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TEXAS HEALTH AND HUMAN SERVICES COMMISSION
OPEN ENROLLMENT (OE)
for
Incurred Medical Expenses (IME) for Dental Services
OE No. #HHS0013184
NIGP Class/Item No(s):
948-07
948-28
948-43
948-48
948-65
948-74
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TABLE OF CONTENTS
SECTION 1. SCHEDULE OF EVENTS ............................................................................................................ 4
SECTION 2. OVERVIEW ................................................................................................................................... 4
2.1. INTRODUCTION ....................................................................................................................................... 4
2.2. LEGAL AUTHORITY ................................................................................................................................. 5
2.3. NO GUARANTEE OF VOLUME, USAGE OR COMPENSATION .................................................................. 5
SECTION 3. DEFINITIONS AND ACRONYMS........................................................................................... 5
SECTION 4. GENERAL INFORMATION ....................................................................................................... 8
4.1. SOLE POINT OF CONTACT ...................................................................................................................... 8
4.2. CHANGES, MODIFICATIONS AND CANCELLATION ............................................................................... 9
4.3. OFFER PERIOD ........................................................................................................................................ 9
4.4. COSTS INCURRED ................................................................................................................................... 9
4.5. OE QUESTIONS OR CLARIFICATIONS ................................................................................................. 10
SECTION 5. HUB SUBCONTRACTING PLAN (HSP) REQUIREMENTS ........................................... 11
SECTION 6. CONTRACT TERM ..................................................................................................................... 11
6.1. TERM OF CONTRACT ............................................................................................................................. 11
6.2. EXTENSION OPTION ............................................................................................................................. 11
SECTION 7. MINIMUM QUALIFICATIONS ............................................................................................. 11
7.1. REQUIRED EXPERIENCE ....................................................................................................................... 11
7.2. LICENSURE AND ACCREDITATION ....................................................................................................... 11
SECTION 8. STATEMENT OF WORK .......................................................................................................... 12
8.1. HHSC RESPONSIBILITIES .................................................................................................................. 12
8.2. CONTRACTOR (PROVIDER) RESPONSIBILITIES ................................................................................ 12
8.3. PERFORMANCE CRITERIA .................................................................................................................... 13
8.4. CONTRACTOR PERFORMANCE .............................................................................................................. 13
8.5. NOTICE OF CRIMINAL ACTIVITY ......................................................................................................... 13
8.6. NOTICE OF INSOLVENCY OR INDEBTEDNESS ..................................................................................... 14
8.7. REPORTING CRITERIA ......................................................................................................................... 15
8.8. INVOICE REQUIREMENTS AND PAYMENT ........................................................................................... 15
8.9. DATA USE AGREEMENT (DUA) .......................................................................................................... 16
8.10. TERMS AND CONDITIONS .................................................................................................................... 17
8.11. STANDARDS OF CONDUCT FOR VENDORS ........................................................................................... 17
SECTION 9. HHSC CONTRACT ADMINISTRATION .............................................................................. 17
SECTION 10. CONFIDENTIAL OR PROPRIETARY INFORMATION ................................................... 18
10.1. PUBLIC INFORMATION ACT ................................................................................................................. 18
10.2. APPLICANT WAIVER – INTELLECTUAL PROPERTY ............................................................................ 20
SECTION 11. BINDING OFFER ...................................................................................................................... 20
SECTION 12. REQUIRED APPLICATION DOCUMENTS ......................................................................... 21
SECTION 13. APPLICATION SUBMISSION REQUIREMENTS ............................................................ 22
13.1. E-MAIL SUBMISSION ........................................................................................................................... 22
13.2. RECEIPT OF APPLICATION ................................................................................................................... 23
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SECTION 14. SCREENING OF APPLICATIONS ........................................................................................ 23
SECTION 15. AWARD PROCESS ................................................................................................................... 25
15.1. CONTRACT AWARD AND EXECUTION .................................................................................................. 25
15.2. COMPLIANCE FOR PARTICIPATION IN STATE CONTRACTS ............................................................... 26
15.2.1. REQUIRED PRE-AWARD VERIFICATIONS ........................................................................................... 26
15.2.2. ADDITIONAL REQUIRED PRE-AWARD VERIFICATIONS .................................................................... 26
15.3. AWARD TO GOVERNMENTAL ENTITIES .............................................................................................. 27
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SECTION 1. SCHEDULE OF EVENTS
Enrollment Period Opens
(Posted to HHS OE Opportunities webpage)
March 15, 2023
Enrollment Period Closes
(Final date for RECEIPT of Applications)
September 15, 2023
Anticipated Contract Start Date
The effective date of a
Contract, if any, awarded to an
Applicant will be determined at
the sole discretion of HHSC.
Applications must be received by The Health and Human Services Commission (“HHSC”)
prior to the closing date as indicated in this Schedule of Events or as changed via an
Addendum posted to the HHS Open Enrollment Opportunities webpage. Every Applicant is
solely responsible for ensuring its application is received before the submission period
closes. HHSC is not responsible for lost, misdirected or late applications.
The dates in the Schedule of Events are tentative. HHSC reserves the right to modify these
dates at any time by posting an Addendum to the HHS Open Enrollment Opportunities
webpage..
By submitting an Application, the Applicant represents and warrants that any individual
submitting the Application and any related documents on behalf of the Applicant is
authorized to do so and to bind the Applicant under any resulting contract.
Withdrawal of Application:
Applications may be withdrawn from consideration or amended at any time prior to the
“Enrollment Period Closes” date by emailing a request to the Point of Contact, Section 4.1.
The email subject line should contain the Open Enrollment (“OE”) number and title as
indicated on the cover page. The Applicant is solely responsible for ensuring requests are
received timely by HHSC. HHSC is not responsible for lost, misdirected or late emails.
SECTION 2. OVERVIEW
2.1. INTRODUCTION
HHSC determines Medicaid eligibility for individuals residing in Nursing Facilities
(“NFs”). HHSC is responsible for making determinations regarding allowable
Incurred Medical Expenses (“IME”) for dental services for NF residents.
HHSC processes between 300-350 dental requests each quarter or about 1200
annually. Collectively, requests may be referred to in this Contract as “cases.”
Each case may contain a request for more than one dental service.
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The purpose of this OE is to provide one or more Texas licensed dentist(s) (the
“dentist”) to assist HHSC to make determinations regarding allowable IME for
dental services for NF residents.
To be considered for award, Applicants must submit a comprehensive Application
which meets all the requirements of this OE and includes all requested
documentation.
