HomeMy WebLinkAboutC-5747 - Agreement for Recovery of Administrative Costs for Implementation and Recovery of Ground Emergency Medical Transportation PaymentsAGREEMENT FOR RECOVERY OF ADMINISTRATIVE COSTS
FOR IMPLEMENTATION AND RECOVERY OF GROUND EMERGENCY
MEDICAL TRANSPORTATION PAYMENTS
This agreement is made and entered into on this � � day of S�P T 201_5
between the Sacramento Metropolitan Fire District, ("Metro Fire") a political subdivision
of the State of California and, the City of Newport Beach, a municipal corporation and
charter city ("GEMT Transporter").
WHEREAS, the State Department of Health Care Services ("State") has
developed and is administering the Medi -Cal Ground Emergency Transportation
Supplemental Reimbursement Program pursuant to the California Welfare and
Institutions Code Section 14105.94 ("State Code") and State Plan Amendments ("SPA")
09-024; and,
WHEREAS, the State has entered into an agreement with Metro Fire for
administrative services related to the Medi -Cal Ground Emergency Transportation
Supplemental Reimbursement Program pursuant to the State Code and SPA 09-024
("State Agreement"), which is attached hereto as Exhibit A, and is incorporated as if set
forth fully herein; and,
WHEREAS under the State Code an eligible provider of ground emergency
medical transportation services may be entitled to supplemental Medi -Cal
reimbursement as set forth in those provisions; and,
WHEREAS an eligible provider as described in the State Code is required to
enter into an agreement to reimburse the State for implementing and administering the
Supplemental Reimbursement Program as a condition of receiving supplemental
reimbursement pursuant to the State Code; and,
WHEREAS pursuant to the State Agreement, Metro Fire has been designated by
the State to recover the administrative and implementation costs required to be paid by
eligible providers under the State Code; and,
WHEREAS Metro Fire will incur administrative and other costs in connection with
billing GEMT Transporter for costs, and has assumed the risk of payment, or non-
payment of the costs from GEMT Transporter;
NOW therefore, the Parties enter into this Agreement for the purpose of setting
forth the manner and terms for payment of administrative costs by the eligible GEMT
providers to Metro Fire, under the following terms and conditions.
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I. PARTIES
Metro Fire is a designated agency for the collection of costs related to the GEMT
Supplemental Medi -Cal Reimbursement Program. GEMT Transporter is an eligible
provider of GEMT services as described in the State Code.
II. TERMS
This Agreement shall be effective and commence as of July 1, 2014 and shall end on
June 30, 2017. However, GEMT transporter acknowledges and agrees that cost
reports submitted by GEMT Transporters are subject to audit by the State of California
for a period of thirty-six (36) months from the date of submission of the reports by the
GEMT Transporter to the State of California. During that period of time, State
administrative costs as defined in the State Code will continue to be incurred by the
State for which the GEMT Transporter agrees to pay to Metro Fire pursuant to Section
IV below. The GEMT Transporter agrees to pay its transporter share of administrative
costs pursuant to Section V. after the termination of this Agreement, whether this
Agreement is terminated by its term, or in the event GEMT Transporter elects to
terminate the Agreement, or in the event that Metro Fire terminates the Agreement.
III. RATIFICATION
Where there has been a need for Metro Fire to provide services essential to the initial
start-up of the GEMT program in the State of California and where such services have
been provided prior to the date of execution of this Agreement, both Parties agree that
the calculation, and payment, of services under this Agreement shall begin on July 1,
2014.
IV. SCOPE OF SERVICES AND RESPONSIBILITIES
Metro Fire will provide the following services:
A. Advance of GEMT administration costs to the State as provided by SPA
09-024 on behalf of the GEMT Transporter.
