HomeMy WebLinkAboutResolution - 121478H - Family Planning Services - TTU School Of Medicine - 12_14_1978:hw
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RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized
and directed to execute for and on behalf of the City of Lubbock an agreement
between Texas Tech School of Medicine and the City of Lubbock for Family
Planning Services, attached herewith which shall be spread upon the
minutes of the Council and as spread upon the minutes of this Council
shall constitute and be a part of this Resolution as if fully copied
herein in detail.
Passed by the City Council this
'ATTEST:
/%
14th day of December
-j*elyaa--C"afffgi, City Secretary -Treasurer
v
,APPROVED AS . -TO FORM:
J n C. Ross, Jr., City Attorney
e e7u d
Denzel Percitjll
Director of Public Ser ices Admin.
, 1978.
i
AGREEMENT
BETWEEN
TEXAS TECH SCHOOL OF MEDICINE
and
CITY OF LUBBOCK
MADE this 14 0day of December , 1978, between Texas Tech University
School of Medicine, acting by and through its Department of Obstetrics and
Gynecology, located in the City of Lubbock, Lubbock County, Texas, hereinafter
called "TTUSM", and the City of. Lubbock, Texas, acting by and through its
Health Department, hereinafter called "CLHD".
WHEREAS, the CLHD desires and agrees to be a subcontractor to TTUSM in
providing the applicable services required in Contract PS-021-04-P-00, Family
Planning, applicable to Title XX, between TTUSM and the Texas Department of
Human Resources, a copy of which is attached hereto as Attachment A, and made a
part of this contract.
NOW, THEREFORE, in consideration of the mutual promises herein contained,
it is agreed that:
THE CLHD:
1. Agrees to comply with all provisions, laws, and other re-
quirements in Attachment A of this contract, and specifically
Sections II, III and IV.
2. Agrees to submit detailed statements of charges each month
developed in the format agreeable to TTUSM and in keeping with
the fee schedule in Attachment A of this subcontract. CLHD
understands and agrees to the deduction of 25% for admini-
strative surcharge costs to TTUSM before submitting a net
billed amount. Such costs include but are not limited to
transportation of specimens, drawing of samples, billing
service, etc.
3. Agrees to obtain within 90 days of signing this agreement
certification by the Texas Department of Human Resources, Title
gig as fiscal intermediary agent and family planning vendor.
After said certification has been received, CLHD agrees to
maintain such during the period of this contract.
THE TTUSM:
1. Agrees to keep CLHD informed of any changes in the requirements
of Title XX.
2. Agrees to reimburse CLHD for one hundred percent (100%) of the
net billed amount submitted under the provisions of this contract,
including Attachment A.
3. Agrees to assure that all CLHD policies and rules, as related to
Family Planning Services, are strictly complied with before
performing service.
Both parties_agreeythat:this contract may be cancelled at any time by mutual
consent or in any event it may be cancelled by either party by giving thirty
(30) days notice in writing to the other party.
This contract shall become effective immediately upon its execution and shall
terminate August 31, 1979.
IN WITNESS WHEREOF, the parties hereto have executed this agreement
as of the day and year first above written.
CITY OF LUBBOCK: TEXAS TECH UNIVERSITY SCHOOL
�4w
By.
^tmmo .-- —
DIRK WEST, MAYOR
ATTEST:
Evelyn Gaf fga, City S c y
Treasurer
APPROVED AS TO FORM:
C_ A
John C. Ross, JR.,City Attorney
APPROVED:
i l ee i7dt/
DENZEL PE IFULL
Direc for f Publi J,
ervices Admin.
OF MEDICINE
RI LOCKWOOD, M.D.
ATTEST:
Secretary
State of Yexas
Department of Public Welfare
Form 2034
April 1977
U. STATE OF TEXAS
joy
COUNTY OF TRAVIS
TITLE XX
FAMILY PLANNING CONTRACT NO._PS-021-04—P-00
The State Department of Public Welfare, hereinafter referred to as the Department, and
TEXAS TECH SCHOOL OF MEDICINE
hereinafter referred to as the Contractor, which has been certified by the Department's Title XIX fiscal
intermediary agent as a Title XIX family planning vendor, do hereby make and enter into this contract,
which constitutes the entire agreement between the Contractor and the Department.
The Department is the single Texas state agency responsible for administering the public welfare program
under the Social Security Act. Federal law and regulations, as well as State law, in TEX. REV. CIV. STAT.
ANN. art. 695c § 402), permit and authorize the Department, subject to certain limitations, to enter
into agreements with public or private agencies for the purposes of providing social and/or other services for
the benefit of eligible individuals. Since the Contractor desires to provide services for the benefit of certain
eligible individuals, as described herein, the Department and the Contractor make this contract.
The parties hereto mutually agree:
A. The scope of the services to be provided by the Contractor and/or subcontracting agencyGes) under this
contract, is limited to those services listed in the Plan of Operation which is attached to this contract
and incorporated into this contract in its entirety by specific reference. Any change, modification, or
amendment thereto, must be made with the prior written approval of the Department except as
otherwise provided in this contract and any such change, modification, or amendment to such Plan of
Operation is not effective until approved by the Department. Such original Plan of Operation together
with any approved amendment as maintained on file by the Department will be considered to be the
controlling instruments in case any disputes arise relative to the wording of any portion of such Plan of
Operation or amendment thereto.