2.2. LEGAL AUTHORITY
Title 1 of the Texas Administrative Code (“TAC”), Part 15, Chapter 358, §358.438
requires HHSC to follow 42 Code of Federal Regulations (CFR) § 435.725 when
determining the co-payment for a person or couple in an institutional setting. Texas
Government Code Section 531.084(a) requires HHSC to establish a fee schedule
for reimbursable IMEs for dental services in long-term care facilities.
2.3. NO GUARANTEE OF VOLUME, USAGE OR COMPENSATION
HHSC does not guarantee any volume, usage, or compensation to be paid to any
Contractor under any Contract resulting from this OE. Additionally, all contracts
resulting from this OE are subject to appropriations, the availability of funds, and
termination.
SECTION 3. DEFINITIONS AND ACRONYMS
Unless the context clearly indicates otherwise, throughout this OE, the definition given to
a term below applies whenever the term appears in this OE, in any Application submitted
in response to this OE, and in any Contract awarded as a result of this OE. All other terms
have their ordinary and common meaning.
TERM
DEFINITION
Addendum
A written clarification or revision to this OE. All
Addenda will be posted to the HHS Open Enrollment
Opportunities web page.
Amendment
A written agreement, signed by the parties hereto,
which documents changes to the Contract other
than those permitted by Technical Guidance Letters,
as herein defined.
Application
All information and materials submitted by an
Applicant in response to this OE.
Applicant
Any person or entity that submits an Application in
response to this OE.
Attachment
Documents, terms, conditions, or additional
information physically added to this Contract
following the execution page or included by
reference, as if physically, within the body of this
Contract.
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TERM
DEFINITION
Contract
Any Contract(s) awarded, the Signature Document,
these Uniform Terms and Conditions, along with any
Attachments, and any Amendments, purchase
orders, or Technical Guidance Letters that may be
issued by the System Agency, to be incorporated by
reference herein for all purposes if issued resulting
from this OE.
Contractor
(Provider)
Each Applicant, if any, awarded a Contract as a
result of this OE, may also be referred to as
Provider. Unless the context clearly indicates
otherwise, all terms and conditions of this OE and
resulting Contract that refer to Applicant apply with
equal force to Contractor (Provider).
Deliverables
Any item, report, data, document, photograph, or
other submission required to be delivered under the
terms of this Contract, in whatever form.
DMD
Doctor of Dental Medicine
DDS
Doctor of Dental Surgery
Durable Medical Equipment
(DME)
Items that are used during treatment and recovery
of an injury, illness or due to age related problems,
such as crutches, wheelchairs, and walkers.
Effective Date
The date agreed to by the Parties as the date on
which the Contract takes effect.
Federal Assurances
Standard Form 424B (Rev. 7-97), as prescribed by
0MB Circular A-102 (non-construction projects); or
Standard Form 424D (Rev. 7-97), as prescribed by
0MB Circular A-102 (construction projects).
Federal Certifications
US Department of Commerce Form CD-512 (12-04),
"Certifications Regarding Lobbying-Lower Tier
Covered Transactions."
Federal Fiscal Year
The period beginning October I and ending
September 30 each year, which is the annual
accounting period for the United States government.
GAAP
Generally Accepted Accounting Principles.
GASB
The Governmental Accounting Standards Board.
Health and Human Services
Commission or HHSC
The Health and Human Services Commission
(HHSC) may be identified as the administrative
agency established under Chapter 531, Texas
Government Code or its designee in this OE or any
resulting Contract(s).
HHS Open Enrollment
Opportunities
The HHS web page where OE are posted:
https://apps.hhs.texas.gov/pcs/openenrollment.cfm
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TERM
DEFINITION
HUB
A Historically Underutilized Business, as defined by
Chapter 2161, Texas Government Code.
Incurred Medical Expenses
(IME)
Means those paid or unpaid bills for medical care
which are recognized under State law.
Intellectual Property
Patents, rights to apply for patents, trademarks,
trade names, service marks, domain names,
copyrights and all applications and worldwide
registration of such, schematics, industrial models,
inventions, know-how, trade secrets, computer
software programs, and other intangible proprietary
information.
Intermediate Care Facility
for Individuals with
Intellectual Disabilities
(ICF-IID)
A facility that serves four (4) or more persons with
intellectual disability or persons with related
conditions and provides health or rehabilitative
services on a regular basis to individuals whose
mental and physical conditions require services
including room, board, and active treatment for
their intellectual disability or related conditions.
Nursing Facilities (NFs)
Nursing homes, also called skilled nursing facilities,
provide a wide range of health and personal care
services.
Open Enrollment (OE)
This document, including all exhibits, attachments,
and addenda, as applicable, posted on the HHS
Open Enrollment Opportunities webpage.
Parties
The System Agency and Contractor, collectively.
Party
Either the System Agency or Contractor,
individually.
Project
The goods and/or Services described in the
Signature Document or an Attachment to this
Contract.
Public Information Act (PIA)
Chapter 552 of the Texas Government Code.
Receiving Agency
The State agency receiving the benefit of the goods
or services provided under this Contract.
Services
The tasks, functions, and responsibilities assigned
and delegated to Contractor.
Signature Document
The document executed by both Parties that
specifically sets forth all the documents that
constitute the Contract.
State Fiscal Year
The period beginning September 1 and ending
August 31 each year, which is the annual accounting
period for the State of Texas.
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TERM
DEFINITION
Statement of Work
The description of services and deliverables in this
OE that the Contractor (Provider) is required to
provide under the Contract.
System Agency
HHSC or any of the agencies of the State of Texas
that are overseen by HHSC under authority granted
under State law and the officers, employees, and
designees of those agencies. These agencies
include: the Department of Aging and Disability
Services, the Department of Assistive and
Rehabilitative Services, the Department of Family
and Protective Services, and the Department of
State Health Services.
Texas Licensed Dentist
Chapter 256 of the Occupations Code
Work
All Services to be performed, goods to be delivered,
any appurtenant actions performed, and items
produced, conceived, or developed, including
Deliverables.
SECTION 4. GENERAL INFORMATION
4.1. SOLE POINT OF CONTACT
All questions, requests for clarification, or other communication about this OE shall
be made in writing only to the HHSC sole point of contact listed below.
Attempts to ask questions by phone or in person will not be allowed or recognized
as valid.
Alethea Flores, CTCM
Senior Administration Manager
Email: alethea.flores@hhs.texas.gov
To be considered for contract award, applications must only be submitted
to this address. See Section #13 for submission requirements.
Do not contact other HHS Agency personnel regarding this OE.