B. Assistance to the State GEMT program on behalf of the GEMT
Transporters including:
a. Cost Report development
b. Information resource to the State and Federal governments
c. Program development to expand the scope of eligible costs
C. Assistance to the GEMT Transporter including:
a. General (offsite) program assistance
b. Ombudsman services when needed
c. Advocate for reimbursements
d. Government relations
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The GEMT Transporter will provide the following services:
A. Accurate reports of transports eligible under the GEMT program
B. Accurate record keeping and retention of records for a period of not less than
seven (7) years
C. Provide all records upon request for audit purposes
V. PAYMENT TERMS
GEMT Transporter agrees to pay Metro Fire the transporter's share of the State
administrative costs as defined in the State Code. The GEMT transporter share will be
based upon the administrative costs per fee for service Medi -Cal transport, multiplied by
the GEMT Transporter's number of fee for service Medi -Cal transports for each
reporting period. The administrative costs per fee for service Medi -Cal transport will be
determined by the State of California based on the total administrative costs of the State
in administering the GROUND EMERGENCY MEDICAL TRANSPORTATION
SERVICES SUPPLEMENTAL REIMBURSEMENT PROGRAM divided by the total
number of fee for service Medi -Cal transports statewide by all participating transporter
agencies for each reporting period. In addition, the GEMT transporter will compensate
Metro Fire one percent (1%) of the GEMT transporter's gross State Supplemental
Reimbursement of GEMT services under the State Code for each reporting period for
Metro Fire's program services, administrative services, expansion of program for future
reimbursements, contracting services, other expenses, cost of advancing funds for the
State, and the risk of non-payment from GEMT Transporters.
A. Metro Fire will notify, via email, the amount due under Section V. of this
Agreement by the GEMT Transporter once the amount is determined.
B. All amounts due under this Agreement will be paid to Metro Fire no
later than 30 days after the first notification is sent to the GEMT Transporter.
C. Non-payment by the GEMT Transporter constitutes a breach of this
Agreement and, if not cured, will result in a termination of this Agreement
pursuant to Section XII below.
1. A breach of this Agreement may be cured by the successful
completion of the payment transaction to Metro Fire by GEMT Transporter
within 30 days' notice by Metro Fire.
2. The State will not provide GEMT supplemental reimbursements to
the GEMT Transporter without a valid Agreement for Recovery of
Administrative Costs for Implementation and Recovery of GEMT
Payments with Metro Fire.
VI. REIMBURSEMENT COSTS ACKNOWLEDGMENT
The GEMT Transporter acknowledges and agrees that the compensation paid to Metro
Fire pursuant to this Agreement is intended to cover the costs for administering the
supplemental reimbursement program under Section 14105.94(d) of the State Code.
Page 3 of 6
The compensation payable to Metro Fire is approved by the State, pursuant to the State
Agreement attached as Exhibit A. The GEMT Transporter hereby agrees to waive any
claim, action, or challenge to the payment method for the collection of costs under
Section 14105.94(d) of the State Code, in the manner set forth in this Agreement.
VII. DISPUTE RESOLUTION
In the event of a dispute between the Parties in the terms of this Agreement as to any
issue arising under this Agreement, the Parties agree to meet and negotiate in good
faith to resolve such dispute. This shall not limit the Parties' right to pursue any available
remedies at law or in equity.
VIII. MUTUAL INDEMNIFICATION
It is agreed that the GEMT Transporter shall defend, hold harmless and indemnify Metro
Fire, its officers, employees, and agents from any and all claims liability, loss or
expense (including reasonable attorney fees) for injuries or damage to any person
and/or any property which arise out of the terms and conditions of this Agreement and
the negligent or intentional acts or omissions of the GEMT Transporter and its officers,
employees or agents. It is further agreed that Metro Fire shall defend, hold harmless
and indemnify the GEMT Transporter and its officers, employees, and agents from any
and all claims liability, loss or expense (including reasonable attorney fees) for injuries
or damage to any person and/or any property which arise out of the terms and
conditions of this Agreement and the negligent or intentional acts or omissions of Metro
Fire, its officers, employees, or agents.
