Community Partners Example MOU

7/29/2019 Community Partners Example MOU

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MEMORANDUM OF UNDERSTANDING

BETWEEN THE

HEALTH &HUMAN SERVICES COMMISSION

AND

COMMUNITYPARTNER

FOROnline Community-Based Application Assistance Services through the

YourTexasBenefits.com

For

Supplemental Nutrition Assistance Program, Temporary Assistance for Needy

Families, Medicaid, CHIP, Long-Term Care Services programs

THIS Memorandum of Understanding (the MOU) is entered into between the

HEALTH AND HUMAN SERVICES COMMISSION (HHSC), an administrative agency

within the executive department of the State of Texas with its central office at 4900 North Lamar

Boulevard, Austin Texas, 78751 and the Community Partner(CP) having an office atXXXXXXX, for the purpose of assisting with online community-based application assistance in

connection with the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistancefor Needy Families (TANF), Medicaid, Long-term Care Services program (LTC), and Childrens

Health Insurance Programs (CHIP). HHSC and CP may be referred to in this agreement

individually as a Party or collectively as the Parties.

I. PURPOSE

The purpose of the Community Partner Program is to strengthen community partnerships

with organizations that assist people in applying for social service programs using theonline application. The CP project will help increase awareness and utilization of online

applications and case information that will build efficiencies and benefits for the people,

the state and community partners.

II. GOALS

The Online Application Assistance project aims to:

x Strengthen community relationships

x

Work together to provide information and supportx Provide report and tracking capabilities to community partners

x Facilitate the application process for people

x Increase access for people through the Internet reducing the need to go to offices

x Increase access to the online application and/or provide application assistancethrough local organizations

x Streamline the eligibility process

x Reduce data entry for HHSC staff

x Complete online applications facilitate eligibility determinations


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III. AUTHORITY

HHSC is authorized to disclose confidential information from SNAP, TANF, Medicaid,

and CHIP programs based upon client consent and/or as permitted by 7 C.F.R. Section272 (SNAP); 45 C.F.R. Section 205.50 (TANF); 42 C.F.R. Section 431.300 et. Seq.

(Medicaid); 42 C.F.R. Section 457.1110 (CHIP).

IV. AGREEMENT

Community Partnerlocated atXXXXXX, agrees to serve as an access point for applicantsand recipients of Health and Human Services benefits programs. For purposes of this

agreement, Health and Human Services benefits programs include the Medicaid program,

Childrens Health Insurance Program (CHIP), the Supplemental Nutrition Assistance

Program (SNAP), the Temporary Assistance to Needy Families (TANF) program, the

Long-term Care Services program (LTC) and any other public assistance benefitsprogram for which an individual may complete an online application through the

YourTexasBenefits.com website.

V. PARTNER LEVELS

The CP agrees to provide at least one of the following levels of Service:

Level I CP (Self Service Site)

The CP will provide access to a computer with an internet connection to applicants andrecipients seeking to apply online for HHSC social service programs (such as SNAP,TANF, Medicaid, CHIP and LTC) using the Your Texas Benefits website. The

Community Partner can agree to provide any of the following additional resources to

applicants and recipients: printer, copy machine, fax machine, telephone, and/ordocument scanner. In providing Level I Services, the CP is acting on behalf of the

applicant or recipient and not on behalf of HHSC.

Level II CP (Assistance Site)

The CP will provide access to a computer with an internet connection to applicants and

recipients seeking to apply online for HHSC social service programs (such as SNAP,

TANF, Medicaid, CHIP and LTC) using the Your Texas Benefits website. Withrecipient/applicant consent, the CP will provide staff and/or volunteers to assist recipients

and applicants with understanding and completing the online application process. The

Community Partner may also, with client consent and HHSC authorization, help researchthe clients case status information. This research will be done by using a Community

Partner inquiry function of the Self Service Portal with log-on information supplied by

the client. This service will assist clients to determine where in the process their current

application is, the benefits they are currently receiving and when their benefit programstarted or will end. The Community Partner can agree to provide any of the following


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additional resources: printer, copy machine, fax machine, telephone, and/or document

scanner. The CP will provide assistance and access to a computer after receiving written

consent (on Form 1826, attached as Attachment A) from the applicant or recipient. Inproviding Level II Services, the CP is acting on behalf of the applicant or recipient and

not on behalf of HHSC.

The CP will complete Attachment B to indicate the levels of service they will provide

and other organization details relating to their Online Application Assistance partnershipwith the HHSC.

