1 Autism Application Technical Assistance Milwaukee County Department of Health and Human Services Disabilities Services Division June 12, 2008

2 DHHS Staff  Geri Lyday, Administrator, Disabilities Services Division  Liz Kraniak, Supervisor, Disabilities Services Division  Dennis Buesing, DHHS Contract Administrator  Diane Krager, DHHS Quality Assurance Coordinator  Wes Albinger, Contract Services Coordinator  Sumanish Kalia, Contract Administration CPA Consultant

3 Some minor revisions have been made to the application. If you have already completed the application, simply complete the changed sections on the new application, as indicated by sections with a shaded background.

4 National Provider Identifier: Covered entities under HIPPA are required to use NPIs to identify health care providers in standard transactions. Go to to learn more. Federal Employer Identification Number. This is the number the IRS issues for filing of payroll tax forms. If you have no employees, use your social security number. Being Medicare/Medicaid certified means you are able to bill Medicare/Medicaid directly for services. If Medicaid certified, please provide your number here.

5 Complete Section A for each site which is currently or proposed to be utilized for services More than one may apply Must have one of these boxes checked if your agency is a corporation

6 Please list agency and your position. For example, you provide in home physical therapy as a physical therapist for ABC agency, and you also work independently as a physical therapist providing in home physical therapy. This must be disclosed to ABC in writing, and a copy of the written notification must be provided with this application.

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10 By site, if applicable, per Service Description

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12 Applies to all coverage types

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14 Submit this Document with Completed Application. Retain a copy in Agency File. CERTIFICATION STATEMENT RESOLUTION REGARDING INSURANCE COVERAGE This is to certify that __________________________________________________________ (Name of Agency/Organization) (1) Will retain current Certificates of Insurance as required in the agency file as indicated above; and (2) Will ensure that Milwaukee County is added as an additional insured on Certificates of Insurance. (3) Will submit a copy of Insurance Certificate to: Dennis Buesing, DHHS Contract Administrator 1220 West Vliet Street, Suite 109 Milwaukee, WI (Authorized Signature of Person Completing Form)(Date) _______________________________________________________________________________

15 Submit this Document with Completed Application. Retain a copy in Agency File. MILWAUKEE COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES Certification Statement-Regarding Individual Service Provider Credential/Educational/&/or Experience as Required per MA Waivers Manual Standards CERTIFICATION STATEMENT REGARDING INDIVIDUAL PROVIDER QUALIFICATIONS This is to certify that __________________________________________________________ (Name of Agency/Organization) (1) will ensure that each service provider meets the minimum credential/educational/&/or experience as required per the MA Waivers Manual Standards, and (2) will retain proof of providers’ qualifications in respective personnel or agency file.

16 Submit this Document with Completed Application. Retain a copy in Agency File. MILWAUKEE COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES Certification Statement-Resolution Regarding Background Checks on Employees of DHHS Contract Agencies and Agencies/Organizations having Reimbursable Agreements that have Direct Regular Contact with Clients or Provide Direct Services to Children and Youth CERTIFICATION STATEMENT RESOLUTION REGARDING BACKGROUND CHECKS This is to certify that __________________________________________________________ (Name of Agency/Organization) (1) will comply with the provisions of ss and ss Wis. Stats. and HFS 12 and HFS 13, Wis. Admin. Code State of Wisconsin Caregiver Program (2) has received and read, “PROVISIONS OF RESOLUTION REQUIRING BACKGROUND CHECKS ON DEPARTMENT OF HUMAN SERVICES CONTRACT AGENCY EMPLOYEES PROVIDING DIRECT CARE AND SERVICES TO MILWAUKEE COUNTY CHILDREN AND YOUTH;” (3) has a written screening process in place to ensure background checks on criminal and gang activity for current and prospective employees providing direct care and services to children and youth; and, (4) is in compliance with the provisions of the Resolution requiring background checks. (Authorized Signature of Person Completing Form)(Date) _______________________________________ (Title)