IX. SEVERABILITY
If any term, condition, or provision of this Agreement is held by a court of competent
jurisdiction to be invalid, void, or unenforceable, the remaining provisions will
nevertheless continue in full force and effect, and shall not be affected, impaired or
invalidated in any way. Notwithstanding the previous sentence, if a decision by a court
of competent jurisdiction invalidates, voids, or renders unenforceable a term, condition,
or provision in this Agreement that is included in the purpose of this Agreement then the
Parties to this Agreement shall either amend this Agreement pursuant to Section X. Or it
shall be terminated.
X. AMENDMENT AND WAIVER
Except as provided herein, no alteration, amendment, variation, or waiver of the terms
of this Agreement shall be valid unless made in writing and signed by both Parties.
Waiver by either party of any default, breach or condition precedent shall not be
construed as a waiver of any other default, breach or condition precedent, or any other
right hereunder.
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XI. INTERPRETATION
This Agreement shall be deemed to have been prepared equally by both of the Parties,
and the Agreement and its individual provisions shall not be construed or interpreted
more favorably for one party on the basis that the other party prepared it.
XII. TERMINATION
Either of the Parties may terminate this Agreement upon thirty (30) days written notice
to the other party. Notice shall be deemed served on the date of mailing. GEMT
Transporter's responsibility for administrative costs incurred by the State associated
with transporter costs reports and/or the State's audit of those costs shall survive the
termination of the Agreement.
XIII. PRIOR AGREEMENTS
This Agreement constitutes the entire Agreement between Metro Fire and GEMT
Transporter regarding the subject matter of this Agreement. Any prior agreements,
whether oral or written, between Metro Fire and GEMT Transporter regarding the
subject matter of this Agreement are hereby terminated effective immediately upon full
execution of this Agreement.
XIV. INTEGRATION CLAUSE
This Agreement and any exhibits attached hereto shall constitute the entire Agreement
among the Parties to it and supersedes any prior or contemporaneous understanding or
agreement with respect to the services contemplated, and may be amended only by a
written amendment executed by both Parties to this Agreement.
XV. CONTROLLING LAW
The validity of this Agreement and its terms or provisions, as well as the rights and
duties of the Parties hereunder, the interpretation and performance of this Agreement
shall be governed by the laws of the State of California.
[SIGNATURES ON NEXT PAGE]
Page 5 of 6
SACRAMENTO METROPOR2ITAN FIRE DISTRICT
Signature: ✓'""� _ \,
Name: Amanda Thomas
Title: Chief Financial Officer
Date: :2(1-7 lzold
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
Date:/Y/15
By:
Aar C. Harp
Cit Attorney
ATTEST:
Date:
By: "&� , b�Q—�
Leilani I. Brown
City Clerk
GEMT TRANSPORTER: City of
Newport Beach, a California
municipal corporation
Date: il)1 22 n 2015
By: 4- :��
Scott Poster
Fire Chief
01
Fo Rrk"> ;
[END OF SIGNATURES]
Attachments: Exhibit A - Agreement with the California Department of Health
Care Services for Administrative Services Related to
Medi -Cal Ground Emergency Medical Transportation
Services Supplemental Reimbursement Program,
Dated April 9, 2015.
Page 6 of 6
Page I of 8
DHCS #14-90001
AGREEMENT WITH THE CALIFORNIA DEPARTMENT OF HEALTH CARE
SERVICES FOR ADMINISTRATIVE SERVICES RELATED TO MEDT -CAL
GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES
SUPPLEMENTAL REIMBURSEMENT PROGRAM
Parties.
The parties to this Agreement are the Sacramento Metropolitan Fire District (SMFD), in
its capacity as the host entity, and the California Department of Health Care Services
(DHCS).
As authorized by California Welfare and Institutions Code section 14105.94, SMFD acts
as the administrative agency for the Medi -Cal Ground Emergency Medical
Transportation Services (GEMT) Supplemental Reimbursement Program on behalf of
all publicly owned and operated GEMT providers in California participating in the
program.
DHCS is the single state agency responsible for administering the California Medical
Assistance Program (Medi—Cal) pursuant to California Welfare and Institutions Code
section 14100.1.
2. Term of the Agreement.
Subject to the provisions of this Agreement, the term of this Agreement shall be from
July 1, 2014, through and including, June 30, 2017.
