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In-Home Services Proposal For Contract

The following information must be submitted to be considered for a participation agreement (contract) to provide in-home services. In order for the Missouri Medicaid Audit and Compliance Unit (MMAC) to conduct an efficient review of the business entity’s proposal, the proposal must meet the requirements as outlined in the Proposal Submission Requirements.

Section I: Forms

  1. IHS Proposal Checklist

  2. IHS Provider Profile
  3. Service Area Commitment (SAC) indicating the services and geographic areas (counties) the applying provider plans to serve.
  4. Business Organizational Structure (BOS) and all required documents as indicated by the section of the form completed. BOS Resource/Guide

Section II: Business Documentation

  1. Notification from the Internal Revenue Service of the business entity’s Federal Employer Identification Number.
  2. Notification from the Missouri Department of Revenue of the business entity’s Missouri Employer Identification Number.
  3. Current Vendor No Tax Due letter from the Missouri Department of Revenue. Information available at http://dor.mo.gov/forms/943.pdf. Make sure both the FEIN and state EIN are included on the letter. A Certificate of No Tax Due is NOT sufficient.
  4. Business license. If not required to be submitted, submit a statement of explanation.  Providers located in Unincorporated St Louis County do not have a business license BUT are required to register their entity as an operating business within the county.  This can be done through the St Louis County Assessor’s Office.  Link to form: St Louis County Mo.gov – Personal Property Registration Merchant or Manufacturer License
  5. Lease agreement or deed for the office location.
  6. Copy of EVV (Electronic Visit Verification or Telephony) contract. A quote is acceptable during the proposal process, but a contract must be in place prior to the final approval for participation. Refer to RSMo 208.909.1.
  7. National Provider Identification Number (NPI). Information is available at https://nppes.cms.hhs.gov. You must register under the business name as an Type 2 -Organizational entity.

Section III: Insurance and Bonding

  1. A Certificate of Insurance that meets the requirements of 19 CSR 15-7.021(18)(E). The certificate holder must be DSSMMAC, PO Box 6500, Jefferson City, MO 65102. Note: A quote or binder is acceptable during the proposal process but coverage must be in place prior to the award of a participation agreement.
  2. Employee Dishonesty Bond that meets the requirements of 19 CSR 15-7.021(18)(E).

Section IV: Business Plan

Applying providers must assure the MMAC that sufficient financial resources exist to provide continuous service to participants. The use of a business plan will help entities manage their business and ensure financial stability. For assistance in developing a business plan contact the Missouri Business Portal At a minimum, the Business Plan must include the following information:

Company – Correct legal name of entity as filed with the Missouri Secretary of State, Internal Revenue Service (“IRS”) and Missouri Department of Revenue (“DOR”) and used throughout the proposal. Description of the entity including if it is new or
existing, its history, purpose, etc.

Office/Plant – Office address and description of area and building. State whether the office is rented, leased or owned. If the business is located in a home, describe the space that is dedicated exclusively for business. Describe how the location meets the Americans with Disabilities Act’s accessibility requirements.

Personnel – Describe the prior experience, education and professional certifications/designations that qualify management to run this type of business. An attached resume to the business plan will also suffice.

Financial Management – Describe a plan for management of the financial resources of the entity.

  • Describe the qualifications of the person(s) handling the financial matters of the entity. Include the name(s) of the individual(s).
  • Include a budget for starting the business (onetime expenses to open your doors)
  • Include a Projected operating costs for the first year of operation (list the expected monthly/yearly expenses to keep your doors open for the first year)
  • Identify the sources of revenue to be used to start the business.

Section V: Training

1. A detailed training plan for new aides that meets the requirements of 192.2000 RSMo; 19 CSR 15-7.021(22); 13 CSR 70-91.010(3)(E) 1; and Section 2.4 of the Personal Care Manual and Section 2.6 of the Aged & Disabled Manual (MO HealthNet Division Personal Care and Aged and Disabled Waiver Provider Manuals). Do not submit training materials to be used.