This restriction, as to only communicating in writing with the HHSC sole
point of contact identified above, does not preclude discussions between
Applicant and agency personnel for the purposes of conducting business
unrelated to this OE.
Failure of an Applicant or its representatives to comply with these
requirements may result in disqualification of the submitted Application.
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4.2. CHANGES, MODIFICATIONS AND CANCELLATION
HHSC reserves the right to change, amend, modify, or cancel this OE at any time.
All Applications, including those submitted after cancellation of the OE, become the
property of HHSC upon receipt.
4.2.1. ADVERTISEMENT OF CHANGES, MODIFICATIONS OR CANCELLATION
If HHSC determines that the OE needs to be changed or modified, either
an addendum will be posted on the OE Opportunities webpage. or the OE
will be canceled. The action to be taken will be determined at the sole
discretion of HHSC. Furthermore, if the OE will be canceled, HHSC will
determine, in its sole discretion, if a new OE will be posted.
No HHS Agency will be responsible or liable in any regard for the failure of
any individual or entity to receive notification of any posting to the OE
Opportunities webpage.
It is the responsibility of each Applicant to monitor the OE Opportunities
webpage for any Addenda or additional information regarding this OE.
Failure to monitor the OE Opportunities webpage will in no way release or
relieve any Applicant or Contractor of its obligations to fulfill the
requirements as posted.
4.3. OFFER PERIOD
By submitting an Application in response to this OE, Applicant agrees that its
Application will remain a firm and binding offer to enter into a Contract under all
terms and conditions of this OE for at least 240 days from the date applications are
due, as stated in Exhibit A, HHS Solicitation Affirmations, unless withdrawn by the
Applicant before the Enrollment Period closes.
An Applicant may extend the time for which its Application will be honored and
include the extended period in the Application.
4.4. COSTS INCURRED
HHSC accepts no obligations for costs incurred in preparing, submitting, and
screening an Application, including, but not limited to, costs or expenses related to
contract execution.
Applicants understand that issuance of this OE or retention of Applications in no
way constitutes a commitment by HHSC to award a Contract. All Applications shall
be prepared simply and economically, providing a straightforward, concise
delineation of the Applicant’s capabilities to satisfy the requirements of this OE and
submitted at the sole expense of the Applicant.
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4.5. OE QUESTIONS OR CLARIFICATIONS
4.5.1. QUESTIONS AND REQUESTS FOR CLARIFICATION
Written questions and requests for clarification regarding this OE are
permitted if submitted by email to the Sole Point of Contact, Section 4.1.
Responses to questions and requests for clarification will not be posted.
However, if HHSC determines, based on a question, request for
clarification, or any other factor (including, but not limited to notices of
ambiguity, conflict, or discrepancy as referenced in Section 4.5.3, below),
that the OE needs to be amended or clarified, either an addendum will be
posted on the OE Opportunities webpage or the OE will be canceled. The
action to be taken will be determined at the sole discretion of HHSC.
Furthermore, if the OE will be canceled, HHSC will determine, in its sole
discretion, if a new OE will be posted.
4.5.2. QUESTION AND CLARIFICATION FORMAT
Questions and requests for clarification must include the following
information:
a. the OE Number
b. the question or request for clarification, providing the following
information:
• OE language, topic, section heading
• Section, Paragraph and Page number(s) or Exhibit/Attachment
The requestor must provide the following contact information:
• Company Name
• Company Representative Name
• Phone Number
• Email address
4.5.3. AMBIGUITY, CONFLICT, DISCREPANCY
Applicants must notify the Sole Point of Contact, Section 4.1, of any
ambiguity, conflict, discrepancy, exclusionary specification, omission, or
other error in the OE. Notices must be submitted in the same manner for
submitting questions.
Each Applicant submits its Application at its own risk.
If an Applicant fails to properly and timely notify the Sole Point of Contact,
Section 4.1, of any ambiguity, conflict, discrepancy, exclusionary
specification, omission or other error in the OE, the Applicant, whether
awarded a contract or not:
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a. shall have waived any claim of error or ambiguity in the OE and any
resulting contract,
b. shall not contest the interpretation by HHSC of such provision(s), and
c. shall not be entitled to additional compensation, relief, or time by reason
of ambiguity, conflict, discrepancy, exclusionary specification, omission,
or other error or its later correction.
SECTION 5. HUB SUBCONTRACTING PLAN (HSP) REQUIREMENTS
HHS has determined subcontracting opportunities are not probable under this OE;
therefore, a HSP is not required to be submitted with the Application.
SECTION 6. CONTRACT TERM
6.1. TERM OF CONTRACT
HHSC may award one or more Contracts under this OE.
Any Contract resulting from this OE will be effective on the signature date of the
latter of the Parties to sign the agreement and will expire five (5) years after
contract execution unless terminated earlier pursuant to the terms and conditions
of the Contract.
6.2. EXTENSION OPTION
HHSC, at its sole option and subject to availability of funding, may extend the
Contract beyond the initial term for up to one year as necessary to ensure continuity
of service, to process a new OE to award new contract(s), for purposes of transition,
or as otherwise determined to serve the best interest of the State of Texas.
SECTION 7. MINIMUM QUALIFICATIONS
To be eligible to apply for a Contract and receive an award, Applicant(s), must be eligible,
qualified, and meet all requirements of this OE. Applicant requirements apply with equal
force to Contractors and Providers awarded contracts under this OE.
7.1. REQUIRED EXPERIENCE
a. To be considered for contract award under this OE, an Applicant shall have an
active or retired Texas state license and must have a minimum of 5 years of
dental practice experience.
b. Texas residents only.
7.2. LICENSURE AND ACCREDITATION
Applicant and all personnel and technicians assigned to provide services under the
Contract must have all licenses and certifications required by applicable law.
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Assigned personnel and technicians, who may include department directors
or equivalent positions, providing services that, by law, require a professional
license or certification, must hold a current, valid, and applicable Texas
license and/or certification in good standing.
Contractor is responsible for ensuring all Contractor staff and subcontractors,
if any, hold current, valid, and applicable licenses and/or certifications in
good standing.
Contractor must provide a copy of either a Doctor of Dental Surgery (DDS)
or a Doctor of Dental Medicine (DMD) and must be submitted with your
Application.
Each Contractor is required to maintain all required licenses and certifications
for the business during the term of the Contract. The Contractor and
Contractor’s personnel and subcontractors, if any, must also maintain their
individual required licenses and certifications during the term of the Contract.
All required licenses and/or certifications must be included with submitted
Applications. During annual contract reviews, Contractor shall provide
updated licenses and/or certifications at HHSC request.
