economic equivalence and (4) hold the County harmless from any charges the PBM may incur from (a) making said changes (e.g., IT costs); (b) auditing or (c) external validation. Contractor will provide written illustration and the statement noted above to the County within at least 75 days of the change. Contractor agrees that in the event of a pricing methodology change or a change in the Contractor’s pricing source, in which the Contractor does not agree to pass through pricing improvements to the County, or if the change results in a higher gross cost (before member cost share) to the County, the County reserves the right to renegotiate financial terms or terminate the contract with 90 days written notice following notice from Contractor of the change in pricing methodology without penalty or early termination charges. In the event of a pricing methodology change or a pricing source change, results in higher gross cost (before participant cost share) to the County then the County reserves the right to renegotiate contract terms or to terminate with 90 days written notice following notice from Contractor of the change in pricing methodology without any termination charges. EXHIBIT 1
Attachment F. Regional Pricing Proposal Tool 1st Tab “Instructions” on Completing Pricing Proposal Sheets 2nd Tab “Regions” – must be filled out 3rd Tab “A-Core Items” – must be filled out 4th Tab “B-Non-Core” – must be filled out 5th Tab “C-Generic Core Items” – must be filled out 6th Tab “D-Generic Non-Core Items” - must be filled out - Will automatically be populated by tab D 7th Tab “Total Price Proposal” – must be filled out - Will automatically be populated by tabs “A- Core Items”, “B-Non-Core”, “C-Generic Core Items”, and “D-Generic Non-Core Items” 8th Tab “Audit Costs” – must be filled out 9th Tab “Volume Discounts” – must be filled out