VI. HHSC: STATEMENT OF DUTIES

HHSC in support of the community partners that assist people in applying for benefits

through this MOU, will provide to the CP:

a) Initial training and training updates as needed on use of the Your Texas Benefitsonline application web site, Application assistance for Level II Service, Casestatus inquiry for Level III, general information about the HHSC benefit

programs, information security, training on confidentiality and any other

appropriate training determined necessary by the HHSC;

b) The standards and process for certifying staff and volunteers providingapplication assistance;

c) Materials such as the HHSC signage, applications, brochures, etc; and access tosupport for website issues, application questions and client case issue resolution;

d) Identification of the CP via the Your Texas Benefits public Internet web page as aCommunity Partner willing to assist applicants or recipients as a Self Service Site

or an Assistance Site.

e) Provide a process for CPs to request information and technical support.

VII. CP: STATEMENT OF DUTIES

a) Service Duties.

The CP, in support of the HHSCs efforts to provide awareness of and access to socialservice programs through the YourTexasBenefits.com website will:

i) At no cost, provide applicants and recipients access to a computer with an internetconnection; and assist applicants and recipients in applying for the HHSC social

service programs if the CP provides Level II or III assistance services;


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ii) Prominently display appropriate HHSC benefit materials such as HHSC signage,applications, brochures, etc.;

iii)Ensure all employees, agents, staff, volunteers, or subcontractors acting on behalfof the CP in providing Services are trained and annually retrained on use of theYour Texas Benefits online application web site, Application/Case assistance for

Level II and III services (as applicable), general information about the HHSC

benefit programs, information security, confidentiality and any other appropriate

training determined necessary by the HHSC;

iv)Refer people to other public assistance programs, as available; and

v) Allow the HHSC access to monitor partner sites and activities for compliance tothe rules of this MOU.

vi)For Level II and Level III CPs, the CP will obtain Applicant Consent on theHHSC form H 1826 CP (Attachment A).

vii)Retain records for seven years of Applicant Consent and lists of employees,volunteers or staff authorized to access or assist applicants to access the

yourtexasbenefits.com Self Service Portal.

b) Compliance Duties.

i) To the extent applicable, the CP is responsible for compliance with all laws,regulations, and administrative rules that govern the performance of the Services

including, but not limited to, all State and Federal tax laws, State and Federal

employment laws, State and Federal regulatory requirements, and licensingprovisions.

ii) To the extent applicable, the CP agrees to assure each of its employees, agents,volunteers or subcontractors who provide Services under the MOU are properly

licensed, certified, and/or have proper permits to perform any activity related to

the Services and will monitor to ensure all trainings and certificationsrequirements are met.

iii)To the extent applicable, the CP warrants that the Services comply with allapplicable Federal, State, and County laws, regulations, codes, ordinances,

guidelines, and policies. The CP will indemnify the HHSC from and against any

losses, liability, claims, damages, penalties, costs, fees, or expenses arising fromor in connection with the CPs failure to comply with or violation of any such

law, regulation, code, ordinance, or policy.

c) Security and Confidentiality Duties.

i) Neither the CP nor the HHSC are the Business Associate of the other, as definedby the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C.

1320d, et seq., and regulations adopted under that act. The CP is solely acting
http://www.ssa.gov/OP_Home/ssact/title11/1171.htmhttp://www.ssa.gov/OP_Home/ssact/title11/1171.htm


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on behalf of the people it provides Level II or Level III Services to, based on the

consent of those individuals described above.

ii) The CP acknowledges that the information it receives based on individual consentfor assistance for Level II and Level III services is highly confidential andsensitive. Certain HHSC information may also be highly confidential. The CP

agrees that the CP, its staff, employees, agents, volunteers and subcontractors

providing Services on the CPs behalf under this agreement will treat all

individual and HHSC information received as confidential to the extent thatconfidential treatment is provided under law and regulations if held by the HHSC.

iii)The CP will access, maintain, retain, modify, record, store, destroy, or otherwisehold, use, or disclose confidential information only in a secure fashion. For

purposes of this Agreement, a secure fashion means that the confidentialinformation is rendered unusable, unreadable, or indecipherable to unauthorized

persons by either encryption or destruction such that the confidential information

cannot be read or otherwise reconstructed. For example the CP will require and

ensure all browser activity and history be cleared and deleted between eachapplicant or recipient the CP assists under Level I or Level II Services, and all

paper copies of applicant or recipient information is adequately private and

secure.

