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HomeMy WebLinkAboutResolution - 3008 - Agreement - TDHS - Medicaid Program - 01/12/1989DGV:da RESOLUTION Resolution #3008 January 12, 1989 Item #34 WHEREAS, the City Council of the City of Lubbock, Texas, deems it to be in the best interest of the citizens of the City of Lubbock to participate in the Title XIX (Medicaid) Program; and WHEREAS, such participation requires execution of a Provider Agreement with the Texas Department of Human Services; NOW THEREFORE: BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT on the 12th day of January , 1989 , at a meeting of the City Council o t e City of Lu bock, Texas, a home -rule municipal corporation, held at the City Council Chambers in the Municipal Building in the City of Lubbock, Lubbock County, Texas, with a quorum of the Council members present, the following business was conducted: THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to execute a Title XIX (Medicaid) Program Provider Agreement(s) and all associated documents with the Texas Department of Human Resources and to do all things necessary to implement, maintain, amend or renew said contract, attached herewith, which shall be spread upon the minutes of this 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. THAT this resolution was passed by a majority of those present and voting in accordance with the laws of the State of Texas. Passed by the City Council on this 12th day of January B.C. McMINN, MAYOR Kantette--boya, city Secretary APPROVED AS TO CONTENT: Rita Harmon, Assistant City Manager for Public Safety and Services APPROVED (A�S\�T\O OFO,IRM- ,nj T o ald G. Vandiver, First Assistant City Attorney 198_. COUNTY OF TRAVIS Resolution #3008 PROVIDER AGREEMENT WITH THE TEXAS DEPARTMENT OF HUMAN SERVICES FOR PARTICIPATION IN THE TEXAS MEDICAID PROGRAM City of Lubbock Health Ll Name of Provider) (`Doing Business "`—(DBA) Name, if applicable) 1902 Texas Avenue, Lubbock, Texas 79408 (Address) (City, State) (Zip) Medicare Provider No. The provider agrees, in accordance with federal and state laws and regulations pertaining to the Medicaid Program and as a condition for participation as a provider in the Texas Medical Assistance Program (Medicaid), to the terms and conditions set forth below and to the Texas Medicaid Provider Procedures Manual, a copy of which will be furnished to the provider and which is hereby incorporated by reference as a part of this agreement. A. To maintain and retain for a period of five (5) years from the date of service, or until audit and all audit exceptions are resolved, whichever period is longer, such records as are necessary to fully disclose the extent of the services provided to the individuals receiving assistance under the Texas Medicaid Program, and the amount claimed for each of such services. If litigation is involved, the records must be retained until litigation is ended or for five years as cited above, whichever is longer. B. To provide unconditionally, upon request, free copies of and access to records pertaining to the services for which claims are submitted to Medicaid to representatives designated by the Texas Department of Human Services (DHS), the United States Department of Health and Human Services (HHS), the Texas Attorney General's Medicaid Fraud Control Unit and/or the health insuring contractor for Medicaid, with respect to the operation of the Texas Medical Assistance Program. C. To comply with the applicable requirements of Title 42 Code of Federal Regulations, Part 455, Subpart B, and disclose, upon request of DHS or its health insuring contractor, information concerning ownership and control, past and/or current business transactions, and other disclosing entities to include the name of any person or entity who has an ownership or control interest in or is an agent or managing employee or entity of the organisation who has been convicted of a criminal offense, patient abuse, fraud, obstruction of investigation, or of offenses relating to controlled substances in any program operated by or financed in whole -'or in part by any federal, state. or local government agency, or who has been formally disciplined or sanctioned by any state health care licensure board, whether or not the action is related to activities in these programa. Revised February 1999 Page 2 D. To accept the payment established by Medicaid under the State Plan as payment in full for covered services and to make no additional charge to the patient, any member of the family, or to any other source for covered services, except where benefits are coordinated with Medicare or private health insurance, or allowed in the Eyeglass or Hearing Aid Programs. E. To comply with Title V1 and Title VII of the Civil Rights Act of 1966 and any amendments thereto by not discriminating against any Medicaid recipient on the grounds of "race, color. religion. sex or national origin. or exclude the recipient from participation in, be denied the benefits of. or be subjected to