B. Medical and social services under this contract are extended to income eligible individuals. Social
services under this contract are extended to current AFDC and SSI recipients. Services offered to current
AFDC recipients, current SSI recipients, and income eligible individuals must be fully integrated with
those offered to patients not subsidized by the Department.
CERTIFIED AS CORRECT COPY
y
Form 2034
F ege 2
C. The basis for payment for services rendered under this contract is indicated in the set fee schedule
included in the aforementioned Plan of Operation. Any Contractor initiated amendment to the fee
schedule is subject to prier written Department approval. The Department -may revise the fee schedule
by giving the Contractor written notice of such revision.
D. The Department, the Contractor and all subcontractors, if any, will carry out the requirements for the
provision of services as set forth in Chapter II, Title 45 of the Code of Federal Regulations, as amended,
will monitor and conduct fiscal and/or program audits at reasonable times and will provide consultative
and technical assistance for the continuous development of the services contemplated by this contract.
The Department shall have authority to monitor and conduct fiscal and/or program audits of both the
contractor and its subcontractor(s) to the extent of services provided under the terms of this contract.'
On site visits as well as access at reasonable times to all books and records will be granted State or
Federal auditing agencies, representatives of the United States Department of Health, Education, and
Welfare and/or the Department when it is deemed necessary by the Department for purposes of
inspection, monitoring, auditing, or evaluating said materials.
E. This contract is subject to the availability of State and Federal funds and if such funds become
unavailable, or if the total amount of funds allocated for this contract should become depleted during
any budget period and the Department is unable to obtain additional funds for such purposes, then this
contract will be terminated.
In the event that the Contractor fails to provide services in accordance with the provisions of this
contract, the Department may, upon written notice of default to the Contractor, terminate the whole or
any part of this contract, and such termination shall not be an exclusive remedy but shall be in addition
to any other rights and remedies provided by law or under this contract.
1� Furthermore, in the event that Federal or State laws or other requirements should be amended or
judicially interpreted so as to render continued fulfillment of this contract, on the part of either party,
substantially unreasonable or impossible, or if the parties should be unable to agree upon any
amendment which would therefore be needed to enable the substantial continuation of the services
contemplated herein, then, and in that event, the parties shall be discharged from any further
obligations created under the terms of this contract, except for the equitable settlement of the respective
accrued interests or obligations incurred up to the date of termination.
F. This contract may be cancelled by mutual consent; however, if such mutual consent cannot be attained,
then, and in that event, either party to this contract may consider it to be cancelled by the giving of
thirty (30) days notice in writing to the other party and this contract shall thereupon be cancelled upon
the expiration of such thirty (30) day period.
G. This contract may be renewed and extended by written notice to the Contractor in the form of an
amendment from the Department; such amendment shall state the term and any conditions under
which the contract is to be renewed and extended, and each of such amendments of renewal shall be
incorporated into and become a part of this contract.
CERTIFIED AS CORRECT COPY
4
Form 2034
Page 3
The Contractor agrees to, and will require Its subcontractors) If any, to agree to:
A. Provide services in accordance with the aforementioned Plan of -Operation and allow the Department to
monitor same.
B. Provide to the Department, in accordance with the procedures prescribed by the Department, a verified
and proper monthly statement of charges, or certification of expenditures, for services which have been
rendered under this contract.
C. Refrain from entering into any subcontract(s) for services without prior approval or waiver of the right
of approval to subcontract.
All subcontracts, if any, entered into by the Contractor shall be written. Any subcontract entered into
by the Contractor shall be subject to the requirements of Title XX of the Social Security Act, as
amended, and of this contract. The Contractor agrees that it shall be responsible to the Department for
the performance of any subcontractor.
D. Comply with all applicable State licensing requirements and/or Federal certification requirements.
E. Furnish the Department with various statistical reports as required by the Department in the format
prescribed by the Department.
F. Make available at reasonable times and for reasonable periods those client records, books, and
supporting documents kept current by the Contractor and its subcontractors) pertaining to provided
services for purposes of inspection, monitoring, auditing, or evaluating by Department personnel or
their representatives.
G. Participate fully in any evaluation study of this program authorized by the Department.
H. Comply with Department rules and regulations pertaining to hearings concerning applicants for and
recipients of services and to abide by the decisions rendered by the Department in such hearings. The
Contractor shall inform all individuals of their right to such fair hearing.
I. Comply with the Federal Civil Rights Act of 1964, as amended, and TEX. REV. CIV. STAT. ANN.
art. 6252-16, as amended, and Executive Order No. 11246, entitled "Equal Employment Opportunity"
as supplemented in 41 C.F.R. Part 60, including but not limited to, giving equal opportuniry both to
those seeking employment and those seeking services without regard to age, race, color, religion, sex, or
national origin.
J. Establish a method to secure the confidentiality of records and other information relating to clients in
accordance with the applicable Federal law. rules, and regulations, as well as the applicable State law and
regulations.
K. Maintain and retain case information concerning those individuals and families who received services
and supporting fiscal documents adequate to ensure that claims for Federal matching funds are in accord
with applicable Federal requirements. Said documents shall be maintained and retained by the
Contractor and all subcontractors, if any, for a period of three (3) years after the date of submission of
the last expenditure report, or until an audit has been concluded, whichever is greater.