SECTION 8. STATEMENT OF WORK
8.1. HHSC RESPONSIBILITIES
a. Provide relevant policy and procedures related to Dental IMEs.
b. Provide dental IME fee schedules for reference.
c. Offer technical assistance to Contractor involving operational issues.
d. Track IME requests submitted to and received from the Contractor.
e. Validate invoices for services delivered by the Contractor against requests
tracked.
f. Make timely payment on services delivered by the Contractor.
8.2. CONTRACTOR (PROVIDER) RESPONSIBILITIES
a. Provide a Texas licensed dentist to review dental IME requests related to the
Medicaid NF program.
1. Ensure treatment requested is indicated and supported by the
individual’s treatment plan and legible and appropriate radiographic
images, if appropriate.
2. Within five business days of receipt respond to the request and “reply
all” to all original requestors with the recommendation regarding
whether to approve or deny the request.
3. Identify the type of records required, and the level of detail needed
within those records, when reviewing a request for dental services and
a dental treatment plan.
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b. Provide suggestions for criteria on the process for future submissions of
Medicaid NF dental IME requests to the contracted dentist (“Guidelines”).
c. Provide expert input upon request to receiving agency staff to classify dental
procedures as routine or non-routine.
d. Participate in Informal Fair Hearings, as necessary, regarding IME decisions
that result in adverse action taken by HHSC. In situations where adverse
actions based on the dental review results in an appeal and request for an
Informal Fair Hearing (pursuant to 1 TAC RULE §357.3 Authority and Right to
Appeal), the Contractor may be requested to participate in the Informal Fair
Hearings process as deemed necessary by HHSC.
e. Use HHSC dental IME fee schedules and other HHSC documents when
reviewing dental IME requests.
f. Provide a report of work performed during the reporting period with the
invoices delivered by the Contractor.
1. Develop a monthly tracking report to include all requests received,
disposition of the requests, and rationale.
2. The report must identify each individual case reviewed by using the
initials of the first and last name of the individual being reviewed, date
the records were reviewed by the contracted dentist, and the amount of
time contributed to the review process.
3. Submit the report to the HHSC’s Contract Manager via email at
DentalIME@hhs.texas.gov by the 15th day of the month following the
report month.
8.3. PERFORMANCE CRITERIA
HHSC will look solely to the Contractor(s) for the performance of all contractual
obligations resulting from an award based on this OE.
No Contractor will be relieved of its obligations for any nonperformance by its
subcontractors. Contractor must ensure that its subcontractors abide by all
requirements, terms, and conditions of this Contract. Unless the context clearly
indicates otherwise, every requirement and every prohibition set forth in this OE
and any resulting contract that applies to a Contractor applies with equal force to
its employees, agents, representatives, and subcontractors.
8.4. CONTRACTOR PERFORMANCE
HHSC, at its sole discretion, may request in writing the immediate removal of
any Contractor from the services being provided under the Contract. Upon
such request, Contractor shall immediately be removed.
8.5. NOTICE OF CRIMINAL ACTIVITY
At the time of submission, Applicants shall provide confirmation that the Applicant,
any person with ownership or controlling interest in Applicant, and Applicant’s agents,
employees, subcontractors, and volunteers who will be providing the required
services:
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a. have not engaged in any activity that does or could constitute a criminal
offense equal to or greater than a Class A misdemeanor or grounds for
disciplinary action by a state or federal regulatory authority; and
b. have not been placed on community supervision, received deferred
adjudication, or been indicted for or convicted of a criminal offense relating
to involvement in any financial matter, federal or state program, or sex crime.
This is a continuing disclosure requirement; prior to Contract award, if any,
Applicants must notify the HHSC Sole Point of Contact within five days of the date
Applicant learns of actions set forth in subsections (a) and (b) above.
Additionally, this is a continuing disclosure requirement for each Contractor, during
the term of the Contract, to immediately report, in writing, to the HHSC contract
manager when Contractor learns of or has any reason to believe it or any person
with ownership or controlling interest in Contractor, or any of Contractor’s agents,
employees, subcontractors or volunteers has: engaged in any activity that does
or could constitute a criminal offense equal to or greater than a Class A
misdemeanor or grounds for disciplinary action by a state or federal regulatory
authority; or been placed on community supervision, received deferred
adjudication, or been indicted for or convicted of a criminal offense relating to
the involvement in any financial matter, federal or state program, or sex crime.
Contractor shall not permit any person who engaged, or was alleged to have
engaged, in any activity subject to reporting under this section to perform direct
client services or have direct contact with clients, unless otherwise directed in
writing by the HHSC contract manager.
Personnel with sex offender, child or adult abuse, or fraud offenses shall not be
allowed to provide Contract services and shall not be allowed access to HHS Agency
property, facilities, or documents.
Key personnel with misdemeanor offenses must receive prior approval by the HHS
Agency before being allowed to work under this contract.
HHSC, at its sole discretion, may terminate any Contract if Contractor, its agents,
employees, subcontractors, or volunteers are arrested, indicted, or convicted of any
criminal activity.
8.6. NOTICE OF INSOLVENCY OR INDEBTEDNESS
At the time of submission, Applicants shall provide with the Application detailed
written descriptions of any insolvency, incapacity, and outstanding unpaid
obligations of Applicant owed to the Internal Revenue Service (IRS) or the State
of Texas, or any agency or political subdivision of the State of Texas. This is a
continuing disclosure requirement; prior to Contract award, if any, Applicants must
notify the HHSC Sole Point of Contact within five days of the date Applicant learns
of such financial circumstances after submission of the Application.
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Additionally, Contractors are under a continuing obligation to notify the HHSC
contract manager, as applicable, within five days of the date Contractor learns
of such financial circumstances after Contract award.
8.7. REPORTING CRITERIA
a. Within five business days of receipt of each case, review Medicaid NF IMEs
submitted by HHSC and respond to the request and “reply all” to all original
requestors, with the recommendation regarding whether to approve or deny
the request.
b. Develop a monthly tracking report to include all requests received,
disposition of the requests, and rationale. This tracking report is to be
submitted to HHSC Contract Manager via email by the 15th day of the month
following the report month.
8.8. INVOICE REQUIREMENTS AND PAYMENT
8.8.1. INVOICE REQUIREMENTS
Contractor shall submit to HHSC detailed and accurate invoice(s) which
include the information below. Each invoice must be submitted to
DentalIME@hhs.texas.gov in the format prescribed by HHSC, not later than
10 calendar days after the contract quarter.
