Bid Event id number: evt0001028 KanCare Medicaid and chip capitated Managed Care Services Preface: High Priority Events and Items

SIGNATURE SHEET
Item: KanCare Medicaid and CHIP Capitated Managed Care Services
Agency: Kansas Department of Health and Environment – Division of Health Care Finance
Closing Date: January 13, 2012
By submission of a bid and the signatures affixed thereto, the bidder certifies all products and services proposed in the bid meet or exceed all requirements of this specification as set forth in the request and that all exceptions are clearly identified.
Legal Name of Person, Firm or Corporation
Mailing Address City & State Zip
Toll Free Telephone Local Cell: Fax
Tax Number

CAUTION: If your tax number is the same as your Social Security Number (SSN), you must leave this line blank. DO NOT enter your SSN on this signature sheet. If your SSN is required to process a contract award, including any tax clearance requirements, you will be contacted by an authorized representative of the Division of Purchases at a later date.
E-Mail
Signature Date
Typed Name Title
In the event the contact for the bidding process is different from above, indicate contact information below.
Bidding Process Contact Name
Mailing Address City & State Zip
Toll Free Telephone Local Cell: Fax
E-Mail
If awarded a contract and purchase orders are to be directed to an address other than above, indicate mailing address and telephone number below.
Award Contact Name
Mailing Address City & State Zip
Toll Free Telephone Local Cell: Fax
E-Mail
Pricing is available to political subdivisions. Yes ____ No ___

(Refusal will not be a determining factor in award of this contract.)
Agencies may use the Business Procurement Card for contract purchases. Yes ____ No ___

(Refusal will not be a determining factor in award of this contract.)

State of Kansas

Department of Administration

Division of Purchases
Supplier Diversity Survey Form
Why is the Division of Purchases requesting this information?
Current statutes governing the activities of the Kansas Division of Purchases do not include preferences or set-asides for Small Business Enterprises (SBEs). The Division of Purchases is interested in determining to what extent purchase orders and contracts are awarded to SBEs under existing work efforts. Please Note: You must submit this form with each bid opportunity.
Persons or concerns wishing to receive a Purchase Order or Contract Award resulting from this bid opportunity must provide the information contained in this document before the award is made. To help expedite this procurement, it is requested that you submit this form with your bid.
COMPANY DATA
Legal Company Name

Doing Business As (if applicable)

Federal Tax ID Number / FEIN

CAUTION: If your tax number is the same as your Social Security Number (SSN), you must leave this line blank. DO NOT enter your SSN on this sheet. If your SSN is required for any reason, you will be contacted by an authorized representative of the Division of Purchases at a later date.
Diversity Program Contact Name Title

Phone Number Fax Number

E-Mail Address Company Web

Address

City State Zip Code

Legal Structure: □ Corporation □ Partnership □ Non-Profit □ Sole Proprietorship □ LLC

Signature Date:
COMPANY DIVERSITY DATA
(A) Business Classification (See Appendix A for definitions):

Is your business a Small Business Enterprise (SBE) as defined by the SBA?

□ Yes □ No □ Don’t Know

Check all that Apply: □ Disabled (DIS) □ SBA-Small Disadvantage Business (SDB)

□ Veteran-Owned (VBE) □ Women-Owned (WBE) □ Service-Disabled Veterans-Owned (DVBE)

□ African American □ Native American □ Minority-Owned Business Enterprise (MBE)

□ Hispanic American □ Asian Pacific American □ Disadvantaged Business Enterprise (DBE)

□ Asian Subcontinent American □ Other: __________________________________________________________
(B) Has your Business Classification Status been certified by a state, municipal, federal or other certifying agency?

□ No □ Yes Certifying Entity:

Other State of Kansas Resources for Small Business Enterprises (SBE)

Kansas Department of Commerce

Office of Minority/Women Business Development

http://www.kansas.gov/ksbdc/

State of Kansas

Department of Administration

Division of Purchases

Supplier Diversity Survey Form
Appendix A

Definition of Terms
Small Business Enterprise / Concern (SBE)

SBEs are businesses that do not exceed the size standard for the product or service it is providing as measured by its employment and/or business receipts in accordance with the U.S. SBA numerical size standards. These standards are defined as FAR 52.219-8, 13 CFR Part 121 and 13 CFR 121.410.

Disadvantaged Business Enterprise (DBE)

DBEs are defined as a business which are (a) owned by socially disadvantaged individuals who have been subjected to racial or ethnic

prejudice or cultural bias because of their identity as a member of a group without regard to their individual qualities; or (b) owned by economically disadvantaged individuals whose ability to compete in the free enterprise system has been impaired due to diminished opportunities to obtain capital and credit as compared to others in the same line of business who are not socially disadvantaged.
Disabled Business Enterprise (DIS)

DIS businesses are at least 51% owned and controlled by one or more U.S. citizens who has a physical or mental impairment which substantially limits one or more of such person’s major life activities.