discrimination under any program or activity receiving Federal Financial Assistance (PFA). Fe To comply with Section 504 of the Rehabilitation Act of 1973 and 'the Aged Discrimination Act of 1975 by not discriminating against any Medicaid recipient because of handicap or age. G. To not discriminate against the individual on the basis the person Is a Medicaid recipient by means of pricing differentials or other means of discriminatory treatment. H. To comply with the Utilization Review Plan (URF) approved by the State Agency or its designee for inpatient hospital admission and continued stay of Medicaid recipients (hospitals only). I. To comply with all requirements of the Texas Medical Assistance Program regulations, rules, handbooks, bu':letins, standards, and guidelines published by DRS or its health insuring contractor. J. To provide services to Medicaid recipients in the same manner and to the same degree and quality that these services are provided to the general public. K. That claims submitted by me or on my behalf for payment by the Texas' Medical Assistance Program shall be for services or items actually provided by me or under my personal supervision, as defined in DHS rules, to the eligible recipient identified as the patient for which I an entitled to payment. I understand that payment and satisfaction of such claims will be from federal and/or state funds, and that any false claims, statements, documents, or concealment of a material fact, may be prosecuted under applicable federal and/or state laws and subject to civil monetary penalty provisions as specified in state and federal law. L. To file cost reports as required by the Texas Medical Assistance Program within ninety (90) days following the end of the provider's fiscal year (for hospitals, nursing facilities, pharmacies, and home health agencies only). M. To keep the information in the enrollment application current with the understanding that the application is hereby made a part of this agreement and to promptly report change of address, change in status including but not limited to change in name, change in ownership. loss of license, certification status, or change in Medicare provider statuso and to notify DHS of any change In ownership information including change of stockholders of corporation status, financial interest or business relationships, if applicable. page 3 N. •To maintain the confidentiality of records and other information relating to recipients in accordance with applicable state and federal lav, rules, and regulations. O. That this provider agreement may be terminated by either party upon thirty (30) days notice to the other party, except that termination may be earlier for loss of..license., certification status, conviction of fraud, provider's breach of this agreement, loss of federal or state funds, change of federal or state laws that necessitate reduction or teroi.nation of the program or parts thereof, or for any actions or conduct specified in this department's agency rules relating to grounds for administrative sanctions. Termination of this agreement shall not affect the records retention or access to records requirements ander Paragraphs A and B above. That at the option of DES this agreement will become invalid upon change in ownership or cessation of operation as a business entity. P. To refund to the Medicaid program any overpayment, duplicate payment, or erroneous payment to which entitlement is not authorited under the Texas Medicaid Program. Q. if eligible to participate as a Medicare provider, agree to maintain provider enrollment and participation in the Medicare Program as a condition to participate in Medicaid. Should Medicare status be terminated, participation In Medicaid may be terminated effective the date of Medicare termination. (Does not apply to Hearing Aid, Eyeglass, EPSDT, Family Planning and Pharmacy providers.) R. That the recipient must be afforded freedom of choice unless otherwise limited by DHS or its designee in selecting services and/or a provider of services and that acceptance of services must be voluntary on the part of the recipient. S. To pay for all reasonable expenses of the Texas Department of Auman Services and/or its health insuring contractor, including the costs of counsel incident to the enforcement of payment of all my obligations as a Medicaid provider by any action or participation in, or in connection with, a case or proceeding under Chapter 7, 11, or 13 of the U. S. Bankruptcy Code, or any successor statute thereto. TEST: . Rane to -Boyd, City Secret4ry Signature) B.C. McMINN Typed or Printed Name of Official) MAYOR of the City of Lubbock (Title) January 12, 1989 (Date) TEXAS 77rT MEDICAID, PROVIDER ENROLLMENT APPLIC N ` MATERNITY CLINIC ALL MS=ORMATION MUST BE COMPLETED OR MARKED 'WA' AND CONTAIN A VALID StONATURE TO BE MOCESSED. PROVIDER OF SERVICE INFORMATION .APPLICANT NAY& (INDIV., 4MOUP, INC, BSA4HOW AS LICENSED) ADDRESS NO. 1 pwwly+ L"wien) .Xity of Lubbock Health Department 1902 Texasy, Aypniip