The email address for submitting an invoice is: DentalIME@hhs.texas.gov
The invoice shall include, at a minimum:
a. Unique invoice number;
b. Invoice date;
c. Service month(s);
d. Contractor's mailing and email (if applicable) address;
e. Contractor's telephone number;
f. Name and telephone number of a person designated by the
contractor to answer questions regarding the invoice;
g. The State agency's name, agency number, and delivery address;
h. The state agency's purchase order number, if applicable;
i. The contract number or other reference number, if applicable;
j. Valid Texas identification number (TIN) issued by the comptroller;
k. Description of the goods or services, in sufficient detail to identify
the order which relates to the invoice;
l. Daily timesheets documenting the date, minutes, and hours worked;
m. Unit numbers corresponding to the amount of the invoice; and
n. Any other relevant information supporting and explaining the
payment requested.
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No payment will be made under this Contract without submission of
detailed, accurate invoices submitted as outlined.
8.8.2. PAYMENT
a. Contractor must submit invoices for cost reimbursement on a
monthly basis or as otherwise indicated on the purchase order;
b. Separate invoices must be submitted for each service month, as
applicable; and
c. Failure to submit an accurate and valid invoice with all required
information may result in delay of payment;
d. Contractor shall be paid a rate of $105.00 per hour for the services
under this Contract. The Contractor shall keep daily timesheets
documenting the date, minutes, and hours worked. HHSC projects
that the assigned dentist may work up to 16 hours per week, each
week for the term of this Contract to provide the required services
identified in Section 8. Contractor may increase or decrease the
number of hours worked per week, however, that any adjustment in
time worked per week shall not:
1) cause the not-to-exceed amount of this Contract to increase; or
2) result in the failure to timely provide required services.
e. Contractor is required to notify HHSC of a change in work hours if
not already requested by HHSC. Contractor is solely responsible for
time management.
8.8.3. DISPUTED INVOICE(S)
In accordance with 34 Texas Administrative Code, Rule §20.487(b), the
HHS Agency will immediately return disputed invoices to the Contractor
but in no event later than the 21st day after the HHS Agency receives the
invoice. The HHS Agency reserves the right to dispute any portion of an
invoice and will attempt to resolve the dispute with the Contractor in good
faith. The HHS Agency shall not be required to pay any disputed portion
of an invoice until the dispute is resolved. Notwithstanding any such
dispute, the Contractor must continue to perform the services and/or
produce deliverables in compliance with the terms of the Contract.
Pending resolution of a dispute, the HHS Agency will continue to process
payments for undisputed amounts and invoices to the Contractor.
8.9. DATA USE AGREEMENT (DUA)
By submitting an Application and, if applicable, signing a contract resulting from
this OE, Applicant agrees to the terms of the Data Use Agreement, Exhibit B. The
Applicant must complete, sign, and return with its Application, (Texas HHS System
- Data Use Agreement – Exhibit B, Security and Privacy Initial Inquiry (SPI) –
Exhibit C).
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8.10. TERMS AND CONDITIONS
Submission of an Application in response to this OE constitutes acceptance of all
Terms and Conditions attached to, referenced, or set forth in the OE. Applicant shall
not submit additional or different terms and conditions.
Any term, condition, or other part of an Applicant’s submitted application that has
been rejected by HHSC, that is not accepted in writing by HHSC, or that conflicts
with applicable law, this OE, any resulting Contract, or applicable terms and
conditions will not constitute part of the Contract.
8.11. STANDARDS OF CONDUCT FOR VENDORS
Pursuant to 1 TAC 391.405(a), contractors, respondents, and vendors interested in
working with HHS are required to implement standards of conduct to apply to all
matters involving, or related to, those solicitations and contract(s) between
themselves and HHS. These standards must adhere to ethics requirements adopted
in rule, in addition to any ethics policy, or code of ethics approved by the HHSC
Executive Commissioner and must be at least as restrictive as those applicable to
HHS personnel in the applicable ethics law and policy provisions.
The standards of conduct must include the ten standards of ethical conduct set forth
in Section I of the HHS Ethics Policy and requirements to comply with ethical
standards set forth in federal and state law (including, but not limited to, 1 TAC
Chapter 391, Subchapter D).
The standards of conduct, together with the responsibilities and restrictions
incorporated herein, also apply to subcontractors of contractors, respondents, and
vendors.
Standards of conduct of any contractor, respondent or vendor may be reviewed
and/or audited by the State Auditor and HHSC. Additionally, pursuant to 1 TAC
391.405(a), HHS may examine a respondent's standards of conduct in the
evaluation of a bid, offer, proposal, quote, or other applicable expression of interest
in a proposed purchase of goods or services.
Any vendor or contractor that violates a provision of 1 TAC Chapter 391, Subchapter
D may be barred from receiving future contracts or have an existing contract
canceled. Additionally, HHSC may report the vendor's actions to the Comptroller of
Public Accounts for statewide debarment, or law enforcement.
SECTION 9. HHSC CONTRACT ADMINISTRATION
HHSC will designate a Contract Manager and provide the manager’s contact information
to the Contractor.
After award of any Contract resulting from this OE, all communications related to the
Contract will be processed through the designated Contract Manager. Additional
requirements apply to legal notices which must be provided to the HHS Chief Counsel as
well as the Contract Manager.
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SECTION 10. CONFIDENTIAL OR PROPRIETARY INFORMATION
10.1. PUBLIC INFORMATION ACT
Applicant Requirements Regarding Disclosure
Applications and contracts are subject to the Texas Public Information Act (PIA),
Texas Government Code Chapter 552, and may be disclosed to the public upon
request. Other legal authority also requires HHSC to post certain contracts and
Applications on HHSC’s website and to provide such information to the Legislative
Budget Board for posting on its website.
Under the PIA, certain information is protected from public release. If Applicant
asserts that information provided in its Application is exempt from disclosure under
the PIA, Applicant must:
a. Mark Original Application:
1. Mark the original Application, on the top of the front page, the words
“CONTAINS CONFIDENTIAL INFORMATION” in large, bold, capitalized
letters (the size of, or equivalent to, 12-point Times New Roman font or
larger); and
2. Identify, adjacent to each portion of the Application that Applicant claims
is exempt from public disclosure, the claimed exemption from disclosure
(NOTE: no redactions are to be made in the original Application);
b. Certify in Original Application - HHS Solicitation Affirmations (attached
as Exhibit A to this OE): certify, in the designated section of the HHS
Solicitation Affirmations, Applicant’s confidential information assertion and the
filing of its Public Information Act Copy; and
c. Submit Public Information Act Copy of Application: submit a separate
“Public Information Act Copy” of the original Application (in addition to the
original and all copies otherwise required under the provisions of this OE). The
Public Information Act Copy must meet the following requirements:
1. The copy must be clearly marked as "Public Information Act Copy" on the
front page in large, bold, capitalized letters (the size of, or equivalent to,
12-point Times New Roman font or larger);
2. Each portion Applicant claims is exempt from public disclosure must be
redacted; and
3. Applicant must identify, adjacent to each redaction, the claimed
exemption from disclosure. Each identification provided as required in
subsection (c) of this section must be identical to those set forth in the
original Application as required in section a.(2), above. The only difference
in required markings and information between the original Application and
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the “Public Information Act Copy” of the Application will be redactions -
which can only be included in the “Public Information Act Copy.” There
must be no redactions in the original Application.