iv)The CP will immediately report to the HHSC any actual, potential or attemptedunauthorized access, use, disclosure, modification, loss or destruction of

confidential information, which has the potential for jeopardizing the

confidentiality, integrity or availability of the confidential information

(collectively an incident). The CP will cooperate fully with the HHSC inaddressing any such unauthorized acquisition, access, use or disclosure, or

suspected or potential unauthorized acquisition, access, use or disclosure ofconfidential information to the extent and in the manner determined by theHHSC. The CPs obligations in this regard begin at the discovery of an Incident

and continues as long as related activity continues, until all effects of the incident

are mitigated, to the HHSCs satisfaction.

v) The CP will ensure its officers, directors, employees, agents, subcontractors andvolunteers are adequately trained and educated and periodically retrained on theimportance of protecting confidential information and promptly reporting any

Incident.

vi)The CP acknowledges any and all unauthorized disclosures or uses of applicantand recipient confidential information or the HHSCs confidential informationmay cause immediate and irreparable harm to individuals or the HHSC and may

constitute a violation of State or federal laws. If the CP, its employees, volunteers,

subcontractors, or agents should use or disclose such confidential information to

others without authorization, the HHSC will immediately be entitled to injunctiverelief or any other remedies to which it is entitled under law or equity without

requiring a cure period.


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VIII. CIVIL RIGHTS

To the extent applicable, the CP agrees to comply with state and federal anti-

discrimination laws, including without limitation:

x Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.);

x Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794);

x Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.);

x Age Discrimination Act of 1975 (42 U.S.C. 6101-6107);

x Title IX of the Education Amendments of 1972 (20 U.S.C. 1681-1688);

x Food Stamp Act of 1977 (7 U.S.C. 200 et seq.); and

x The HHSCs administrative rules, as set forth in the Texas Administrative Code,to the extent applicable to this Agreement.

a) The CP agrees to comply with all applicable amendments to the above-referenced

laws, and all applicable requirements imposed by the regulations issued pursuantto these laws. These laws provide in part that no persons in the United States may,on the grounds of race, color, national origin, sex, age, disability, political beliefs,

or religion, be excluded from participation in or denied any aid, care, service or

other benefits provided by Federal or State funding, or otherwise be subjected to

discrimination.

b) To the extent applicable, the CP agrees to comply with Title VI of the CivilRights Act of 1964, and its implementing regulations at 45 C.F.R. Part 80 or 7

C.F.R. Part 15, prohibiting the CP from adopting and implementing policies and

procedures that exclude or have the effect of excluding or limiting the

participation of people in its programs, benefits, or activities on the basis ofnational origin. The CP agrees to provide alternative methods for ensuring access

to services for applicants and recipients who cannot express themselves fluently

in English.

c) The CP agrees to ensure that its policies do not have the effect of excluding orlimiting the participation of persons in its programs, benefits, and activities on the

basis of national origin.

d) The CP agrees to take reasonable steps to provide services and information, bothorally and in writing, in appropriate languages other than English, in order to

ensure that persons with limited English proficiency are effectively informed and

can have meaningful access to programs, benefits, and activities.

e) The CP agrees to comply with Executive Order 13279, and its implementingregulations at 45 C.F.R. Part 87 or 7 C.F.R. Part 16. These provide in part that any

organization that participates in programs funded by direct financial assistancefrom the United States Department of Agriculture or the United States

Department of Health and Human Services shall not, in providing services,

discriminate against a program beneficiary or prospective program beneficiary on

the basis of religion or religious belief.


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Nonwaiver. Failure of either party to insist on performance of any term or condition of

this MOU or to exercise any right or privilege hereunder shall not be construed as a

continuing or future waiver of such term, condition, right or privilege.

XII. NOTICES

All written notices, requests and communications, unless specifically required to be given

by a specific method, may be sent to the address or telefacsimile number set forth below,by one of the following methods: (1) delivered in person, obtaining a signature

indicating successful delivery; (2) sent by a recognized overnight delivery service,

obtaining a signature indicating successful delivery; (3) sent by certified mail, obtaining asignature indicating successful delivery; or (4) transmitted by telefacsimile, producing a

document indicating the date and time of successful transmission. Either party may atany time give notice in writing to the other party of a change of address or telephone ortelefacsimile number.

To the CP

:

Address

Name/Title

City, State ZIP

Telephone:

Telefacsimile:

To the HHSC

Marc WernliTexas Health and Human Services Commission

9013 Tuscany Way, Suite 100

Austin, Texas 78754Telephone: 512-919-5744

Telefacsimile: 512-928-1828


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XIII. GENERAL TERMS

Amendments. This MOU may be amended or modified by the consent of both parties at

any time during its term. Amendments to this MOU must be in writing and signed by theHHSC and the CP. No change in, addition to, or waiver of any term or condition of this

MOU shall be binding on the HHSC unless approved in writing by an authorized

representative of the HHSC

.