CERTIFIED AS CORRECT COPY
Form 2034
Page A
L. Be primarily responsible for any audit exception or other payment deficiency in the program covered by
this contract which is found to exist after monitoring or auditing by the Department or the United
States Department of Health, Education, and Welfare, and be primarily responsible for the collection
and proper reimbursement to the Department of any amount paid in excess of the proper billing
amount.
M. Submit billings and statistical documentation as required by the Department by the forty-fifth (45th)
day following the last day of the month in which a service was performed, and in any event, no later
than the ninetieth (90th) day following the last day of the month in which service was provided.
Failure to do so will be considered failure to comply with the contract. Such failure to comply is valid
justification for immediate termination of this contract.
N. Offer family planning sevices without regard to maternity, marital status, parenthood, or age; with
respect for the dignity of the individual; upon referral from any source including the patient's own
application; on a voluntary basis, ensuring the patient complete choice of provider and choice of
contraceptive method which is medically feasible. Patients may accept or reject contraceptive services
and supplies under this program with complete freedom from coercion or pressure of mind and
conscience.
O. Use money received through the planned reimbursement mechanism specifically for family planning
services.
P. Accept reimbursement from the Department up to the maximum amount allowed by the Department as
set forth in the Plan of Operation as payment in full for services listed in the Plan of Operation rendered
— to individuals eligible under this contract, and to make no charge to the patient, any member of his
W family, or to any other source excepting insurance companies for such services.
The Contractor may accept reimbursement from insurance companies, -provided that any such
reimbursement received from an insurance company shall be deducted from the amount to be
reimbursed by the Department, The Contractor further agrees to secure agreements to ensure that all
physicians and any others participating in the Contractor's family planning program make no additional
charge to any source other than to the Contractor for covered services rendered to persons eligible under
this contract for such services.
Q. Attempt to serve an increasing number of those estimated to be eligible individuals in the area served
by the agency, through such conveniences as outreach services, child care services, night and weekend
clinics, etc.
R. Abide by Department program guidelines as the Department develops them for purposes of clarifying,
expanding, and improving family planning services.
S. Determine eligibility of individuals according to policies and procedures promulgated by the
Department as set forth in the Plan of Operation.
CERTIFIED AS CORRECT COPY
• )KL 1
,d
r � '
14
IV.
This Article IV is:
0 Applicable ❑ Inapplicable
The Contractor further agrees:
Form 2034
Page 5
A. To provide the Department with detailed statements of charges each month developed in the format
prescribed by the Department, and to promptly forward such bill to the Department along with a
-statement certifying that the Contractor has provided each and every service for which billing is
rendered.
B. That funds certified by the Contractor for matching purposes in accordance with the terms of this
contract, will be funds which can be used to match Federal funds under the Social Security Act and
appropriate Federal rules and regulations. Records will be maintained to verify the source and amount
of funds certified by the Contractor for matching purposes for a period of three (3) years after
submission of the certification statement, or until an audit has been concluded, whichever is greater.
C. That to reimburse the Department for administrative and other operational costs incurred in procuring
federal funds, the Department shall be entitled to retain from any allowable reimbursement due the
Contractor an amount equal to zero percent ( %) of the total amount
certified to the Department as having been expended.
M
The Department agrees to:
A. Pay the Contractor 90 % (percent) of the approved monthly billings for services which have been
rendered in accordance with the terms of this contract and its attached set fee schedule.
B. Recognize the fiscal policies and procedures of the Contractor and its subcontractor(s), if any, except
where they are in conflict with Federal and/or State law, policies, rules, and regulations.
C. Perform such evaluation studies that the Department determines to be necessary and report to the
appropriate officers of the Contractor and its subcontractor(s), if any, the preliminary results of the
study before the evaluation is concluded and the findings made a matter of record.
For the faithful performance of the terms of this contract, the parties hereto in their capacities as stated, affix
their signatures and bind themselves effective the first day of September '
1978, and continuing until September lr
STATE DEPARTMENT OF PUBLIC WELFARE
Commissioner
t t e
CERTIFIED AS CORRECT COPY
19 79.
T TECH SCHOOL OF MEDICINE
Agency Name
t
ViCP PrPcirlPTl tSeIenees Centers
Title
R
State of Texas
Department of Public Welfare
CONTRACT TRANSMITTAL
Form 2028
April 1877
TO: FROM:
Lewis Mondy, Ph.D. Nathan Martin
Program Manager Regional Administrator
Family Planning & Family Region * 021
Services Division Lubbock , Texas
Social Services Branch Mail Code— 17—
State Office 528-0
Date: August 7, 1978
Region * 021 is requesting the Commissioner's signature on the attached
purchase of social services contract between the Department of Public Welfare
(DPW) and Texas Tech University School of Medicine for the purchase
of Fs_mi ly Planning Services as authorized by the Title XX
Comprehensive Annual Services Program . Plan for Texas and the Legislative
Appropriations Request for this biennium.