By submitting an Application to this OE, Applicant agrees that, if Applicant
does not mark the original Application, provide the required certification
in the HHS Solicitation Affirmations, and submit the Public Information Act
Copy, Applicant’s Application will be considered to be public information
that may be released to the public in any manner including, but not limited
to, in accordance with the Public Information Act, posted on HHSC’s public
website, and posted on the Legislative Budget Board’s website.
If Applicants submit partial, but not complete, information suggesting
inclusion of confidential information and failure to comply with the
requirements set forth in this section, HHSC, in its sole discretion, reserves
the right to (1) disqualify all Applicants that fail to fully comply with the
requirements set forth in this section, or (2) to offer all Applicants that fail
to fully comply with the requirements set forth in this section additional
time to comply.
Applicant should not submit a Public Information Act Copy indicating that the entire
Application is exempt from disclosure. Merely making a blanket claim that the entire
Application is protected from disclosure because it contains any amount of
confidential, proprietary, trade secret, or privileged information is not acceptable,
and may make the entire Application subject to release under the PIA.
Applications should not be marked or asserted as copyrighted material. If Applicant
asserts a copyright to any portion of its Application, by submitting an Application,
Applicant agrees to reproduction and posting on public websites by the State of
Texas, including HHSC and all other state agencies, without cost or liability.
HHSC will strictly adhere to the requirements of the PIA regarding the disclosure of
public information. As a result, by participating in this OE process, Applicant
acknowledges that all information, documentation, and other materials submitted
in the Application in response to this OE may be subject to public disclosure under
the PIA. HHSC does not have authority to agree that any information submitted will
not be subject to disclosure. Disclosure is governed by the PIA and by rulings of
the Office of the Texas Attorney General. Applicants are advised to consult with
their legal counsel concerning disclosure issues resulting from this process and to
take precautions to safeguard trade secrets and proprietary or otherwise
confidential information. HHSC assumes no obligation or responsibility relating to
the disclosure or nondisclosure of information submitted by Applicants.
For more information concerning the types of information that may be withheld
under the PIA or questions about the PIA, refer to the Public Information Act
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Handbook published by the Office of the Texas Attorney General, or contact
the attorney general’s Open Government Hotline at (512) 478-OPEN (6736) or toll-
free at (877) 673-6839 (877-OPEN-TEX). The Public Information Act Handbook
may be accessed at:
https://www.texasattorneygeneral.gov/open-government/members-public
10.2. APPLICANT WAIVER – INTELLECTUAL PROPERTY
SUBMISSION OF ANY DOCUMENT TO ANY HHS AGENCY IN RESPONSE TO
THIS OE CONSTITUTES AN IRREVOCABLE WAIVER, AND AGREEMENT BY
THE SUBMITTING PARTY TO FULLY INDEMNIFY THE STATE OF TEXAS,
HHSC FROM ANY CLAIM OF INFRINGEMENT BY HHSC REGARDING THE
INTELLECTUAL PROPERTY RIGHTS OF THE SUBMITTING PARTY OR ANY
THIRD PARTY FOR ANY MATERIALS SUBMITTED TO HHS BY THE
SUBMITTING PARTY.
SECTION 11. BINDING OFFER
All Applications should be responsive to the OE as issued or amended through written and
posted Addenda, not with any assumption that HHSC will negotiate any or all terms,
conditions, or provisions of the OE. Furthermore, all Applications constitute binding offers.
Any Application that includes any type of disclaimer or other statement
indicating that the Application submitted in response to this OE does not
constitute a binding offer will be disqualified.
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SECTION 12. REQUIRED APPLICATION DOCUMENTS
All documentation listed must be returned for a complete Application. Provide the
documentation in the same sequence as outlined below by using the Item number(s)
and title(s) as necessary.
1. Exhibit A – HHS Solicitation Affirmations
Must be completed and signed.
Important Note: Applications received without the signed Exhibit A will be
disqualified.
2. OE Addenda, if applicable - signed
3. Exhibit B - DUA (Data Use Agreement) – completed and signed
4. Exhibit C – SPI (Security and Privacy Initial Inquiry) - completed and signed
5. Exhibit D – Federal Assurances – Non-Construction - completed and signed
6. Exhibit E - Face Page
• Applicant Business Structure or Company Type:
Provide the entity type (e.g., Private, Non-Profit, State Agency, Local Government, etc.).
If Corporation, provide State of Incorporation and filing number.
• Court or Governmental Agency Proceedings, Investigations, or Other Actions:
Applicant shall provide information required pursuant to the HHS Solicitation Affirmations
(Exhibit A), paragraph 36.
• Former Employees of a Texas State Agency:
Applicant must provide the following information regarding individuals that formerly
worked for any Texas state agency and now work for Applicant or any of Applicant’s
subcontractors:
Name
Address
Phone Number
State agency for which previously worked
Dates of employment for each identified state agency
Any additional information requested by HHS regarding identified individuals must be
provided by Applicant.
7. Exhibit F – HHS Uniform Terms and Conditions (UTC), Vendor Version 3.3, July
2022
8. Minimum Qualifications – Reference Section #7
Required Experience:
Provide documentation of demonstrated experience to confirm the Applicant meets the
minimum requirements.
Licensure or Accreditation
Provide current copies of all required Licensure and Accreditation for the Applicant and
Applicant’s personnel as applicable.
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SECTION 13. APPLICATION SUBMISSION REQUIREMENTS
The Application must be submitted in accordance with this section.
The complete Application must be submitted to:
Health and Human Services Commission
Access and Eligibility Services
Eligibility Operations and Disability of Determination Services Contracts (EODDS)
Email: DentalIME@hhs.texas.gov
Each Applicant is solely responsible for ensuring its Application is submitted in
accordance with all OE requirements and ensuring timely receipt by
HHSC.