XIV. ASSIGNMENT

Neither party shall assign any right, benefit or duty under this MOU without the other

partys prior written consent.

TEXAS HEALTH AND HUMAN COMMUNITY PARTNER

SERVICES COMMISSION

By: ______________________________ By: ______________________________

NAME: Liz Garbutt NAME:

TITLE: Director TITLE:

Office of Community Access


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ATTACHMENT A

Level II Consent Form

Sharing Facts About Me and My Case

Case name: _______________________________________________ Case number (if any) ____________________

By signing this form, I understand ______________________________________ is helping me apply for HHSC benefitsby allowing me to:

x Use a computer that connects to the Texas Health and Human Services Commissions (HHSC) Your Texas Benefits website.Using this website I can apply for HHSC benefit programs such as SNAP, TANF, Medicaid, and the Childrens HealthInsurance Program (CHIP).

x Work with staff or volunteers who will help me understand and apply for HHSC benefits through the Your Texas Benefitswebsite. I know that when I am applying through this website, I may need to share facts about myself and my family, includingfacts about my health, with the agency listed above so they can help me fill-out and submit the application form.

x Use other equipment I might need to apply through the Your Texas Benefits website. This other equipment might be a printer,copy machine, fax machine, phone, or paper scanner. I understand that by using these items I may need to share facts aboutmy health and my case with staff or volunteers for the agency listed above.

I understand that the Community Partner agency listed above is acting on my behalf and is not acting on behalf of HHSC.

I know that I do not have to sign this form to:

xApply for HHSC benefits.

xBe approved for HHSC benefits.

xGet services through HHSC benefits.

However, I understand that to get help applying for HHSC benefits from the Community Partner agency listed above, I mustunderstand whats in this form and sign it.

My Signature Date

Note: If you cannot sign your name, you must make a mark (X) and two witnesses to that mark must sign below. We canaccept one witness signature in cases where it is not possible to get two witness signatures but you must document thereason in the case record.

Witness Signature Date



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Level III Consent Form

Sharing Facts About Me and My Case

SECTION I

Case name: __________________________________________________ Case number (if any) ____________________

By signing this form, I understand ___________________________________ is helping me apply for HHSC benefits by

allowing me to:

x Use a computer that can connect to the Texas Health and Human Services Commissions (HHSC) Your Texas Benefits websitUsing this website I can apply for HHSC benefit programs such as SNAP, TANF, Medicaid, and the Childrens Health InsurancProgram (CHIP).

x Work with staff or volunteers who will help me understand and apply for HHSC benefits through the Your Texas Benefitswebsite. I know that when I am applying through the website, I may need to share facts about myself and my family, includingfacts about my health, with the agency listed above so they can help me fill-out and submit the application form.

x Use other equipment I might need to apply through the Your Texas Benefits website. This other equipment might be a printer,copy machine, fax machine, phone, or paper scanner. I understand that by using these items I may need to share facts aboutmyself and my family, including facts about my health and my case, with staff or volunteers for the agency listed above.

x Work with staff or volunteers who will help me find facts about my case or my application using the Your Texas Benefits websit

This includes help finding the status of my application and facts about HHSC benefits Im getting, including when my benefits wstart or end. I understand that to get this help I will need to share with staff and volunteers my username, Social SecurityNumber or Case number, and I may need to share facts about myself and my family, including facts about my health and mycase.

I understand that the agency listed above is acting on my behalf and is not acting on behalf of HHSC.

I know that I do not have to sign this form to:

Apply for HHSC benefits.

Be approved for HHSC benefits.

Get services through HHSC benefits.

However, I understand that to get help applying for HHSC benefits from the Community Partner agency listed above, I mustunderstand whats in this form and sign it.

My Signature Date

SECTION ll

I authorize HHSC to share facts about my case with the following person or agency. I understand the facts aboutmy case may include private facts about my health.

Case Name:

Community Partner Agency (if any):

Address:

City, state, ZIP:

Phone number:


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Check one of the following:

Share all of my case record.

Share only the following facts from my case record:_________________________________________________________________________________________________________

__________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Reason for sharing case record:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

___________________________________________________________________________

This agreement ends on: _________________________________________________________________

(Give date or describe when you want your permission to stop)

Signature Section

My Signature Date

If you are signing as the Legally Authorized Representative (defined as those persons listed below) of the personwhose case record is being shared, check the box next to the phrase that best describes your authority to act for theperson. We also may need to see proof of this relationship.

___A parent or legal guardian if the person is a minor.___A legal guardian if a judge has ruled the person is not competent to manage their own personal affairs.___An agent named as the persons durable power of attorney for health care.___The persons court-appointed attorney ad litem.