y ramet " NL#dW Street Roo uft -TELEPHONE NUMBER "—Ce" (806 ) 762-6411, ext. 2899 or 2900 Lubbock Texas 79405 ` Chy staft VP TYPE OF PROVIDER tPRIMARY SPECIALTY) ADDRESS SO. t PesswA to AWreWISAN pewit T-94 Ambulatory Prenatal Care P.O. Box 2548 NrrbrStreet a A NAME OF RESPONSIBLE PHYSICIAN(S) Anthony B. Way, M.D. Lubbock Texas 794q8 NYSICIMi LICENSE I SOCIAL SECURITY # I TAX LD. # E0181 1-75-6000590-6 # 00 NOT WRITE IN THIS AREA To the best of my knowledge, the Information suppred on =this document Is accurate and complete and b hereby released to National Heritage Insurance Company and Texas Department of Human Services for the purpose of issuing a Provider Number. C"RIV Type Lose,ty snwe" oma. 1 1 1 1 w w l 1 I 1 l I 1 I I I j Signature of Applicant' °" RETURN FORM TO: - ,� Q•t-�+r 6•-•.� (Rita H a r n o n) N. f {.I.C. Provider Enrollment signature Assistant City Manager 10-19-88 11044 Research Blvd., Bldg.'C" Austin, Texas 78759 TItI. Date Department of Health and Human Services Form Approved Health Care Financing Administration OMB No. 0938-0086 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT 1.Identifying Information (a). Name of Entity D/B/A Provider No. Vendor No. Telephone No. 806 Street Address City, County, State Zip Code 1902 Texas K�enue Lubbock, Lubbock, -TI 79408 (b) (To be completed by HCFA Regional Office) Chain Affiliate No. LJLJLJLJLJ LBi Il. Answer the following questions by checking "Yes" or "No". If any of the questions are answered "Yes", list names and addresses of individuals or corporations under Remarks on page 2. Identify each item number to be continued. A. Are there any Individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the Involvement of such persons, or organizations in any of the programs established by Titles XVIII, XIX, or XX? Yes ©No LB2 B. Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVIII, XIX, or XX? ElYes F� No 1-63 C. Are there any individuals currently employed by the Institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ❑ Yes © No L64 Ill. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under "Remarks" on Page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks. Name Address EIN LBS (b) Type of Entity: ❑ Sole Proprietorship ❑ Partnership ❑ Corporation LBS ❑ Unincorporated Associations ❑ Other (Specify) (c) K the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks. Check appropriate box for each of the following questions (d) Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example, sole proprietor. partnership or members of Board of Directors.) K yes, list names, addresses of individuals and provider numbers. E]Yes M No LB7 Provider Number Form HCFA -1513 (5.66) Pace 1 Department of Health and Iluman Services Form Approved Health Care Financing Administration OMB No. 0938.0086 IV. (a) Has there been a change in ownership or control within the last year? ` If yes, give date Yes No LB8 (b) Do you anticipate any change of ownership or control within the year? If yes, when? Yes © No LB9 (c) Do you anticipate, filing for bankruptcy within the year? If yes, when? Yes No LB10 V. Is this facility operated by a management company, or leased in whole or part by another organization? If yes, give date of change in operations Yes ® No LB11 VL Has there been a change in Administrator, Director of Nursing or Medical Director within the last year? Yes ® No 111312 VII. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN) Name EIN # ElYes ® No L613 Address LB14 Vll. (b) If the answer to Question Vll.a. is No, was the facility ever affiliated with a chain? (If YES, list Name, Address of Corporation and EIN) Name EIN # Yes ® No LB18 Address LB19 VIII. Have you increased your bed capacity by 10% or more or by 10 beds, whichever is greater, within the last 2 years? If yes, give year of change ❑ Yes N No LB15 Current beds LB16 Prior beds LB17 WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR THE SECRETARY, AS APPROPRIATE. Name of Authorized Representative (Typed) Title Signature I Date Remarks CONTRACT FOR PARTICIPATION as OUTSTATION -BASE FOR ONE CLERK III under the TEXAS INCOME ASSISTANCE PROGRAM CITY OF LUBBOCK HEALTH DEPARTMENT 1902 Texas Lubbock, Texas 79408-9969 I. The Texas Department of Human Services, hereinafter referred to as the Department, is the single Texas State Agency responsible for administering (AFDC) Aid to Families with Dependent Children, Food Stamps and the Medical Assistance Program operated under Title XIX of the Federal Social Security Act. City of Lubbock Health Department, hereinafter referred to as the Health Department, desires to participate in an outstation -based program for one Clerk III. Therefore, the Department and the Health Department mutually agree to the terms and conditions set forth below: 2 II. The Health Department agrees: A. The primary duties of the assigned Clerk III will be to provide clerical assistance for the outstation -based eligibility workers, answer telephones, and serve as receptionist. The list of specific job duties of the assigned Clerk III is attached to this agreement. (Refer to Attachment #1.) The Health Department understands that applications for public assistance and food stamps in Texas must be voluntary. The outstation -based Clerk III cannot force an individual to apply and the process by which individuals are screened for classification cannot insist that they apply for public assistance. B. To provide needed services without discrimination on the grounds of race, color, national origin, age, sex, orhandicap. C. To notify the Department promptly of any change in status of the Health Department. D. To comply`,with all requirements of the Texas Aid to Families with Dependent Children and Medical Assistance Programs, and of this contract. 