Small Disadvantage Business Concern (SDB)

SDB businesses are certified by the SBA as meeting the following criteria: (1) they are small business concern and (2) must be at least 51% owned and controlled by one or more U.S. citizens who are socially and economically disadvantaged. African Americans, Asian Pacific Americans, Asian Subcontinent Americans, Hispanic Americans and Native Americans are presumed to qualify as being socially disadvantaged. Other individuals can qualify if they show by a preponderance of the evidence that they are socially disadvantaged. In addition, the personal net worth of each eligible owner applicant must be less than $750,000, excluding the values of the applicant’s ownership interest in the business seeking certification and the owner’s primary residence. Successful applicants must also meet applicable size standards for small businesses in their industry. SDB regulations can be found in FAR 52.219-8 and 13 CFR parts 121 & 124.

Veterans-Owned Business Concern (VBE)

VBE businesses are at least 51% owned and controlled by one or more U.S. citizens who are Veterans of the U.S. Armed Forces. In the case of any publicly owned business, at least 51% of the stock is owned by one or more veterans and one or more veterans must control the management and daily business operation. The term “Veteran” means a person who served in the active military, naval or air service and who was discharged or released there from under conditions other than dishonorable. VBE regulations can de found in FAR 52.219-9 & 38 USC 101 (2).

Service-Disabled Veterans-Owned Business Concern (DVBE)

DVBE businesses are at least 51% owned and controlled by one or more U.S. citizens who are service-disabled Veterans of the U.S. Armed Forces. In the case of any publicly owned business, at least 51% of the stock is owned by one or more service-disabled veterans and one or more veterans must control the management and daily business operation. The term “Veteran” means a person who served in the active military, naval or air service and who was discharged or released there from under conditions other than dishonorable. The term “Service-Disabled” means a veteran of the U.S. Military Service has a service-connected disability with a disability rating of 0%-100%. In the case of permanent or severe disability, the spouse of caregiver of such a service-disabled veteran may control the management and daily operations. DVBE regulations can be found in FAR 52.219-9 & 38 USC 101 (2) & USC 101 (16).

Women-Owned Business Concern (WBE)

WBE businesses are at least 51% owned and controlled by one or more U.S. citizens who are female gender. In the case of any publicly owned business, at least 51% of the stock is owned by one or more women and one or more women must control the management and daily business operations. For Federal contracting regulations see FAR 52-219-8.

Minority-Owned Business Enterprise (MBE)

MBE businesses are at least 51% owned and controlled by one or more U.S. citizens belonging to certain ethnic minority groups. In the case of any publicly owned business, at least 51 % of the stock is owned by one or more minorities, and one or more minorities must control the management and daily business operations. “Ethnic Minority Groups” are people of Asian Pacific American, Asian Subcontinent American, African American, Hispanic American and Native American descent.

African Americans: People whose origins lay in any of the Black racial groups of Africa.
Asian Pacific Americans: People whose origins lay in Brunei, Burma, China, Guam, Indonesia, Japan, Kampuchea (Cambodia), Korea, Laos, Malaysia, Northern Mariana Islands, Republic of the Marshall Islands, Federated States of Micronesia, Republic of Palau (U.S. Trust Territory of the Pacific Islands), the Philippines, Samoa, Singapore, Taiwan, Thailand and Vietnam.
Asian Subcontinent Americans: People whose origins lay in Bangladesh, Bhutan, India, Pakistan, Sri Lanka or Nepal.
Hispanic Americans: People whose origins are in the South and Central America, Mexico, Puerto Rico, Cuba or the Iberian Peninsula (including Portugal).
Native Americans: American Indians, Inuit (Eskimos), Aleuts, and native Hawaiians of Polynesian ancestry.