3. Maximum Payable Amount.
In full consideration of DHCS' performance of the services described in Schedule A and
the conditions in Section6., the amount that SMFD shall be obligated to pay for
services rendered for the term of this Agreement shall not exceed $700,000 each State
Fiscal Year (SFY) beginning SFY 2014-15. The State Fiscal Year begins on July 1st
each year and ends on June 30th.
The maximum payable amount shall be further subject to annual limits not to exceed:
$700,000 -for July 1St, 2014, through and including June 301h, 2015.
$700,000 - for July 1St, 2015, through and including June 30th, 2016.
$700,000 -for July 1St, 2016, through and including June 30th 2017.
4. Purpose of the Agreement.
The purpose of this Agreement is for DHCS to perform the administrative .services
related to administering the GEMT supplemental reimbursement program as described
in Schedule A, attached hereto and incorporated by reference herein. Further, the
purpose of this agreement is to designate SMFD as the host entity that will collect
administrative costs, as defined in Welfare and Institutions Code section 14105.94,
subdivision (d), pursuant to written contracts between SMFD and eligible providers.
The eligible providers are required to enter into written contracts by the Provider
Page 2 of 8 DHCS #14-90001
Participation Agreement, which are entered into between the eligible providers and
DHCS. The Provider Participation Agreement between the eligible providers and
DHCS requires the eligible providers to satisfy their responsibilities for reimbursing
DHCS for its administrative costs by conditioning their participation in the supplemental
payment program and their receipt of such supplemental funds upon entering into the
written reimbursement contracts between SMFD and the eligible providers for the
payment of DHCS' administrative costs, the subject of this Agreement. It is understood
by both SMFD and DHCS that payments set forth under this Agreement are for the
purpose of reimbursing DHCS for all direct and indirect expenses related to performing
these activities.
5. Contact Persons.
Any notice, request, demand or other communication required or permitted hereunder,
shall be deemed to be properly given when deposited in the United States mail, postage
prepaid, and addressed:
In the case of SMFD, to:
GEMT Coordinator
Sacramento Metropolitan Fire District
Attn: Chief Financial Officer
10545 Armstrong Avenue, Suite 200
Mather, CA 95655
l
Or to such person or address as SMFD may, from time to time, fumish in writing to
DHCS.
In the case of DHCS, to:
California Department of Health Care Services
Safety Net Financing Division
Attn: Stacy Fox, Medi -Cal Supplemental Payments Section
1501 Capitol Avenue, MS 4504
P.O. Box 997436
Sacramento, CA 95899-7436
Or to such person or address as DHCS may, from time to time, furnish in writing to
SMFD.
6. Payment Terms and Invoicing.
A. SMFD shall compensate DHCS for services listed in Schedule A, as authorized
by Section 7 of this agreement, within forty-five (45) days of receipt of an invoice
from DHCS, which specifies both the total federally claimable administrative cost
and the nonfederal share of the total cost.
B. Failure by SMFD to timely compensate DHCS pursuant to paragraph A shall
constitute a material breach of this Agreement by SMFD, which at DHCS'
discretion, may result in termination by DHCS pursuant to Section 9. SMFD may
cure such breach by rendering payment of the amount owed to DHCS prior to the
Page 3 of 8
DHCS #14-90001
termination of this Agreement pursuant to Section 9, at which point such notice of
termination shall be automatically rescinded.
C. In no event shall payment be made by SMFD for any invoice or portion thereof
exceeding the Agreement amount specified in Section 3. Payment for any
services rendered by DHCS exceeding the Agreement amount shall require an
amendment to this Agreement pursuant to Section 8. Services rendered by
DHCS shall cease until an amendment is executed.
D. DHCS shall submit annual invoices to SMFD no sooner than forty-five (45) days
following the close of each SFY. DHCS' invoice shall include the supplemental
form identifying the following summarized categories of costs for the period
billed: salary, benefits, operating expenses, and total costs.
