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AMENDMENT #17 <br />Exhibit A, Statements of Work Page 22 of 42 Contract Number CLH18249-17 <br />Revised as of September 15, 2020 <br />Task <br />Number Task/Activity/Description *May Support PHAB <br />Standards/Measures Deliverables/Outcomes Due Date/Time Frame <br />Payment <br />Information and/or <br />Amount <br />3c Develop 2019-2020 MCHBG Action Plan for <br />October 1, 2019 through September 30, 2020 <br />using DOH-provided template. <br /> Submit MCHBG Action Plan to <br />DOH contract manager <br />Draft August 17, 2019 <br />Final- September 5, <br />2019 <br />must only reflect <br />activities paid for <br />with funds provided <br />in this statement of <br />work for the <br />specified funding <br />period. <br /> <br />See Program <br />Specific <br />Requirements and <br />Special Billing <br />Requirements. <br />3d Report activities and outcomes of 2018-2019 <br />MCHBG Action Plan using DOH- provided <br />template. <br /> Submit Action Plan monthly reports <br />to DOH contract manager <br />Monthly, on or before <br />the 15th of the following <br />month <br />3e Develop 2020-2021 MCHBG Action Plan for <br />October 1, 2020 through September 30, 2021 <br />using DOH-provided template. <br /> Submit MCHBG Action Plan to <br />DOH contract manager <br />Draft August 16, 2020 <br />Final September 6, 2020 <br />3f Report activities and outcomes of 2019-2020 <br />MCHBG Action Plan using DOH- provided <br />template. <br /> Submit Action Plan monthly reports <br />to DOH contract manager <br />Monthly, on or before <br />the 15th of the following <br />month <br />3g Report activities and outcomes of 2020-21 <br />MCHBG Action Plan using DOH-Provided <br />template. <br /> Submit Action Plan reports to DOH <br />contract manager <br />October 15, 2020 <br />January 15, 2021 <br />April 15, 2021 <br />July 15, 2021 <br />3h Develop 2021-2022 MCHBG Action Plan for <br />October 1, 2021 through September 30, 2022 <br />using DOH-Provided template. <br /> Submit MCHBG Action Plan to <br />DOH contract manager <br />Draft August 20, 2021 <br />Final September 10, <br />2021 <br />Children and Youth with Special Health Care Needs (CYSHCN) <br />4a Complete Child Health Intake Form (CHIF) <br />using the CHIF Automated System on all infants <br />and children served by the CYSHCN Program as <br />referenced in CYSHCN Program Manual <br />guidance. <br />Ensure client data is collected on all children <br />served by CYSHCN contractors, including <br />neurodevelopmental centers, regional <br />maxillofacial coordinators, and the DOH <br />Newborn Screening Program. <br /> Submit CHIF data into Secure File <br />Transport (SFT) Access Washington <br />website: https://sft.wa.gov <br />https://secureaccess.wa.gov <br />January 15, 2018 <br />April 15, 2018 <br />July 15, 2018 <br />October 15, 2018 <br />January 15, 2019 <br />April 15, 2019 <br />July 15, 2019 <br />October 15, 2019 <br />January 15, 2020 <br />April 15, 2020 <br />July 15, 2020 <br />October 15, 2020 <br />January 15, 2021 <br />April 15, 2021 <br />July 15, 2021 <br />Reimbursement for <br />actual costs, not to <br />exceed total funding <br />consideration. <br />Action Plan and <br />Progress Reports <br />must only reflect <br />activities paid for <br />with funds provided <br />in this statement of <br />work for the <br />specified funding <br />period. <br /> <br />See Program <br />Specific <br />Requirements and <br />Special Billing <br />Requirements. <br />4b Administer requested DOH Diagnostic and <br />Treatment funds for infants and children per <br />CYSHCN Program Manual when funds are used. <br /> <br />Identify unmet needs for CYSHCN on Medicaid, <br />and refer to DOH CYSHCN Program for <br /> Submit completed Health Services <br />Authorization forms and Central <br />Treatment Fund requests directly to <br />the CYSHCN Program as needed. <br />30 days after forms are <br />completed.