TA Recipient Option 3 Request Form

The purpose of this survey is to gather information for organizations interested in the TA Marketplace but have not yet contracted or engaged with an MCP for Enhanced Care Management and/or Community Supports. A Recipient may only use this form if they have already begun to engage with MCPs to ensure that they are the type of organization that may be able to contract with an MCP.

After submitting this survey, DHCS will review your responses. You will receive an email notification from the TA Marketplace regarding their decision and any additional questions that may be required.

Below, you will find descriptions of Option 1 and Option 2 Recipient Submission Instructions. If you can complete an application for either of the two, please do so and DO NOT complete the following form.

If you have any questions or concerns regarding this survey, please email ta-marketplace@ca-path.com.
Option 1 "Contracted" Submission Instructions

Follow these instructions if you are contracted with a Managed Care Partner (MCP) (or other eligible entity) to provide ECM/Community Supports services:

Organizations that meet Option 1 eligibility are required to provide the completed signature page from their contract with Managed Care Partner (MCP) to document their eligibility to receive TA through the Marketplace. This contract must include signatures from both parties. In addition to submitting the signature page from your organization’s contract, organizations are required to submit a signed Contracted Attestation Form. This form only needs by be signed by your organization.

Please apply to be a TA Recipient here and select "Contracted" and upload the Contracted Attestation Form.
Option 2 "Planning to Contract" Submission Instructions

Follow these instructions if you are planning to contract with an MCP (or other eligible entity) to provide ECM/Community Supports services OR actively exploring the possibility of contracting with an MCP (or other eligible entity) to provide ECM/ Community Supports services:

Option 2 eligibility requires a signed "Planning to Contract" attestation form OR Letter of Intent with an MCP:

Attestation Instructions:

If you submit the attestation form, your organization signs page 2 and the Managed Care Partner (MCP) signs page 3 to show that your are currently engaged and working with them.

Letter of Intent Instructions:

If you have a letter of intent with the MCP, you may submit this as proof of your engagement but the letter must include at least the following: 1) the Name of Managed Care Organization, 2) Name of potential TA Recipient organization, 3) Language noting the TA Recipient is currently or intending to be a contracted provider for ECM and/or Community Support services with the MCP, and 4) Signature of authorized representative of MCP.

Please apply to be a TA Recipient here and select "Planning to Contract." Next, upload either the Planning to Contract Attestation Form OR Letter of Intent with an MCP
Name*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Name of Organization *
How did you hear about the TA Marketplace and the Option 3 Attestation option? If the answer is "TA Vendor," please name the Vendor.*
YesNo
YesNo
Please provide a list of the organizations you work with and specify if they provide ECM and/or Community Supports and their MCP contracting status (ex: 1. org name; ECM and contracted with MCP, 2. org name; community supports and not contracted with MCP). *
YesNo
YesNo
*PLEASE NOTE*

Organizations not contracted or planning to contract with MCPs to provide ECM and/or Community Supports are not eligible be a TA Recipient and are therefore not eligible to submit a request form.
YesNo
YesNo
YesNo
If they have responded, please provide an explanation as to why the MCP is not able to complete the Option 2 form. If they have not responded, please provide documentation below to the extent that you have communicated with the MCP. *
Please provide documentation to show how you have begun engagement with an MCP(s). This may include an email or other communication you have had with the MCP.

Cancelof
Organization Mission*
Organization Service Offerings (including populations served)*
For which county/counties does your organization provide services?*
Please provide a description of your current ECM and/or Community Support services. If you are not currently providing these services, please describe the services you will offer and explain how you intend to provide these services. Please see the links below for specific examples.*
Enhanced Care Management Services

Community Supports Services
Reason for seeking to access TA through the TA Marketplace, including specific types of TA or TA Projects your organization might pursue (if known at this time). *
Yes
Should be Empty:

*PLEASE NOTE*

PLEASE NOTE