3 E. That in the event that federal or state laws or other requirements should be amended or judically 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 modifying amendments which should be needed to enable the substantial continuation of the services contemplated herein, because of such amendments or judicial interpretations, 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. To provide office space for the Clerk III, a telephone, a desk, a desk chair, two side chairs, typewriter and an adding machine. Clerical supplies will be provided by the Health Department in accordance with the Health Department's policy and procedures. All eligibility forms are to be provided, at no cost, by the Department necessary for the assigned Clerk III to discharge his/her responsibilities. (3 :-I G. To pay the Department 50% of the actual cost of salary and fringe benefits and the amount specified for supervisory cost for the position listed on the attached budget estimate. The Health Department further agrees that if the Clerk III receives a salary increase as the result of merit awards or statewide employee salary increases or if fringe benefits are increased, the amount to be paid shall be 50% of the salary and fringe benefits and specified supervisory cost actually paid by the Department. The amounts listed on the attached budget estimate are the Depart- ment's best estimates of the costs to be incurred under this contract, but are not controlling as to the amount to be paid hereunder. (Refer to Attachment #2.) A revised budget estimate may be substituted for existing budget estimates by exchange of letters from the Department and the Health Department. H. The Health Department will certify that no federal funds obtained expressly and solely for the funding of this program are being used in the Health Department's reimbursement to the Department. I. It is understood that the Health Department is paying for one half of the cost of a Clerk III and that the Department is paying the other half. The Clerk III will work forty (40) hours a week at the outstation location except for time needed for conferences, staff training, holidays, sick and annual leave, and time off to the Department for case maintenance. 5 The Department' agrees: A. The Department will hire and train a person to fill the following position: Clerk III. Such individual will be assigned to a supervisor within the Department for training, staff development and other supervision. The Department will retain all policy responsibility and will furnish all tools specific to eligibility determination, at no charge to the Health Department. Further, it is agreed and understood that the employee -employer relationship exists between the Department and the Clerk III and all benefits, rights and employee employer res�-bnsibilities will rest with the Department. B. To make their records pertaining to this contract available, at all reasonable times, to the Health Department or its agents for verification. The Department agrees not to hold the Health Department responsible for loss of or damage to the Department's property. C. To bill the Health Department on a monthly basis and allow approx- imately 30 for forwarding of payment. n M The Department and Health Department mutually agree: A. That should either party breach this contract, the nonbreaching party may, at their option, terminate this contract immediately without prior notice. B. This contract may be canceled at any time by mutual agreement, or if not by such agreement, either party may cancel this contract at any time by giving thirty (30) days written notice in advance to the other party. C. The terms of the contract shall be for six (6) months commencing on the effective date. The contract shall be automatically renewed and extended for one-year periods on any anniversary thereof unless amended or canceled by written notice given by either party as stated in (B) above. D. The effective date of this contract is March 1, 1989, through August 31, 1989. TEXAS DEPARTMENT OF HUMAN SERVICES By &14� VC4�� Charles Stevenson Acting Commissioner Date: ,REVIEWED BY LEGAL DIVISION CITY OF LUBBOCK HEALTH DEPARTMEMT C ► B. C. McMinn Mayor Date: /- Jo — � 9 ATTACHMENT I Clerk III Job Duties 1. Perform computer inquiry as necessary. 