___The persons court-appointed guardian ad litem.___A personal representative or statutory beneficiary if the person is deceased.___An attorney retained by the person or by another person listed on this form.___If the person is deceased; their personal representative must be the executor, independent executor,

administrator, independent administrator, or temporary administrator of the estate.

Note: If you cannot sign your name, you must make a mark (X) and two witnesses to that mark must sign below. We canaccept one witness signature in cases where it is not possible to get two witness signatures but you must document thereason in the case record.



SECTION III

You can change your mind. You can withdraw permission and tell us you do not want the agency listed above to sharefacts about your health or your HHSC benefits case, unless the agency listed above has already shared those facts basedon your permission. You must withdraw your permission in writing to the Community Partner at:

______________________________________________________.

(Community Partner address)


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ATTACHMENT B

Community Partner Online Application Assistance Project

Service Level and Organization Information

[INSERT CP NAME AND ADDRESS]

Internet Listing

The name and street address of the Community Partner may be identified as an Self Service or Assistance Site

and listed on the Community Partner Program web pages.

You agree to have your organizations telephone and fax number listed on the Your Texas Benefits web page.

Yes No

Please select the level of customer access that your organization can provide:

PUBLIC

(services available for general public and new clients/customers)

LIMITED

(services available for agency clients/customers only)

Service Level

The Community Partner agrees to provide at least one of the following Levels of Service:

Partnership Level I: Self Service Site

This option is recommended for organizations that have computers for people to use. For example, a public

library may have computers available for people to apply online for HHSC benefit programs.

Computer

Provide people with access to a computer and an internet connection to apply

online for HHSC benefits without receiving help.

Informational Materials

Display posters and other printed materials aboutYourTexasBenefits.com.

Partnership Level II: Assistance SiteThis option is recommended for organizations that have employees and volunteers available to help people with

the online application and help people manage their benefit case/s.

Computer

Provide people with access to a computer and an internet connection to apply

online for HHSC benefits without receiving help.
https://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsp


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Informational Materials

Display posters and other printed materials aboutYourTexasBenefits.com.

Application Assistance

Provide employees and volunteers certified to help people with completingand submitting HHSCs online application. The Community Partner must first

obtain the applicants signed permission.

Case Assistance

Provide employees certified to log in toYourTexasBenefits.comto help clients

research information about their HHSC benefit cases, including case status, the

benefits they are receiving, and when their benefits started and will end. The

Community Partner must first obtain the applicants signed permission.

This service is best suited for organizations that provide case management

services to clients and families, have demonstrated a positive history of

protecting client information, and have employees that are highly accountable.

Monitoring

Submit regular reports to HHSC verifying that employees with log in access to

YourTexasBenefits.comare only viewing information of clients that have

signed a Client Consent Form.

Because Case Assistance service allows partners increased access to confidential information of applicants andclients, HHSC will determine an organizations suitability to certify employees to provide Case Assistance and

will electronically monitor the activity of employees logged in toYourTexasBenefits.com.

The access level(s) of our organization is/are:

Level I Partner Level II Partner

Additional Services

Your organization can provide additional services. The other services provided by your organization include:

Scanner Phone Copy Machine Printer Fax Machine
https://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsphttps://www.yourtexasbenefits.com/ssp/SSPHome/ssphome.jsp


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Community Partner Site Manager

HHSC requires that your organization designate a person to serve as the point of contact for HHSC and

manages your organizations participation in the Community Partner Program.

Initial Requirements

The person listed below will serve as the contact for HHSC and shall be responsible for following initial

requirement to get an organization starting as a Community Partner:

x Complete Web-Based Training Lessons

x Request Community Partner Login Accounts

x Certify Employees and Volunteers as Your Texas Benefits Navigators

Ongoing Requirements

After completing the initial requirements for getting a Community Partner started with the program, the site

manager has six ongoing areas of responsibility:

x Manage Login Access Towww.yourtexasbenefits.com

x Manage the Certification Process

x Maintain Client Consent Records

x Notify HHSC of Unauthorized Disclosure of Information

x Provide Program Updates to Employees and Volunteers

x Update Community Partner Information

NAME & TITLE PHONE NUMBER FAX NUMBER

E-MAIL ADDRESS

ORGANIZATION MAILING ADDRESS: NUMBER STREET CITY ZIP CODE
http://www.yourtexasbenefits.com/http://www.yourtexasbenefits.com/http://www.yourtexasbenefits.com/http://www.yourtexasbenefits.com/

Community Partners Example MOU

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