17 Applicable to All Applicable only if you have 50 or more employees

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20 Other Contract Obligations  HFS 94 Patient Rights and Resolution of Patient Grievances (  Emergency preparedness and notification  Right of access and review of service documentation- agency, provider, client, and fiscal  Compliance with all laws and regulations for client confidentiality, including HIPAA  Compliance with Service Descriptions and Billing procedures in effect during the contract period, including revisions and updates

21 Overview of Budget Forms and Audit & Reporting Presented By: Dennis Buesing, DHHS Contract Administrator

22 Budget & Other Forms

23 Budget and Other Forms Form 1 Form 1 Program Volume Data and Unit Rate Calculation A separate Form 1 and Unit Rate must be developed for each Waiver service The term Program on all budget forms is inter- changeable with the term Waiver service. Programs/services funded by site must include separate Form1 for each site.

24 Budget and Other Forms Contd ….. Form 2 Form 2 & Form 2A Agency Employee Hours and SalariesForm 2A Use Form 2A only if agency has 14 or fewer employees otherwise use multiple copies of Form 2 with Form 2A being the final page. Column 1 - Position Title Enter the title of each position with any portion of its time directly allocated to a Waiver service – 1 line per employee. If a position is vacant, list the title of the position and "vacant" under it.

25 Budget and Other Forms Contd ….. Form 2 Form 2 & Form 2A Agency Employee Hours and Salaries, cont’dForm 2A Column 2 - Code Refer to Form 3S Control Acct No (Salaries). Use the same number as the last digit of the Sub-Account No. which corresponds to the Acct Description. (e.g., 1 for Executive Salaries, 2 for Professional Salaries, 3 for Clerical Staff Salaries, 4 for Technical Salaries, 5 for Maintenance Employee’s Wages, 6 for Temporary Clerical Help, 7 for Student Stipends, and 8 for Other Staff Salaries Note:The totals for salaries and employees health and retirement benefits should match respective totals for Control Accts 7000 & 7100 on Form 3S.

26 Budget and Other Forms Contd ….. Form 2 Form 2 & Form 2A Agency Employee Hours and Salaries, cont’dForm 2A Column 3 - Ethnic/Race and Gender Codes In column 3 enter the code representing the race or ethnicity of the employee. Ethnic/Race Codes:Gender Codes: A:Asian or Pacific IslanderF:Female B:BlackM:Male H:Hispanic I:American Indian W:White

27 Budget and Other Forms Contd… Form 2B Employee Demographic Summary (will fill automatically from data on Forms 2 & 2A) Form 2C Employee Hours Related Information Disclosure (only applies to agencies whose employees work for more than one related organization). Forms 3 Forms 3 & Form 3S Anticipated Program ExpensesForm 3S A separate budget tab must me used for each Waiver service. Fill Form 3S first! For 2007 Budget column use 2007 actual expenses. Control account subtotals will automatically come forward to corresponding control account on Form 3.

28 Budget and Other Forms Contd… Form 4 Form 4 & Form 4S Anticipated Program RevenueForm 4S A separate budget tab must me used for each Waiver service. Please Fill Form 4S first! For 2007 Budget column use 2007 actual revenue. Control account subtotals will automatically come forward to corresponding control account on Form 4.

29 Budget and Other Forms Contd….. Form 5 Form 5 Total Agency Anticipated Expenses Form 5A Total Agency Anticipated Revenue Form 5A Report Total Agency expenses on col. B, C and D. For col. C, 2007 budgeted expenses, use 2007 actual expenses Each respective service’s Form 3 expenses will automatically come forward to its respective column E1 thru E6 of Form 5. Report Total Agency revenue on col. B, C and D. Each respective service’s Form 4 revenue will automatically come forward to its respective column E1 thru E6 of Form 5A.

30 Budget and Other Forms Contd… Form 6 and 6D Through 6H Form 6 and 6D Through 6H Indirect Cost Allocation Plan To be submitted only if Agency provides more than one service to Milwaukee County, or one or more services to Milwaukee County and one or more services to other purchasers. Or if expenses are allocated to other functions like fund raising, or allocated between agency and an affiliate. Allocation Plan document Allocation Plan document with formulas are also available on the web.