E. SMFD shall not be obligated to pay DHCS for the administrative services
covered by any invoice if DHCS presents the invoice to SMFD more than one (1)
year after this Agreement terminates.
F. Payments shall be sent to DHCS at the following address:
California Department of Health Care Services
Safety Net Financing Division
Attn: Medi -Cal Supplemental Payments Section
1501 Capitol Avenue, MS 4504
P.O. Box 997436
Sacramento, CA 95899-7436
Scope of Work.
In consideration of the payments hereinafter set forth, DHCS shall perform the activities
related to administering the GEMT supplemental reimbursement program as described
in Schedule A, attached hereto and incorporated by reference herein. It is understood
by both SMFD and DHCS that payments set forth under this Agreement are for the
purpose of reimbursing DHCS for all direct and indirect expenses related to performing
these activities. Should the scope of work or services to be performed under this
Agreement conflict with DHCS' responsibilities as the single agency for Medicaid in
California (Medi -Cal), the single state agency responsibilities shall take precedence.
DHCS' cessation of any activities due to single state agency responsibilities does not
relinquish the obligation of SFMD to reimburse DHCS for administrative costs actually
incurred by DHCS.
8. Amendments.
Amendments to this Agreement shall be made only by a written agreement signed by
the parties to this Agreement, and If required by State law, by approval of the California
Department of General Services. Notwithstanding the previous sentence, updates on
who will serve as the contact person identified in Section 5 may be transmitted by email
to the other contact person or;persons. In conformance with state law requiring SMFD
to pay the State for the nonfederal share of its federally reimbursable administrative
costs in administering the GEMT supplemental reimbursement program, by entering
Page 4 of 8
DHCS #14-90001
into this Agreement, SMFD acknowledges and accepts that this Agreement shall be
automatically amended to reflect updates to the State's administrative costs.
9. Termination.
This Agreement may be terminated by any party upon written notice given at least thirty
(30) calendar days prior to the termination date. Notice shall be addressed to the
respective parties as identified in Section 5 of this Agreement. SMFD shall be obligated
to pay for all of the administrative costs incurred from the services duly performed by
DHCS until the termination date.
The terms of Section 6 (Payment Terms and Invoicing), the last sentence of Section 9
(termination), Section 10A (Indemnification), and Section 100 (Records) shall survive
the termination of this Agreement.
10. General Provisions.
A. Indemnification. It is agreed that SMFD shall defend, hold harmless, and
indemnify DHCS, its officers, employees, and agents from any and all claims,
liability, loss or expense (including reasonable attorney fees) for injurles or
damage to any person and/or any property which arise out of the terms and
conditions of this Agreement and the negligent or intentional acts or omissions of
SMFD, its officers, employees, or agents.
Severability. If any term, condition, or provision of this Agreement is held by a
court of competent jurisdiction to be invalid, void, or unenforceable, the remaining
provisions will nevertheless continue in full force and effect, and shall not be
affected, impaired or invalidated in any way. Notwithstanding the previous
sentence, if a decision by a court of competent jurisdiction invalidates, voids, or
renders unenforceable a term, condition, or provision in this Agreement that is
included in the purpose of this Agreement then the parties to this Agreement
shall either amend this Agreement pursuant to Section 8, or it shall be
terminated.
C. Records.
1) Upon written notice, DHCS agrees to provide to SMFD, or any federal or
State department having monitoring or reviewing authority, access to and
the right to examine and audit its applicable records and documents for
compliance with relevant federal and State statutes, rules and regulations,
and this Agreement.
2) DHCS shall maintain and preserve all records relating to this Agreement
for a period of three (3) years from receipt of the last payment of federal
financial participation (FFP) or until audit findings are resolved, whichever
is greater.
D. Compliance with Applicable Laws. All services to be performed by DHCS
pursuant to this Agreement shall be performed in accordance with all applicable
federal and State laws,'_ including, but not limited to:
Page 5 of DHCS #14-90001
1) The Americans with Disabilities Act of 1990, as amended;
2) Section 504 of the Rehabilitation Act of 1973, as amended;
3) Title 42, United States Code (U.S.C.) § 1396 et seq.;
4) Welfare and Institutions Code (W&I), § 14000 et seq;
5) Government Code § 53060;
6) The California Medicaid State Plan;
7) Laws and regulations including, but not limited to licensure, certification,
confidentiality of records, quality assurance, and nondiscrimination.