Date of Last Update: March, 2007

Tax Clearance INSTRUCTIONS
PLEASE NOTE: This information has changed effective 10/27/09
A “Tax Clearance” is a comprehensive tax account review to determine and ensure that the account is compliant with all primary Kansas Tax Laws administered by the Kansas Department of Revenue (KDOR) Director of Taxation. Information pertaining to a Tax Clearance is subject to change(s), which may arise as a result of a State Tax Audit, Federal Revenue Agent Report, or other lawful adjustment(s).
To obtain a Tax Clearance Certificate, you must:

Go to http://www.ksrevenue.org/taxclearance.htm to request a Tax Clearance Certificate

Return to the website the following working day to see if KDOR will issue the certificate

If issued an official certificate, print it and attach it to your bid response

If denied a certificate, engage KDOR in a discussion about why a certificate wasn’t issued
Bidders (and their subcontractors) are expected to submit a current Tax Clearance Certificate with every event response.
Per KSA 75-3740-(c), the Director of Purchases may reject the bid of any bidder who is in arrears on taxes due the State of Kansas. The Secretary of the Kansas Department of Revenue is authorized to exchange such information with the Director of Purchases as is necessary to determine a bidder’s tax clearance status, notwithstanding any other provision of law prohibiting disclosure of the contents of taxpayer records or information.
Please Note: Individual and business applications are available. For applications entered prior to 5:00 PM Monday through Friday, results typically will be available the following business day. Tax clearance requests may be denied if the request includes incomplete or incorrect information.
Please Note: You will need to sign back into the KDOR website to view and print the official tax clearance certificate.
Information about Tax Registration can be found at the following website:

http://www.ksrevenue.org/busregistration.htm
The Division of Purchases reserves the right to confirm tax status of all potential contractors and subcontractors prior to the release of a purchase order or contract award.
In the event that a current tax certificate is unavailable, the Division of Purchases reserves the right to notify a bidder (one that has submitted a timely event response) that they have to provide a current Tax Clearance Certificate within ten (10) calendar days, or the Division may proceed with an award to the next lowest responsive bidder, whichever is determined by the Director of Purchases to be in the best interest of the State.

CERTIFICATION REGARDING

IMMIGRATION REFORM & CONTROL

All Contractors are expected to comply with the Immigration and Reform Control Act of 1986 (IRCA), as may be amended from time to time. This Act, with certain limitations, requires the verification of the employment status of all individuals who were hired on or after November 6, 1986, by the Contractor as well as any subcontractor or sub-subcontractor. The usual method of verification is through the Employment Verification (I-9) Form. With the submission of this bid, the Contractor hereby certifies without exception that Contractor has complied with all federal and state laws relating to immigration and reform. Any misrepresentation in this regard or any employment of persons not authorized to work in the United States constitutes a material breach and, at the State’s option, may subject the contract to termination and any applicable damages.

Contractor certifies that, should it be awarded a contract by the State, Contractor will comply with all applicable federal and state laws, standards, orders and regulations affecting a person’s participation and eligibility in any program or activity undertaken by the Contractor pursuant to this contract. Contractor further certifies that it will remain in compliance throughout the term of the contract.
At the State’s request, Contractor is expected to produce to the State any documentation or other such evidence to verify Contractor’s compliance with any provision, duty, certification, or the like under the contract.
Contractor agrees to include this Certification in contracts between itself and any subcontractors in connection with the services performed under this contract.

____________________________________________ ______________________

Signature, Title of Contractor date

VENDOR RESPONSE CHECK-LIST
The following items are provided to assist bidders in ensuring all requirements are met and all required submissions are included with the bid. Vendors are instructed to utilize this list and include it with their bid submission. In order to ensure fair and accurate evaluation, page numbers indicating the location of your response within your bid shall be included, where indicated.
Bidders must complete the page numbers required below.
Response Page No. Signature Sheet (RFP page 2)

Response Page No. Supplier Diversity Survey Form (RFP page 3)

Response Page No. Tax Clearance (including individual subcontractor

information)

(RFP page 5)

Response Page No. ___ Certification Regarding Immigration (RFP page 6)

Response Page No. Transmittal Letter (RFP Response Section)

Response Page No. Timeline (RFP Response Section)

Response Page No. Methodology (RFP Response Section)

Response Page No. Experience (RFP Terms and Conditions Section)

Response Page No. Qualifications (RFP Response Section)

Response Page No. References (RFP Response Section)

Response Page No. Subcontractor information, if applicable (RFP Response Section)

Response Page No. Exceptions to RFP noted, if applicable (RFP Instructions Section)

The following items have been submitted, as required:
Literature submitted as required (RFP Response Section)

Insurance/Bond information provided as required (RFP Terms & Conditions Section)

Proper number of copies submitted (RFP Response Section)

Cost and Technical packets separate (RFP Response Section)

Proprietary/Confidential information in separate packet (RFP Instructions Section)

Samples included, if required (RFP Specifications Section)

Media on separate CD/disks, if applicable (RFP Response Section)

Cost Sheet

Quarterly Report Contact Information (See RFP Specifications Section)
Contact Person for Quarterly Report Issues:

Company Name:

Mailing Address

City & State Zip Code

Toll Free Telephone Local Cell: Fax
E-Mail