  • Fully describe each section of the required training. Break out each section and provide a copy of the agendas with topic start and stop times. Agendas must include a short description of each topic as listed in SECTION 2.4 of the MO HealthNet Division Personal Care and Section 2.6 of the Aged and Disabled Waiver Provider Manuals.

2. A detailed training plan for aides that will deliver Advanced Personal Care that meets the requirements of 13 CSR 70-91.010(5)(E)2, 4, 5 & 6.

  • Provide a copy of the agenda with topic start and stop times. Agendas must include a short description of each topic. Fully explain APC task competency training.

3. A detailed in-service training plan that meets the requirements of 19 CSR 15-7.021(22)(B); 13 CSR 70-91.010(3)(E)2; Section 2.4 of the MO HealthNet Division Personal Care and Section 2.6 of the Aged and Disabled Waiver Provider Manuals.

  • Include a training schedule and a short description of each topic (can be found in Section 2.4 of the MO HealthNet Personal Care and Section 2.6 of the Aged & Disabled Provider Manuals). Include the procedures for ensuring all staff meet the attendance requirements.

4. Fully explain the procedures for waiving training in compliance with the requirements of 19 CSR 15-7.021(22)(A)3 and (23)(B); 13 CSR 70-91.010(3)(E)1 & 2 and (5)(E)2; Section 2.4 and 2.7 of the MO HealthNet Division Personal Care Manuel and Section 2.6 Aged and Disabled Waiver Provider Manuals.

  • Basic: 19 CSR 15-7.021(22)(A)3&4; 13 CSR 70-91.010(3)(E)(1)C&D, PC Manual 2.4
  • APC : 13 CSR 70-91.010(5)(E)(2)A&B; (5)(E)(5) PC Manual 2.7
  • In Service: 19 CSR 15-7.021(23)(B); 13 CSR 70-91.010(3)(E)2, PC Manual 2.4

5. Fully explain the documentation of training provided in compliance with 19 CSR 15-7.021(23)A & C; and 13 CSR 70-91.010(3)(E)4.

Section VI: Policies and Procedures

1. Policy and procedures for telephone contact with state agencies and participants during business hours and after business hours in compliance with the Program Requirements (2.3.a).

2. Policy and procedures for notifying participants of any changes in provider’s telephone number, address, and/or posted business hours in compliance with the Program Requirements (2.3.e & f).

3. Policy and procedures regarding elder abuse, neglect and exploitation including identification and reporting in compliance with 192.2400-192.2500 RSMo; 565.188, RSMo; 19 CSR 15-7.010(8); 19 CSR 15-7.021(18)(Q), Section 2.2 of the MO HealthNet Division Personal Care Provider Manual and the Program Requirements (5.12).

4. Policy and procedures for preventing and detecting conduct or actions that are improper or abusive of the MO HealthNet program, including reporting or resolution of improper or abusive conduct in compliance with 13 CSR 70-3.030(3) & (6). Improper conduct or actions include, but not limited to, misappropriation of participant property and/or funds, falsification of service delivery documents, falsification of agency records, etc.

5. Policy and procedures for informing participants and/or their representatives, and employees of the Client Rights, Code of Ethics and confidentiality statement in compliance with 19 CSR 15-7.021(18)(I) & (O) and (24)(B)5 and Section 2.2, 2.4 & 2.5 of the MO HealthNet Division Personal Care Provider Manual. The confidentiality statement must include both personal and medical information. Include a copy of the Client Rights, Code of Ethics and confidentiality statement to be distributed.

6. Policy and procedures for providing services to participants in compliance with 19 CSR 15-7.021(13). Include services that are prohibited.

7. Policy and procedures for performing nurse assessments/visits including the duties that must be performed in addition to the assessment of the participant in compliance with 13 CSR 70-91.010(3)(J); (6)A & D and Section 2.6 of the MO HealthNet Division Personal Care Provider Manual.

8. Policy and procedures for closing or discontinuing services to participants in compliance with 19 CSR 15-7.021(16) and 13 CSR 70-91.010(1)(C) .