In no event will HHSC be responsible or liable for any delay or error in
submission or delivery.
The Application must be submitted by email.
13.1. EMAIL SUBMISSION
Each Applicant is solely responsible for ensuring its Application is submitted in
accordance with all OE requirements, including, but not limited to, the Section 13,
Required Application Documents and ensuring timely email receipt by HHSC.
The Application, including all documentation outlined in Section 13, must be sent
in its entirety in one or more emails.
In no event will HHSC be responsible or liable for any delay or error in
delivery. Applications must be RECEIVED by HHSC before the OE period
closes as identified in Schedule of Events, Section 1, or subsequent
Addenda.
The email subject line should contain the OE number, title as indicated on the cover
page and number of emails if more than one (e.g., Email 1 of #, etc.). The Applicant
is solely responsible for ensuring that Applicant’s complete electronic Application is
sent to and RECEIVED by HHSC at the proper destination server before the
submission deadline.
The Application documentation must not be encrypted to prevent HHSC from
opening the documents.
IMPORTANT NOTE: HHSC recommends a 10MB limit on each attachment. This may
require Applicants to send multiple emails to HHSC at [email protected].gov to
ensure all documentation contained in an Application is received.
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All documents should be submitted in Microsoft office® formats (Word® and
Excel®, as applicable) or in a form that may be read by Microsoft office® software.
Any documents with signatures shall be submitted as an Adobe® portable
document format (pdf) file. HHSC is not responsible for documents that cannot be
read or converted. Unreadable applications may be, in HHSC’S sole discretion,
rejected as nonresponsive.
Please be aware Internet Service Providers may limit file sizes on outgoing emails;
therefore, it is recommended Applications not contain graphics, pictures,
letterheads, etc., which consume a lot of space. These typically include *.tif/*.tiff,
*.gif, & *.bmp file extensions, but may use others, as well. HHSC’s firewall virus
protection always runs, so during times of new active virus alerts, incoming traffic
may be delayed while virus software scans emails with attachments. HHSC takes
no responsibility for emailed Applications that are captured, blocked, filtered,
quarantined, or otherwise prevented from reaching the proper destination server
by any HHSC anti-virus or other security software.
Applicants may email the Point of Contact, Section 4.1 to request confirmation of
receipt.
13.2. RECEIPT OF APPLICATION
All Applications become the property of HHSC upon receipt and will not be returned
to Applicants.
HHSC will NOT be held responsible for any Application that is mishandled by the
Applicant, any Applicant’s delivery, or mail service or for Applications sent by email
that are captured, blocked, filtered, quarantined or otherwise prevented from
reaching the proper destination server by any HHSC anti-virus or other security
software.
Applications received after the OE Period closes will not be considered.
SECTION 14. SCREENING OF APPLICATIONS
Neither issuance of this OE nor retention of Applications constitutes a commitment on the
part of HHSC to award a Contract. HHSC maintains the right to reject any or all
Applications and to cancel this OE if HHSC, in its sole discretion, considers it to be in the
best interests of HHSC to do so.
Submission and retention of Applications by HHSC confers no legal rights upon any
Applicant.
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HHSC reserves the right to select qualified Applicants to this OE with or without discussion
of the Applications with Applicants. It is understood by Applicant that all Applications,
contracts, and related documents are subject to the Texas Public Information Act.
14.1. INITIAL SCREENING OF APPLICATIONS
An initial screening of Applications will be conducted by HHSC to determine which
Applications are deemed to be responsive and qualified for further consideration for
award. This screening includes a review to determine that each Applicant meets the
minimum requirements, qualifications and each Application includes all required
documentation.
HHSC reserves the right to:
a. Ask questions or request clarification from any Applicant at any time during the
OE and screening process, and
b. Conduct studies and other investigations as necessary to evaluate any
Application.
Informalities:
HHSC reserves the right to waive minor informalities in an Application. A "minor
informality" is an omission or error that, in HHSC’s determination if waived or
modified when screening Applications, would not give an Applicant an unfair
advantage over other Applicants or result in a material change in the Application or
OE requirements.
HHSC, at its sole discretion, may give an Applicant the opportunity to submit
missing information or make corrections. The missing information or corrections
must be submitted to the Point of Contact email address in Section 4.1 by the
deadline set by HHSC. Failure to respond before the deadline may result in HHSC’s
rejecting the Application and the Applicant not being considered for award.
Note: Any disqualifying factor set forth in this OE does not constitute an informality
(e.g., Exhibit A, HHS Solicitation Affirmations which must be signed and submitted
with the Application).
14.2. VERIFICATION OF PAST VENDOR PERFORMANCE
HHSC reserves the right to conduct studies and other investigations as necessary
to evaluate any Application. By submitting an Application, the Applicant generally
releases from liability and waives all claims against any party providing information
about the Applicant at the request of HHSC.
Applicants may be rejected as a result of unsatisfactory past performance under
any contract(s) as reflected in vendor performance reports, reference checks, or
other sources.
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An Applicant’s past performance may be considered in the initial screening process
and prior to making an award determination.
Reasons for which an Applicant may be denied a contract include but are not limited
to:
a. Applicant has an unfavorable report or grade on the CPA Vendor Performance
Tracking System (VPTS).
VPTS may be accessed at:
https://comptroller.texas.gov/purchasing/programs/vendor-performance-tracking/
OR,
b. Applicant is currently under a corrective action plan through HHSC, OR,
c. Applicant has had repeated, negative vendor performance reports for the same
reason, OR,
d. Applicant has a record of repeated non-responsiveness to vendor performance
issues, OR,
e. Applicant has contracts or purchase orders that have been cancelled in the
previous 12 months for non-performance or sub-standard performance.
f. Verify the dentist’s license on the Texas State Board of Dental Examiners
website.
In addition, HHSC may examine other sources of vendor performance which may
include information provided by any governmental entity, whether an agency or
political subdivision of the State of Texas, another state, or the Federal government.
The performance information may include, but is not limited to:
• Notices of termination,
• Cure notices,
• Assessments of liquidated damages,
• Litigation,
• Audit reports, and
• Non-renewals of contracts.
Further, HHSC, at its sole discretion, may initiate investigations or examinations of
vendor performance based upon media reports. Any negative findings, as
determined by HHSC in its sole discretion, may result in HHSC’s removing the
Applicant from further consideration for award.
SECTION 15. AWARD PROCESS
15.1. CONTRACT AWARD AND EXECUTION
HHSC, at its sole discretion, reserves the right to cancel this OE at any time or
decline to award any contracts as a result of this OE.