The undersigned certify that the proposed contract meets the standards and
regulations of DPW and the Federal government. ,
IRenal Administrator Regional Director for gocial
Nathan Martin Services
7FrSeale
N/A
Regional Director for Education Assistant Regional Administrator
(Training Contracts)
Carrol Crum
Attachments
• ". CERTIFIED AS CORRECT COPY
FORM 2028
Page 3
Needs Identification/Assessment
I hereby certify that:
1. No other DPW or community resource is available or sufficient to meet the
clients' need for this service.
2. There exists sufficient potential benefit to the clients to justify the purchase
of services.
3. The proposed contract can provide the resource required to meet the
identified need and to measurably benefit the clients.
4. The Federal, State, and/or local funds required for the purchase of this
service have been identified and are available for use in purchasing this
service.
Program Director, f7
Social Services lS
4Sire Title Date
Linda Flippen
Purchasability
I hereby certify that:
1. The service to be provided under the terms of this contract is purchasable
under 45 C.F.R. § 228 and the Comprehensive Annual Services Program Plan
for Texas (CASPP). " ,,
2. The clients to whom the service is. to be provided under this contract will be
selected from only those client groups authorized to receive this service
under 45 C.F.R. § 228 and the CASPP.
3. The proposed contract complies with the standards, limitations,. • and
priorities set by the Board of Public Welfare.
. Program Director,
Contract Services
Signature Title
Carol A. Lindemann
Date
CERTIFMIItCORRECT COPY
►.i,•..,.....n:��,�,!,:.:75.7'y1re.:.:.h.111�J..V';1r:L►'►fj'N'�►��'
Ttxas Department
of Human Aesources
Contract No.
021-04—P-00
SECTION I — Prime Contractor Data
INFORMAT ION SHEET
PURCHASE OF SERVICE CONTRACT
Form 2029
July 1978
Region No. County No
..
02 152
Legal Name
Contract Effective Date
Texas Tech University School
of Medicine
09-01-77
Commonly Used Name (if different from above)
Contract Termination Date
08-31-79
Address
Telephone No.
P.O. Box 4269 Texas Tech Universit , Lubbock 79409
806/743-2340
Person Authorized to Sign Contract
Title
Type of Ownership (Cbeck one)
Richard A. Lockwood
VP for Health Science Centers
®Public El Private
Charter No.
Employer I.D. No.
Contact Person
Telephone No.
75-600-2622
Jon Bernier Exec. Director
806/743-2340
SECTION II — Summary of Pavment
EFFECTIVE PAYMENT DATES
BUDGET NAME
BUDGET
NUMBER
UNIT
RATE
NUMBER
ELIG. UNITS
MAXIMUM
REIMBURSABLE
Less fees from eligible clients (unit rate payment only)
—
Total Regional Allocation for this contract
SECTION III — Funding
LOCAL FUNDS CONTRACT
$ 9500 Matching $ 9,500
-0-
$ 9500
v
ry
- CERTEF'il«
ministrative Overhead
I Total Local Fund
y -
"RECT COPY
State Funds — 0 —
Federal Funds 85,500
Contract Total $ 95,000
Form 2029
Page' 2 of 2
^VCTION IV —Service and/or Subcontractor Data (complete a separate sheet (SECTION III) for each different service or for each different
' subcontract)
Program Activity Name Code
Family Planning 591
Service Activity Name
Social & Educational Family Planning
Code
16E, 16K
Name of Subcontracting Agency Of applicable
Name of Contact Person
Address of Subcontracting Agency
Telephone No.
1. Client categories to be served (check all applicable):
®Current AFDC ®Other Income Eligible
®CurrentSSI ❑Without Regard to Income
®MAO Income Eligible ❑Ineligible
2. Total Number of Clients to be Served: ..566 P'KQgz-lTQ .PQFQripI;ion Page 1 ❑ per day ❑ per week
3. Number of Eligible Clients to be Served: ❑ per day ❑ per week
4. Unit of Service: .......:...........................................................
5. Number of Units of Service to All Clients: ................................................. _
6. Number of Units of Service to Eligible Clients: .............................................. _
A. 7. B. (Complete only if service is children's day care)
® per month
❑ per month
Fee Schedule
ADDRESS(ES) OF
PROVIDING FACILITY(IES)
HOURS OF
OPERATION
NUMBER OF CHILDREN IN EACH AGE GROUP
0-2 YRS.
3.5 YRS.
6.14 YRS.
0-5 YRS.
0-14 YRS.
0-17 YRS.•
See -Attached List '
TOTALS
8. Geographic Area Served: See Attached List
9. Goals (check all applicable):
QI U11 GI111 ❑IV
Source of Federal Funds (check all applicable):
,)[:Rxx ❑IV-B
11 Basis of Payment (check one):_NIA
- mentaiiy, rnysicany, or tmotionany rtanoicappeo
12. Funding:
caV TOTAL AMOUNT OF
STATE FUNDS -
MATCH AMOUNT OF
LOCAL FUNDS
TOTAL AMOUNT OF
FEDERAL FUNDS
❑Fixed Unit Rate of .................. I ....... &n'r, _,r UWr/t,s CORRErT COPY
0Cost Reimbursement FG 1ANOTOTAL
S
S
9,500
135,000
95,000
Contract No. 021-01+ P-00
' Effective: 9-1-78
Texas Department Page 1 Form 2040
of Human Resources April 1078
FAiAlLY PLANNING CONTRACT PROGRAM DESCRIPTION
Goals -
Pursuant to the mandate of PL 93-647, the Family Planning Program defined
by the terms of this document shall operate toward the achievement of.the
following goals:
A. Achieving or maintaining economic self-support to prevent, reduce, or
eliminate dependency.
