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Proposal for Contract

Adult Day Health Care (ADHC) Provider Information

Thank you for your interest in the Adult Day Health Care (ADHC) program.  This program is intended to provide funding for Medicaid spend-down clients during periods of Medicaid ineligibility.

FUNDING SOURCE

  • ADHC is funded through Social Services Block Grant/General Revenue (SSBG/GR) with the Department of Health and Senior Services during periods of Medicaid ineligibility.

PRE-APPROVAL REQUIREMENTS

The following requirements must be met prior to submission of a proposal:

  1. Entities must have an Adult Day Care (ADC) license in good standing issued by the Department of Health and Senior Services, Division of Regulation and Licensure pursuant to 19 CSR 30-90.010 and 19 CSR 30-90.020.  If the ADC is not currently licensed, an Application for License is available on the department’s website. 
  2. Entities must have a MO HealthNet participation agreement with the Department of Social Services, MO HealthNet Division (MHD) pursuant to 13 CSR 70-92.010.  MHD can be contacted regarding MO HealthNet enrollment by e-mail at providerenrollment@dss.mo.gov.
  3. Entities must register as a vendor with the State of Missouri through the Missouri Office of Administration website at www.oa.mo.gov/purch, then choose the following links:  Show Me….where to register as a vendor, New Vendor Registration.

PROCESS OF REVIEW AND APPROVAL
Upon receipt of a proposal, the Department:

  • Will process the proposal and determine the ADC’s eligibility for an agreement.  The Department will conduct any investigation necessary to verify, supplement or change the information contained within the proposal.
  • If the proposal is incomplete or further information is needed from the applicant to verify or supplement the proposal, the Department will request the information in writing.
  • When the review is complete, and if the ADC is found to be in good standing, a Participation Agreement for Home and Community Based Care for Adult Day Health Care will be forwarded for the applicant’s signature.  The Agreement will not become effective until it is signed by the Department’s Director of the Division of Administration. 
  • Once the agreement has been fully executed by the Department, the ADC will receive a copy of the fully executed agreement and written notification of their SSBG/GR provider number. 
  • Upon receipt of the SSBG/GR provider number, the ADC can begin providing services to clients of the Department authorized by the Department to receive services. 

ADDITIONAL ASSISTANCE
Should you require additional information or have questions regarding the proposal, please feel free to contact the Contract Administrator, HCS Provider Contracts by e-mail at ihscontracts@dhss.mo.gov.
PROPOSAL SUBMISSION
All items listed in the Proposal Outline must be included in the proposal and must be organized according to the outline.  All information must be submitted to:
Department of Health and Senior Services
DSDS - HCS Provider Contracts
920 Wildwood Dr.
P.O. Box 570
Jefferson City, MO 65102-0570
PROPOSAL OUTLINE FOR HOME AND COMMUNITY BASED PARTICIPATION AGREEMENT TO PROVIDE ADULT DAY HEALTH CARE

SECTION I – PROVIDER PROFILE

Document the following information on the Provider Profile form:

  1. Legal name as filed with the Missouri Secretary of State
  2. Name of the owner, Chairman of the Board or Chief Executive Officer
  3. On-site manager or contact person for the center
  4. Mailing Address.
  5. City, State, Zip Code
  6. Physical Address, if different
  7. City, State, Zip Code
  8. Telephone Number
  9. FAX Number
  10. E-Mail Address
  11. Federal Tax ID Number
  12. Medicaid Provider Number
  13. Adult Day Care License Number
  14. Counties for Which Transportation Will Be Provided

SECTION II – POLICIES/PROCEDURES AND ASSURANCES

  1. Describe the system used to allow clients, family members, employees and the Department to have verbal contact with the Provider at all times, including:
    • Assurance the main phone line will be answered by clearly identifying the agency by name.
    • An explanation of the system (voice mail, pager, answering system, etc.) that allows contact with the ADC twenty-four (24) hours a day, seven (7) days per week.
  2. Assurance to immediately notify all authorized clients of the Department and the client’s representative of any changes in the exact street address, telephone number or business hours. 
  3. Assurance to immediately notify the Department of changes in the exact street address, telephone number or business hours.
  4. Assurance to maintain Internet access in order to retrieve information posted on the Department website.
  5. Assurance to maintain an e-mail address in order to communicate with the Department and receive written communications.

SECTION III – APPENDIXES

  1. A copy of the Federal Employer Identification Number (FEIN) notification from the Internal Revenue Service.
  2. A copy of the Missouri Employer Identification Number notification from the Missouri Department of Revenue.
  3. A copy of a current Vendor No Tax Due certificate issued by the Missouri Department of Revenue.  Information regarding this certificate is available on the internet at http://www.dor.mo.gov/tax/business/sales/hb600.htm.    
  4. A copy of the ADC license issued by the Division of Regulation and Licensure.
  5. A copy of the notification letter from MHD of the MO HealthNet provider number.