E. Controlling law. The validity of this Agreement and its terms or provisions, as
well as the rights and duties of the parties hereunder, the interpretation and
performance of this Agreement shall be governed by the laws of the State of
California.
F. Integration Clause. Notwithstanding the GEMT supplemental reimbursement
program Provider Participation Agreement in Section G. listed below, this
Agreement and any exhibits attached hereto shall constitute the entire
agreement among the parties to it and supersedes any prior or contemporaneous
understanding or agreement with respect to the services contemplated.
G. Provider Participation Agreement. This Agreement does not alter, amend, or
override any of the eligible provider's obligations and SMFD's obligations
contained in the Provider Participation Agreement. The Provider Participation
Agreement is an agreement between DHCS and each of the eligible providers,
including SMFD in its capacity as an eligible provider. The Provider Participation
Agreement provides the terms and conditions for the eligible providers to
participate in the supplemental payment program. Such terms and conditions
include, but are not limited to, (i) the requirement that the eligible providers
reimburse SMFD for their share of the administrative costs incurred by DHCS in
administering the supplemental payment program authorized in section
14105.94, subdivision (d), and (ii) the term that DHCS shall immediately and
automatically without prior notice cease making supplemental payments and
initiate a recovery effort against an eligible provider that fails to pay its
administrative costs pursuant to the terms of the Provider Participation
Agreement.
H. Periodic Assessment. Pursuant to 14105.94, subdivision (d), SMFD enters into
this Agreement in order to implement the GEMT supplemental reimbursement
program under which its eligible facilities may participate and for which SMFD will
pay for the nonfederal share of all federally reimbursable administrative costs
incurred by DHCS performing activities described in Section 7. SFMD agrees
that DHCS may conduct a periodic assessment, as determined by DHCS, of
such costs incurred by DHCS to determine compliance with Welfare and
Institutions Code section 14105.94, subdivision (d), and further agrees that all
invoicing as described in Section 6 and any other relevant documentation will be
accordingly updated to ensure compliance with Welfare and institutions Code
section 14105.94, subdivision (d).
Conformance Clause. This Agreement is entered in accordance with Welfare
and Institutions Code section 14105,94, subdivision (d). Any provision of this
Agreement in conflict with the present or future governing authorities of the
Page 6 of 8
DHcs #14-90001
Welfare and Institutions Code or other applicable state law or federal law and
rules, including but not limited to, Title XIX of the Social Security Act, California's
Medicaid State Plan, implementation directives promulgated by DHCS, and
implementation directives promulgated by the Centers for Medicare & Medicaid
Services, is hereby amended to conform to those authorities. Such amended
provisions supersede any conflicting provision in this Agreement.
The persons signing this Agreement on behalf of SMFD and DHCS, as applicable,
represent and warrant that he or she is an individual duly authorized and having
authority to sign on behalf of, and approve for, SMFD or DHCS, as applicable, and is
authorized and designated to enter into and approve this Agreement on behalf of SMFD
or DHCS, as applicable.
SACRAMENTO METROPQa ITAN FIRE DISTRICT
Signature: ��s
Name: Mark A. Wells—
Title:
eils
Title: Fire Chief
Date: .2!,a—n—
SACRAMENTO METR0�13P�E DISTRICT
Signature: f
Namtf Clough
Title: Assistant Chief
Date:
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
Contract Management Unit Jj
Signature: ave of
Name:
Title: 1n�a' ComF Ct AtiNdM�E 004
Date: 15
CALIFORNIA DEPARTMENT OF GENERAL SERVICES
Office of Legal Services
'
Signature:
Name:
Title:
Date:
Page 7 of 8 1 DHCS #14-90001
SCHEDULE A
SCOPE OF WORK
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES JULY 1, 2014 - JUNE 30,
2017
DHCS agrees to:
A. Lead the development, implementation, and administration for the GEMT
program and ensure compliance with provision set forth in SPA 09-024.