13. Achieving, or maintaining self-sufficiency, including reduction or preven-
tion of dependency.
C. Preventing or remedying neglect, abuse, or exploitation of children, and
adults unable to protect their own interests, or preserving, rehabilitating,
or reuniting families.
11. Objectives and Measures
A.
To offer social and educational family planning services to 120 cur-
rent recipients of AFDC, SS1, and MAO within the contract period.
B.
To offer social . and .,, educational : family -pi ftnnliili�servites tot
.,
�.�_tncome eligible' persons .within the'tohtracc period. f
,
C.
To offer `medical family, planning services co,,O.,in�omc eligible;
persons within the:contma pe'ribd
1
r •"
$ D
1 � r,L
S
llfeasure The'pumbet of rurtelit recipients rid income Aigtble.persons
y _
who receive` famhy.'platining sefvt, within the contract pcnod.'
'
11l, Scrvl� s to be Covered
A.
Office or,Clinic Visits (Physician Directed)
The Department will provide reimbursement for the following services
and procedures a he❑ prescribed,' furnished, directed, or supervi:ed by s
physician.
' (Cde 6.,to Completeliealth history and Physical Examianon
a '
consist of:
jj
y4nd
a. Complete obstetric gynecologic .'htstor)►, (including,,
menarche, menstrual,Egravidity, parity, pregnancy outcomes, -
and complications of pregnancy/delivery
r +'
f
II N
- •
1 i,
I
CERTIFIED AS CORRECT COPY
_�
Contract No. 021-04—P-00
Effective: 9-1-78
" • . Page 2
Form 2040
Page 2
b. History of significant illness -morbidity, hospitalization, and
previous medical care, including; particularly information about
throrabocnnbolic disease, hepato•renal disease, breast and
genital neoplasm, diabetic and predi.abetic conditions,
cepha lgia and migraine, hematologic phenomena, pelvic
inflamatory disease, visual disturbances, and mental depression.
C. History of problems relating to previous contraceptive use.
d. Family, social, physical, and mental health history.
C. Physical examination. Recommended procedures for examina-
tion should include, but are not limited to:
a. Thyroid palpation
b. Examination of breasts and axillary glands
c. Ausculation of heart and lungs
d. Blood pressure
e. Weight and height
f. Abdominal examination
F Pelvic examination
h. Examination of extremities
f. Patient consulation. Consultation includes:
a. Instruction of reproductive anatomy and physiology.
b. Overview of available methods of contraception including
consultation on the use of a natural family planning or
rhythm method if chosen by the patient.
g. Duration or frequency
There is a limit of one, annual comprehensive examination and
evaluation for each eligible patient per State fiscal year (Sep-
tember I through August 31), excepting that a second com-
prehensive cxaminai:ion may be provided where a user of a
temporary contraceptive method elects surgical sterilization, in
which case a second comprehensive examination may be billed.
2. Follow-up Visits
a. There may be follow-up visits (Code 02) or examinations
when medically necessary including home visits as required.
b. A medical honne visit (Code 34) is one made in response to an
acute medical circumstance, requiring a medically -trained pro-
fessional. It must be conducted under the standing orders of a
physician.
CERTIFIED AS CORRECT COPY
k
11
Contract No. 021-04—P-00
• 1,f fCCUVC: 9-1-78
PaF;e 3
` Form 2040
Page 3
B. Laboratory Services
I. The following laboratory services are reimbursable as routine pro-
cedures covered under family planning services:
R. Hernatocrit (Code 03) and/or hemoglobin (Code 04)
b. Urinalysis (for sugar and protein) (Code 05)
C. Papanicolaou smear (including cervical and vaginal) (Code 06)
d. Miscellaneous culture or smear for gonorrhea .(if indicated)
(Code 07)
C. Syphilis serology (if indicated) (Code 08)
f. Bacteria smear (e.g., bacterial study for Trichomoniasis,
Monilia infection, etc.) (Code 09)
g. Triglycerides fasting level confirmation test for patients 40
years of age and over (Code 55).
h. SMA-12 fasting level confirmation test for patients 40 years of
age and over (Code 56).
2. The special laboratory services and procedures noted below will be
covered if needed as a result of positive history or if deemed
medically necessary at the time of examination:
a. Tuberculosis skin test (Code 10)
b. Microscopic analysis or culture of urine (Code 11)
C. Sickle cell screening (Code 12)
d. Post -prandial blood glucose (blood sugar) (Code 13)
e. Rubella hemaglutination test (antibody screen) (Code 14)
f. Pregnancy testing (Code 15)
g. Blood type and/or Rh factor determination (Code 45)
h. Triglycerides fasting level confirmation test for patients over
40 years of age (Codc 55).
i. SNIA-12 fasting level confirmation test for patients over 40
years of age (Code 56).
CERTIFIED AS CORRECT COPY
Contract No. 021-01+ P-00
Effective: 9-1-78
4 Page 4
Form 2040
Pape 4
3. Duration or Frequency
a. In connection with the annual exai-tination and evaluation, the
procedures listed as routine will be covered immediately.
b. Additional laboratory procedures noted as special will be
covered if indicated as the result of positive history or if
deemed medically necessary at the time of examination by the
attesidins; physician or medical director in charge.