2. Types notice of applications (NOAs). 3. Duplicates material as necessary. 4. Prepares case folders. 5. Schedules appointments. 6. Answers telephones - provides information to clients on status of case, information needed, etc. 7. Types letters, memorandums, travels, etc. 8. Greets clents and routes appropriately. 9. Handles incoming verification and mail for hospital-based workers. C" 10. Performs quality assurance batching tasks for 1000A/Bs. 11. Calls and/or travels to income assistance offices to check on status of cases as necessary., Budget Estimate Clerk III City of Lubbock Health Department November 1, 1988 MONTHLY Salary Insurance Retirement Social Security Travel Supervisory Cost YEARLY Salary Insurance Retirement Social Security Travel Supervisory Cost Hospital's Costs 57.50 42.00 80.16 50.00 80.00 $909.66 Hosoital's Cost $ 7,200.00 690.00 504.00 961.92 600.00 960.00 $10,915.91 Texas Department Human Services COMMISSIONER P.O. Box 3700 BOARD MEMBERS Ron Lindsey Amarillo, TX 79116-3700 Rob Mosbacher 806/376-7214 Chairman, Houston Maurice L. Barksdale Arlington David Herndon Austin Glenn McMennamy Amarillo Ida K. Papert Dallas Louis P. Terrazas San Antonio R. Doug Goodman Public Health Administration City of Lubbock Health Department P.O. Box 2548 Lubbock, TX 79408-9961 Dear Mr. Goodman: I am attaching a fully executed copy of the contract for the DHS clerical employee at your facility. Thank you for your help in getting this contract signed. Sincerely, Joyce Clard Indigent Health Care Coordinator JB:7J RE CONTRACT FOR PARTICIPATION as OUTSTATIONED BASE FOR ONE CLERICAL EMPLOYEE CONTRACT #0205015 TEXAS INCOME ASSISTANCE PROGRAM with City of Lubbock Health Department 1902 Texas Lubbock, Texas 79408-9969 The Texas Department of Human Services, hereinafter referred to as the Department, is the single Texas State Agency responsible for administering (AFDC) Aid to Families with Dependent Children, Food Stamps, and the AFDC -related medical programs operated under Title XIX of the Federal Social Security Act. The Department's intent „in contracting with hospitals, clinics and medical providers for outstationed staff is to facilitate the process by which applicants and clients can apply for Medicaid. Outstationed staff can often see applicants sooner and provide additional assistance to clients in completing the application process than staff in regular TDHS offices. City of Lubbock Health Department, hereinafter referred to as the Contractor, desires to participate .in an outstation -based program for one clerical employee. Therefore, the Department and the Contractor mutually agree to the terms and conditions set forth below: 2 II. The Contractor agrees: A. The primary duties of the assigned clerical employee are described in Attachment #1. The Contractor understands that applications for public assistance and food stamps in Texas must be voluntary. This means the outstation -based staff cannot insist that individuals apply for public assistance. B. The Department retains all supervision of the assigned clerical employee for items such as time accountability, holidays, day-to-day supervision and general work activities assigned., C. To provide needed services without discrimination on the grounds of race, color, national origin, age, sex, or handicap. D. To notify the Department promptly of any change in status of the Contractor, including change in name, change in ownership or change in Medicaid provider status. E. To comply with all requirements of the Texas Aid to Families with Dependent Children and AFDC -related medical programs, and of this contract. F. That 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 modifying amendments which should be needed to enable the substantial continuation 3 of the services contemplated herein, because of such amendments or judicial interpretations, then, and in the 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. G. To provide appropriate office space for the clerical employee that is conducive to the client's right to confidentiality, typewriter, a telephone, a desk, desk chair, two side chairs, and an adding machine and clerical supplies. H. To pay the Department 50% of the actual cost of salary, travel and fringe benefits and the amount specified for supervisory cost for the individual assigned as outstation -based clerical employee. The Contractor further agrees that if the clerical employee receives a salary increase as the result of merit awards or statewide employee salary increases or if fringe benefits are increased, the amount to be paid shall be 50% of the amount actually paid by the Department. Attached is a budget estimate for a clerical employee which is the Department's best estimate of the cost to be incurred under this contract for each employee but is not controlling as to the amount to be paid hereunder. (Refer to Attachment #2.) A revised budget estimate may be substituted for existing budget estimate by a letter from the Department to the Contractor with attached revised budget estimate. 