HHSC intends to award one or more contracts as a result of this OE.
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All awards are contingent upon approval of the HHSC Executive Commissioner or
the HHSC Executive Commissioner’s designee.
15.2. COMPLIANCE FOR PARTICIPATION IN STATE CONTRACTS
15.2.1. REQUIRED PRE-AWARD VERIFICATIONS
In addition to the initial screening process, the following verification
checks are required to be conducted for each Applicant to determine
compliance for participating in State contracts.
The Applicant’s Legal Name and, if applicable, Assumed Business Name
(DBA) will be used to conduct these checks.
Applicants found to be barred, prohibited, or otherwise excluded from
contract award will be disqualified from further consideration.
a. State of Texas Debarment
Must not be debarred from doing business with the State of Texas
through the Comptroller of Public Accounts (CPA):
https://comptroller.texas.gov/purchasing/programs/vendor-
performance-tracking/debarred-vendors.php
b. System of Award Management (SAM) Exclusions List - Federal
Must not be excluded from contract participation at the federal level.
This verification is conducted through SAM, official website of the US
Government which may be accessed at this link:
https://www.sam.gov/SAM/pages/public/searchRecords/search.jsf
Note: If the link does not work, copy/paste the link into browser bar.
c. Divestment Statute Lists
Must not be listed on the Divestment Statute Lists provided by CPA
which may be accessed at:
https://comptroller.texas.gov/purchasing/publications/divestment.php
https://comptroller.texas.gov/purchasing/publications/divestment.php
1. Companies that boycott Israel;
2. Scrutinized Companies with Ties to Sudan;
3. Scrutinized Companies with Ties to Iran;
4. Designated Foreign Terrorist Organizations; and
5. Scrutinized Companies with Ties to Foreign Terrorist Organizations.
15.2.2. ADDITIONAL REQUIRED PRE-AWARD VERIFICATIONS
After the checks performed in Section 16.2.1, the following verifications
will be conducted for each Applicant. The verifications will be based on
the legal name and, if applicable, the Assumed Business Name (DBA),
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and/or the Secretary of State (SOS) charter number, the Federal ID or
Texas Payee ID numbers, or the CPA Franchise Tax number provided, as
applicable, on Exhibit A, HHS Solicitation Affirmations.
The results of the checks below will be used to further consider an
Applicant for award and may result in disqualification.
a. Texas Franchise Tax Status
The Texas franchise tax is a privilege tax imposed on each taxable
entity formed or organized in Texas or doing business in Texas.
Although not all entities are required to file or pay franchise taxes,
HHSC will process a search of the Applicant through the CPA Franchise
Tax system to verify the Applicant is in good standing.
Franchise tax checks may reveal as to applicable entities (1) debts or
delinquencies owed to the state (implicating contracting limitations)
and (2) forfeiture of the right to transact business in Texas.
b. Texas Warrant Hold Status
The check for warrant holds through the CPA is required to determine
if an Applicant is on hold for any reason. Texas Government Code
Section 2252.903 requires agencies to verify the warrant hold status
no earlier than the seventh day before and no later than the day of
contract execution for transactions involving a written contract. In
accordance with Section 3.3 of Exhibit F Uniform Terms and
Conditions, payments under any contract resulting from this OE will
be applied directly toward eliminating the Applicant’s debt or
delinquency regardless of when it arises.
c. Texas Secretary of State
Must be registered, if required by law, with the Texas Secretary of
State as a public or private entity eligible to do business in Texas:
https://direct.sos.state.tx.us/acct/acct-login.asp
15.3. AWARD TO GOVERNMENTAL ENTITIES
If Applicant is a governmental entity, responding to this OE in its capacity as a
governmental entity, certain terms and conditions may not be applicable including,
but not limited to, any HSP requirement. Furthermore, to the extent permitted by
law, if an Application is received from a governmental entity, HHSC reserves the
right to enter into an interagency or interlocal agreement with the governmental
entity.
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Exhibit A
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Exhibit C
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Exhibit D
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Health and Human Services Commission
Exhibit E FACE PAGE
CONTRACTOR INFORMATION
1) LEGAL BUSINESS NAME:
2) MAILING Address Information (include mailing address, street, city, county, state and 9-digit zip code):
Check if address change
3) PAYEE Name and Mailing Address, including 9-digit zip code (if different from above):
Check if address change
4)
DUNS Number (9-digit) required if receiving federal funds:
5) Federal Tax ID No. (9-digit), State of Texas Comptroller Vendor ID Number (14-digit) or
Social Security Number (9-digit):
*The Contractor acknowledges, understands and agrees that the Contractor's choice to use a social security number as the vendor identification number for the contract,
may result in the social security number being made public via state open records requests.
6) TYPE OF ENTITY (check all that apply):
City
Nonprofit Organization*
Individual
County
For Profit Organization*
Federally Qualified Health Centers
Other Political Subdivision
HUB Certified
State Controlled Institution of Higher Learning
State Agency
Community-Based Organization
Hospital
Indian Tribe
Minority Organization
Private
Faith Based (Nonprofit Org)
Other (specify):
*If incorporated, provide 10-digit charter number assigned by Secretary of State:
7) PROPOSED BUDGET PERIOD:
Start Date:
End Date:
8) COUNTIES SERVED BY PROJECT:
9) AMOUNT OF FUNDING REQUESTED:
11) PROJECT CONTACT PERSON
10) PROJECTED EXPENDITURES
Name:
Phone:
Fax:
Email:
Does Contractor’s projected federal expenditures exceed $500,000, or
its projected state expenditures exceed $500,000, for Contractor’s
current fiscal year (excluding amount requested in line 9 above)? **
Yes No
**Projected expenditures should include anticipated expenditures under all
federal grants including “pass through” federal funds from all state agencies,
or all anticipated expenditures under state grants, as applicable.
12) FINANCIAL OFFICER
Name:
Phone:
Fax:
Email:
13) AUTHORIZED REPRESENTATIVE
Check if change
14) SIGNATURE OF AUTHORIZED REPRESENTATIVE
Name:
Title:
Phone:
Fax:
Email:
15) DATE
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Exhibit F
HHS Open Enrollment
Version 2.2, July 2021
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HHS Open Enrollment
Version 2.2, July 2021
Page 75 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 76 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 77 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 78 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 79 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 80 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 81 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 82 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 83 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 84 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 85 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 86 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 87 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 88 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 89 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 90 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 91 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 92 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 93 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 94 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 95 of 96
HHS Open Enrollment
Version 2.2, July 2021
Page 96 of 96