C. The follow-up visits and subsequent laboratory procedures will
be covered if deemed necessary by the attending physician or
medical director and if considered an integral part of family
planning services.
d. These services and procedures must be provided in the context
of medical judgment using policies and practices that con-
stitute high duality family planning services.
C. Contraceptive Methods and Devices.
Reimbursement will be made by DHR for these services:
1. Vasectomy (Code 17) — Components covered by this fee include
physician services, procedure room, equipment, supplies, anesthesia,
one sperm count, and tissue analysis. If performed in a free-standing
facility, any subsequent hospital charges must be billed to Code 44,
Treatment of Complications. If performed in a hospital -connected
facility, the only specific hospital charges allowed are for Code 53,
Post-Operrtive In -Patient Hospital Care, except hospital charges for
complications which must be billed to Code 44, Treatment of Com-
plications. Sterilization claims must be accompanied by a written
infurmed'consent document and must comply with Federal steriliza-
tion regulations (45 C.F.R 205.35).
2. Voluntary female sterilization.
a. Elective, non -therapeutic hysterectomy (Code 31) — The
single surgical component covered by this fee is that of the pri-
mary physician. Hospital charges must be billed to Code 00,
Complete In -Patient Hospital Care, except hospital charges for
complication which must be billed to Code 44, Treatment of
Complications. Sterilization claims must be accompanied by a
written informed consent document and must comply with
Federal sterilization regulations (45 C.F.R. 205.35).
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A claim for reimbursement of elective, non -therapeutic
hysterectomy must be accompanied by a copy of certification
that three criteria were met: the patient must have specifically,;
requested this sterilization procedure.;, the physician must have
certified that the hysterectomy was not for the correction of any
known existing pathology; and the physician must have cer
tified that hysterectomy (major surgery) was justified over.tubal
ligation/resection (minor surgery). r ;.
b. Tubal ligation (Code 16) — The single surgical component
covered by the fee is the primary physician. Hospital charges
must be billed to Code 00, Complete In -Patient Hospital Care,
except hospital charges for complication which must be billed.
to Code 44, Treatment of Complications. Sterilization claims
must be accompanied by a written informed consent document
and must comply with Federal sterilization regulations
(45 C.F.R. 205.35).
3, Contraceptive menstrual aspiration (Code 48) — Components
covered by the fee include, physician services, procedure room,
equipment, supplies, anesthesia, and tissue analysis. This procedure
is allowed only prior to the definitive determination of the existence
of pregnancy. Documentation of the uncertain status of pregnancy
hiust be included in the patient's record. If performed in a free-
standing facility, any subsequent hospital charges must be billed on
Code 44, Treatment of Complications. if performed in a hospital
facility, the only hospital charges allowed are Code 53, Post -Opera-
tive In -Patient Hospital Care, except hospital charge's*for complica-
tion which must be billed to Code 44, Treatment of Complications.
4. Furnishing and insertion of intrauterine (IUD) contraceptive
devices (Code 20).
5. The fitting and furnishing of diaphragms when furnished by the
clinic and not by prescription (Code 21).
6. When furnished by prescription, payment will be made for the
following contraceptive supplies. Cost of supplies is defined as
acquisition price plus 3% for handling and storage.
a. Oral contraceptives (Code 40) and compact containers. In addi-
tion, payment will be made for dispensing oral contraceptives
in quantities of three or more cycles (Code 46).
b. Jellies (Code 36), creams (Code 35), foams (Code 38), and
suppositories (code 37).
C. Diaphragms (Code 41).
d. Condoms (Code 42).
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C. Natural family planning supplies (Code 43) (e.g., instruction
books, charts, thermometers).
f. Medications for treatment of vaginal/cervical infections (Code
39).
D. Localization of Intrauterine Device (Codes 22, 23 artd 24) — Reim•
bursernent will be made by DHR for X-rays plus interpretation, and/or
for sonograhhy, to localize an intrauterine device not otherwise detecta-
ble.
E. Social Services Counseling'— These services are generally unavailable
to DHR clients through casework services offered by DHR field staff.
1. Initial Patient Education and Counseling (pre exam counseling)
(Code 2 5)
a. Education of patient concerning the various contraceptive tech-
niques from which the patient may choose a method most per-
sonally suitable.
h. Education of the patient regarding elementary reproductive
anatomy in order to facilitate more affective use of the method
chosen.
C. Allowable as a reimbursable expense once during each period
of active Patient status with any one provider agency. A
patient's chart must have been closed for at least one year
before this benefit can be billed again for a reactivated patient
with the same agency.
2. Post Exam Specific Education/Counseling on Method Chosen (Code
26)
a. After the patient has been examined by the physician and has
chosen the most personally suitable contraceptive method,
education and counseling are given to the patient about its
Proper use, possible side effects, reliability, reversibility, etc.
b. This service will be paid for after an initial exam, annual exam,
or when the patient changes method or experiences difficulty
with a contraceptive method.
3. Follow-up Home Visit, Non Medical (Code 27)
a. Social services home visit follow-up consists of contacting'
patients for such reasons as having missed medical appoint-
ments, or for Pap smear results.