31 Budget and Other Forms Contd… Linked Budget FormsLinked Budget Forms: All budget forms Form 1-Form 6 are now available as linked forms with formulas at: Agency can use these linked form to report up to 6 programs/services or sites without redoing Form 2, 5 and 6. Other forms are also linked so numbers automatically carry forward wherever they are repeated, or whenever calculated based on another form.

32 Audit & Reporting

33 Contract and Audit Requirements Contracts are required for Purchase of Care and Services over $10,000 under State Statute Audits are also required by State Statute (4)(c ), if the Care & services purchased with State funding exceeds $25,000 per year  Statutes require audits to be performed at least every other year. County contracts typically require annual audits  Standards for audits are found in DHFS/DWD/DOC Provider Agency Audit Guide, 1999 Revision (on line at  Non-profit providers that receive $500,000 or more in federal awards must also have audit performed in accordance with OMB Circular A-133 Audit of State, Local Governments, and Non-Profit Organizations. Fed audit requirements are for an annual audit

34 Audit Waiver  Statutes allow the Dept. to waive audits. Audits may not be waived if the audit is a condition of state licensure, or is needed to claim federal funding (Group Foster Care or CCI).  Waiver request can only be entertained if agency does not need to have an audit according to Federal Audit requirement.  Waivers need to be approved on case by case basis by regional office based on a risk assessment ( Funding <$75,000 is considered low risk)  DHHS has been approving Audit Waivers for Fee for Service contracts mainly on basis of economic hardship for providers that receive less than $150,000 from state and a county annually.  In case of small residential care providers ( Family Group Home and AFH) county has the authority to grant a waiver.  Waiver Form is available at the bottom of the web page at:

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36 Allowable Costs & Allowable Profits or Reserves  Per State Statute, ultimately, all agreements with Milwaukee County DHHS for client Care & Services paid with dept. funding are cost reimbursement contracts  For-profit providers may retain up to 10% in profit per contract; 7½% of allowable costs, plus 15% of net equity ( Allowable Cost Policy Manual, Section III.16) Allowable Cost Policy Manual  Nonprofit providers paid on a unit-times-unit-price contract (i.e. FFS) may add surpluses of up to 5% of contract amount to reserves each yr., up to a cumulative maximum of 10%.

37 Maintaining Financial Records  Both Federal and State contracting guidelines require provider agencies to maintain orderly books and adequate financial records.  Maintain a uniform double entry accounting system and a management information system compatible with cost accounting and control systems.  Providers should maintain an accurate and up-to-date general ledger and timely financial statements for management & board members  Financial Statements must be prepared in conformity with accounting principles generally accepted in the U.S. (GAAP) and on the accrual basis of accounting. Contractor must request, and receive written consent of County to use other basis of accounting in lieu of accrual basis of accounting.

38 Maintaining Financial Records  Amounts recorded in the general ledger should be adequately supported by invoices, receipts or other documentation  Providers should maintain a separate cost center or dept. in their general ledger for each contract, or program/facility within a contract  Whenever possible, costs should be charged directly to a contract, all other costs should be allocated using a reasonable and consistent allocation method and supported by an Indirect Cost Allocation Plan  Providers must not commingle personal and business funds. A separate checking account should be established & providers should not use personal credit cards for agency business  All Provider agencies should maintain and adhere to a board approved, up-to-date Accounting Policy & Procedures Manual

39 LINKEDLINKED FORM WITH SAMPLE DATA LINKED FORMS TUTORIAL

40 Contact Info: Program :  Liz Kraniak, Supervisor, Disabilities Services Division (414) Technical :  Diane Krager, DHHS Quality Assurance Coordinator (414)  Wes Albinger, Contract Services Coordinator (414) Budget:  Sumanish Kalia, Contract Administration CPA Consultant (414)

41 Thank You Have a nice day