9. Policy and procedures regarding staff providing services to their family members and transporting participants in compliance with 19 CSR 15-7.021(18)(G) and (13)B. Include procedures for education, prevention, detection, reporting violations and repayment of funds.

10. Policy and procedures for maintaining participant files in compliance with 19 CSR 15-7.021(24)(A) and the Program Requirements.

11. Policy and procedures for maintaining employee files in compliance with 19 CSR 15-7.021(24)(B), Section 2.5 of the MO HealthNet Division Personal Care Provider Manual and the Program Requirements.

12. Policy and procedures, including the hiring and continuing education requirements, for employing a designated manager in compliance with 19 CSR 15-7.021(14) & (19)(B) and 13 CSR 70-91.010(3)(G).

MMAC contracts with providers to deliver in-home services to the most vulnerable residents in the state. The premise of the contractual agreement is that the health, safety and welfare of the state’s participants will not be compromised and the provision of in-home services will be a safe alternative to more costly care. In an effort to maximize protection, certain individuals are prohibited from serving as employees or volunteers in the delivery of in-home services. Screening requirements are located in the statutes and regulations listed in In-Home Services’ General Information. It is the responsibility of the provider to ensure prospective employees are screened sufficiently to fulfill this expectation as evidenced by the provider’s policies and procedures submitted for items #13 through #16.

13. Policy and procedures for ensuring employees are registered, screened and employable per the Family Care Safety Registry (FCSR) and criminal background record checks are performed in compliance with 192.2495.3 RSMo; 210.900 – 210.936, RSMo and 19 CSR 30-82.060 and Program Requirements (4.6.3).

14. Policy and procedures for screening employees against the Employee Disqualification List (EDL) in compliance with 192.2490 RSMo and the Program Requirements (4.3 & 4.6.3).

15. Policy and procedures for maintaining documentation of FCSR, criminal background record and EDL screenings in compliance with 19 CSR 15-7.021(24)(C) and the Program Requirements (4.6.2).

16. A copy of the employment application that must be completed prior to participant contact. The application must be in compliance with 192.2490.1 RSMo; 19 CSR 15-7.021(24)(B)1; Section 2.5 of the MO HealthNet Division Personal Care Provider Manual and the Program Requirements (4.6.1).

17. Policy and procedures for ensuring provider acknowledges responsibilities regarding Electronic Visit Verification (EVV) in compliance with 13 CSR 70-3.320(2)A-L, include a list of services exempt from the use of EVV.

Section VII: Assurances

Complete both pages of the In-Home Services Assurances form. No additional documentation needs to be submitted with this form. However, applying provider’s policies and procedures must incorporate the assurances noted in items #4 through #25.

Section VIII: Staff Documentation & Screening Requirements

1. A current employment application or resume, any license(s) or degree(s) and the Certified Manager certificate for the Designated Manager. If the Certified Manager certificate was received more than twenty-four (24) months prior to the submission of this proposal, submit verification of attendance of annual division sponsored training.

2. A current employment application or resume, license(s), and degree(s) for the RN Supervisor.

3. Include in your proposal a list of the exact name, date of birth and social security number(s) used for all of the individuals listed below for screening purposes.

  • All owners with 5% or more direct or indirect ownership or control interest, all corporate Officers, Directors, and all members of LLCs. 
  • Executive Director
  • Designated Manager
  • Registered Nurse Supervisor
  • Each individual listed on the Business Organizational Structure
  • Managing Employees” as defined in 13 CSR 65-2.010(25)

Registration with Family Care Safety Registry (FCSR) is required for individuals that will have direct contact with Medicaid participants, including but not limited, to those listed above. The registration should now be completed online. Visit http://health.mo.gov/safety/fcsr/ for the online registry and instructions. Include the FCSR registration from DHSS with your proposal.

SUBMIT THE COMPLETED PROPOSAL TO

Mailing Address:
Missouri Medicaid Audit and Compliance
Provider Contracts
P.O. Box 6500
Jefferson City, MO 65102-6500		 Physical Address:
Missouri Medicaid Audit and Compliance
Provider Contracts
3418 Knipp Drive, Suite F
Jefferson City, MO 65109