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b. This service will be paid for as often as the program director
deems it necessary to serve a patient.
C. This benefit includes personal visits only. Telephone and mail
contacts are not included.
4, Problem counseling (Code 28) includes counseling with patients
and referrals to other agencies for such as medical problems, prob-
lem pregnancy assistance, and VD treatment. This service will be
paid for each time it is deemed necessary by the physician. Allowa-
ble once for each counseling session, whether counseling an
individual, a couple, or a large group.
5. Introduction to family planning/hospital setting (Code 30), consists
of a general overview to an individual of the benefits of family plan-
ning. Allowable only once for each person individually introduced
to family planning within a hospital setting.
6. Instruction in natural family planning methods (Code 47) consists
of two sessions for complete instruction of a couple in one or more
methods of natural family planning (defined as methods for deter-
mining the fertile and infertile periods in a woman's cycle by such
approaches as calendar record keeping, monitoring basal body tem-
perature, andlor analyzing the woman's cervical mucus). This
instruction is allowable as a reimbursable expense once during each
period of active patient status with any single provider agency.
F. Complete In -patient Hospital Care for Female .Sterilization Per-
formed in a Hospital Only (Code 00) -- Reimbursement as set forth in
the fee schedule will be made by the Department for all in -patient
expenses actually incurred in the performance of tubal ligations or elec
tive, non -therapeutic hysterectomies to a maximum of five', days of con-
finement for tubal ligations and seven days for hysterectomies. Expenses
incurred in the treatment of complications are not to be included when
billing on this code. A copy of the entire bill must be submitted with the
claim for reimbursement for in -patient care which itemizes in detail the
services rendered. This claim must not be billed separately from the
claim for family planning surgery to which it corresponds. For hospi-
talization on multiple procedures, 65% of the in -patient care must be r
charged to non -family planning procedures and 35% to family planning
procedures.
G. Post -operative In -patient Hospital Care for Contraceptive
Menstrual Aspiration and Vasectomy Performed in a Hospital Only
(Code 53) -- Reimbursement for all expenses actually incurred for post-
operative care, including bedroom, meals, attendant care, and incidental
services and supplies while recovering post -operatively. At least one ;
night's stay must have occurred post -operatively. A maximum of five
days confinement is allowed. A copy of the detailed hospital bill must be
submitted which iterizes in detail the services rendered. These services
must not be billed separately from the billing for the surgery to which
they relate. Expenses incurred in the treatment of complications must
not be billed on this code. _
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Yl. Treatment of Complications from Family Planning Surgery or IUD
Insertion (Code -1-0 — Reimbursement will be uoade by the Depart-
ment for all expcn.es act,ic:lly incurred in the care and treatment of com-
plications from fancily planning surgery (sterilization -or contraceptive
menstrual aspiration) or IUD insertion, to the maximum dollar amount
per occurrence as set forth in the fee schedule. An explanation of the
type of complication and circumstances of occurrence of the complica-
tion must accompany such a claim for reimbursement of treatment of
complications. A detailed itemization of services must be attached to the
clainrts form to document services rendered.
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Texas Department
* of Human Resources
14
Contract No. 021-04 P-O0
Effective; 9-1--78
Page 9 Form 2042
April 1978
FAMILY PLANNING CONTRACT
FEE SCHEDULE (Local Match)
SERVICE CODE FEE SERVICE
CODE FEE
OFFICE OR CLINIC VISITS
CONTRACEPTIVE DRUGS AND
Health History and Physical
SUPPLIES
Exam
01
$ 20.00
Creams
35
cost
Follow-up Office Visit
02
8.00
Jellies
36
cost
Follow-up Home Visit. Medical
34
10.00
Suppositories
37
cost
Foam
38
cost
LABORATORY _...
Medication for Vaginal/
PROCEDURES
Cervical Infection
39
cost
Oral Contraceptives
40
cost
Hematocrit
03
3.00
Dispensing Fee, Private
Hemoglobin
04
3.00
Pharmacist. 3 or more cycles
46
$2.50
Urinalysis
05
3.00
Dispensing Fee, Clinic
Papanicolaou Smear
06
7.00
Physician. 3 or more cycles
46
$1.37
Miscellaneous Culture
07
5.00
Diaphragm for Supply
41
cost
Syphilis Serology
08
6.00
Condoms
42
cost
Bacteria Smear
09
5,00
Natural Family Planning
T.B. Skin Test
10
7.50
Supplies
43
cost
Microscopic Analysis -Urine
11
4.00
Sickle Cell Screening
12
3.00
SOCIAL SERVICES: EDUCATION/
Post -prandial Blood Glucose
13
5.00
COUNSELING
Rubella Test
14
8.00
Pregnancy Test
15
8.00
Initial Patient Education
25
$6.00
Blood Type and/or RH Factor
45
4.50
Post -exam Method Specific
Triglycerides Fasting Level
Education/Counseling
26
6.00
Confirmation Test
55
13.50
Follow-up Home Visit, Social
27
7.00
SMA-12 Fasting Level
Problem Counseling -
28
10.00
Confirmation Test
56
14.00
Introduction to Family Planning/
Hospital Setting
30
7.00
Instruction in Natural Family
FAMILY PLANNING SURGERY
Planning Methods
47
16.00
Vasectomy
17
160.00
Elective Non -therapeutic
IN -PATIENT HOSPITAL CARE
Hysterectomy
Tubal Ligation
31
16
240.00
240.00
Complete In -patient Hospital
00
cost
Menstrual Aspiration
48
70.00
Care for Female Sterilization
Max 5-7
days
Post -operative In -patient
CONTRACEPTIVE DEVICES
Hospital Care. for Menstrual
53
cost
Insertion of Intrauterine
Aspiration and Vasectomy
Max 5
Device (including the
days
device)
20
25.00
Fitting and furnishing of
TREATMENT OF
diaphragm
21
15.00
COMPLICATIONS
LOCALIZATION OF IUD
Reimbursement for all expenses
44
cost up
actually incurred in the care
to Max,
One X-ray and interpretation
22
24.00
and treatment of complications
$800.00
Two X-rays and interpretation
23 '
28.00
from family planning surgery
per
Sonography
24
28.00
or IUD insertion
occur-
rence
t APPROVED:
APPROVED:
F--+- / _ /- l- ?.?