4 I. The Contractor will certify that no federal funds obtained expressly and solely for the funding of this program are being used in the Contractor's reimbursement to the Department. The Department agrees: A. To hire and train individuals to fill the clerical employee position. The clerical employee will be assigned to a supervisor within the Department for training, staff development, and all supervision. The Department will retain all policy responsibility. Further, it is agreed and understood that the employee -employer relationship exists. between the Department and the clerical employee and all benefits, rights and employee -employer responsibilities will rest with the Department. B. To provide information to medical providers based on current TDHS and regional policy regarding release of information. This includes information in case records and electronic information regarding a, client's eligibility and circumstances. C. To provide all Department eligibility forms at no cost necessary for the assigned clerical employee to discharge his/her responsibilities. 5 D. To bill the Contractor on a monthly basis and allow approximately 30 days for forwarding of payment. IV. The Department and Texas Tech Health Science Center.mutually agree: A. That should either party breach this contract, the non -breaching party may, at - their option, terminate this contract immediately without prior notice. B. This contact may be cancelled at any time by mutual agreement, or if not by such agreement, either party may cancel this contract at any time by giving thirty (30) days written notice in advance to the other party. C. The terms of the contract shall be one year commencing on the effective date. The contract shall be automatically renewed and extended for additional one-year periods on any anniversary thereof unless amended or cancelled by written notice given by either party as stated in (B) above. D. The effective date of this contract is December 1, 1989. TEXAS DEPARTMENT OF HUMAN SERVICES By Terry T e, R6gio&l Administrator Date: NOV 3 0 1988 CITY OF LUBBOCK By B. C. McMinn, Mayor Date: - AA -Cr9 Attachment #1 SPECIFIC JOB DUTIES 1. Types notice of applications (NOAs). 2. Duplicates material as necessary. 3. Prepares case folders. 4. Schedules appointments. 5. Answers telephones - provides information to clients on status of case, information needed, etc. 6. Types letters, memorandums, travels, etc. 7. Greets clients and routes appropriately. 8. Handles incoming verification and mail for hospital-based workers. 9. Performs quality assurance batching tasks for 1000A/Bs. 10. Perform computer inquiry to provide information to contractor based on current TDHS release of information policies. 11. Performs duties of unit secretary as necessary. 12. Provide information and referral to other sources of assistance in the community. 13. The same job performance standards will be expected of these hospital/clinic based clerical as clerical in any other TDHS office in the region. 14. Because these hospital -based -clerical are housed in space that belongs to a hospital or clinic, these clerks are considered to be located at "satellite IAS offices". Attachment #2 Salary Insurance Retirement Social Security Travel Supervisory Cost Total Cost Budget Estimate Clerical Employee 09-01-89 Yearly 15,120.00 2,123.16 1,058.40 1,905.12 1,200.00 5,037.12 26,443.80 Monthly 1,260.00 176.93 88.20 158.76 100.00 160.00 1,943.89 Contractor's Share (50%) 13,221.90 971.95 REQUEST TO CANCEL CONTRACT We, B. C. McMinn, Mayor of the City of Lubbock, and Terry Temple, Regional Administrator of Texas Department of Human Services, do hereby mutually agree to terminate the following contract: Contract.for Participation as Outstation Base for One Clerk III under the Texas Income Assistance Program and City of Lubbock Health Department Contract 021-88-P-00 30014 HB 02J5012 We are requesting the cancellation. of the above contract effective November 30, 1989, as we are entering into a new contract effective December 1, 1989. e• B. C. McMi n Mayor, City of Lubbock Nov 3 0 1989 Terry TpolLs Regiondl Administrator Texas Department of Human Services MEMORANDUI\ll TEXAS DEPARTMENT OF HUMAN SERVICES SUBJECT: Request for Approval and Signatures City of Lubbock Health Department Contract .0205015 Contract Period 12-01-89 (Self -renewing) TO: FROM: Legal Services Contract Services State Office 170-W DATE: November 27, 1989 Joyce Boland Indigent Health Care Coordinator Amarillo 005-2 7 Attached is a blue -backed copy of the above-named contract signed by the authorized representative of the contractor and the Regional Administrator. The effective date of this contract is 12-01-89. This contract is for the following: Standardizing all hospital-based contracts. A request to cancel the old contract is also attached. The regional contact person is Joyce Boland, STS 847-5211. o land JB:jj Attachments APPROVED: Regional Attatmey cc: Carrol Crum, 217-7 NOV 3 p jgn- AN EQUAL OPPORTUNITY EMPLOYER