ency Representative Date n a i e D
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Conttact No. 021-044--00
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Page 10
Y. Service
Delivery Sites
A. Medical Services Sites
1.
Texas Tech University School of Medicine Ambulatory Clinic
Department of OB/GYN, Thompson Hall
Texas Tech University Campus
Lubbock, Texas 79409
2.
Texas Tech University School of Medicine Ambulatory Clinic
Department of OB/GYN, New Medical Building
Fourth and Indiana
Lubbock, Texas 79409
3.
Texas Tech Family Practice Clinic (Telephone: 806/353-9101)
1901 Medi Park Place
Amarillo, Texas 79106
B. Social/Educational Services (Only) Sites
1.
Texas Tech University School of Medicine Ambulatory Clinic
Department of OB/GYN, Thompson Hall
Texas Tech University Campus
Lubbock, Texas 79409
2.
Texas Tech University School of Medicine Ambulatory Clinic
..,
Department of OB/GYN, New Medical Building
W
Fourth and Indiana
Lubbock, Texas 79409
3.
Texas Tech Family Practice Clinic (Telephone: 806/353-9101)
1901 Medi-Park Place
Amarillo, Texas 79106
4.
Health Sciences Center Hospital
Fourth and Indiana
Lubbock, Texas 79409
5.
St. Mary of the Plains Hospital
4000 24th Street
Lubbock, Texas 79410
6.
University Hospital
6600 Quaker Avenue
Lubbock, Texas. 79414
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CITY OF LUBBOCK
MEMO
TO: Evelyn Gaffga, City Secretary
FROM: John C. Ross, Jr., City Attorney
SUBJECT: Contract Between Texas Tech University School of
Medicine and the City of Lubbock
DATE: January 5, 1979
I have reviewed the attached contract and have approved this
document as to form for execution by the Mayor, however, I do wish
to call to your attention that prior to approving this document I
had a detailed discussion with Mr. Jerry D. Brown, Assistant
Public Health Director, concerning the requirements imposed upon
the City as a result of Exhibit A which is attached to the agree-
ment and made apart thereof for all purposes. Exhibit A places
the same requirements upon the City that the State places upon the
Medical School, inother words, we could be required to perform to
the same degree under the contract that the contractor, Texas Tech
School of Medicine, is required to perform and .this could en-
compass more work on the part of the City than was originally
anticipated.
I specifically call your attention to paragraph one of this
agreement which reads as follows:
"Agrees to comply with all provisions, laws, and other
requirements in Attachment A of this contract, and specif-
ically Sections II, III and IV."
I also wich to call your attention to paragraph three of attach-
ment A which requires the Contractor, in this case the Texas Tech
School of Medicine, to require of the subcontractor's, in this
case the City of Lubbock, to agree to all of those items set forth
under paragraph three of said attachment which I here now refer
you to for your review.
In any event, I have thoroughly discussed this with Mr. Brown and
have ask him to call this to Dr. Orr's attention which they have
done as evidenced by a memorandum from Jerry Brown to myself dated
January 3, 1979, and attached hereto.
i
Evelyn Gaffga
Page 2
January 5, 1979
The purpose in this communication to you is to apprise you of the
points that I have discussed with Mr. Brown who nevertheless feels
that the contract is beneficial to the community and should be
undertaken.
JCR:cl
cl-
o n C. Ross, Jr.
JAN 8 1979
CITY S REThRY
CITY OF LU66OCK
M E M O
To: John Ross, City Attorney DAY E: January 3, 1979
FROM: Jerry D. Brown, Assistant Public Health Director
SUBJECT* Laboratory Services Contract With Texas Tech Medical School
I appreciate very much the thorough analysis of our proposed contractual
arrangement with Texas Tech Medical School by both you and Don Vandiver.
I have reviewed with Dr. Orr the specific points which you raised regarding
the Title XX Family Planning Contract which would govern our agreement
with the Medical School.
With full understanding of these provisions, it is the recommendation of
both Dr. Orr and myself that we proceed with the execution of this contract
as soon as possible.
Thank you for your assistance in this matter.
xc: Denzel Percifull
LEGAL DEPT., -z
Memo No. '2 6 '� � RECEIVED
Time :?, o O Date y—? 1
crredl to
SIGNED
1-2-4 (j