Submit claims for federal financial participation (FFP) based on expenditures for
GEMT services that are allowable expenditures under federal law.
C. On an annual basis, submit any necessary materials to the federal government to
provide assurances that claims for FFP will include only those expenditures that
are allowable under federal law.
D. Reconcile certified public expenditure (CPE) invoices with supplemental
reimbursement payments and ensure that the total Medi -Cal reimbursement
provided to eligible GEMT providers will not exceed applicable federal upper
payment limit as described in 42 C.F.R. 447 -Payments For Services.
Complete the audit and settlement process of the interim reconciliations for the
claiming period within three years of the postmark date of the cost report and
conduct on-site audits as necessary.
R Calculate the actual costs for administrative accounting, policy development, and
data processing maintenance activities, including the indirect costs related to the
Medi -Cal Ground Emergency Medical Transportation Services (GEMT)
supplemental reimbursement program provided by its staff based upon a cost
accounting system which is in accordance with the provisions of Office of
Management and Budget Circular A-87 and 45 Code of Federal Regulations
Parts 74 and 95.
G. Maintain accounting records to a level of detail which identifies the actual
expenditures incurred for personnel services which includes salary/wages,
benefits, travel and overhead costs for DHCS' staff, as well as equipment and all
related operating expenses applicable to these positions to include, but not
limited to, general expense, rent and supplies, and travel cost for identified staff
and managerial staff working specifically on activities or assignments directly
related to the GEMT supplemental reimbursement program. Accounting records
shall include continuous time logs for identified staff that record time spent in the
following areas: the GEMT supplemental reimbursement program, general
administration.
H. Ensure that an appropriate audit trail exists within DHCS records and accounting
system and maintain expenditure data as indicated in this Agreement.
Page 8 of 8 DHCS #14-90001
k
I. Designate a person to act as liaison with SMFD in regard to issues concerning
this Agreement. This person shall be identified to SMFD's contact person for this
Agreement.
J. Provide a written response by email or mail to SMFD's contact person within
thirty (30) days of receiving a written request for information related to the GEMT
supplemental reimbursement program.
K. Provide accounting, and program technical assistance, and training related to the
GEMT supplemental reimbursement program to SMFD personnel after receiving
a written request from SMFD contact person.
r—
is
AGREEMENT FOR RECOVERY OF ADMINISTRATIVE COSTS
FOR IMPLEMENTATION AND RECOVERY OF GROUND EMERGENCY MEDICAL
TRANSPORTATION PAYMENTS
This Agreement for Recovery of Administrative Costs for Implementation and
Recovery of Ground Emergency Medical Transportation Payments ("Agreement") is made
and entered into on this _ day of ru a r..ss_s.,2014 between the Sacramento
Metropolitan Fire District, a political subdivision of the State'of California ("Metro Fire") and
the City of Newport Beach, a municipal corporation and charter city ("GEMT Transporter").
WHEREAS, the State Department of Health Care Services ("State") has developed
and is administering the Medi -Cal Ground Emergency Transportation Supplemental
Reimbursement Program pursuant to California Welfare and Institutions Code Section
14105.94 ("Section 14105.95") and State Plan Amendments 09-024 ("SPA 09-024"); and
WHEREAS, the State has entered into an agreement with Metro Fire for
administrative services related to the Medi -Cal Ground Emergency Transportation
Supplemental Reimbursement Program pursuant to Section 14105.94 and SPA 09-024,
which agreement is attached hereto as Exhibit A, and is incorporated as if set forth fully
herein; and
WHEREAS, under Section 14105.94, an eligible provider of ground emergency
medical transportation services may be entitled to supplemental Medi -Cal reimbursement as
set forth in that Section; and
WHEREAS, an eligible provider as described in Section 14105.94 is required to enter
into an agreement to reimburse the State for implementing and administering the
Supplemental Reimbursement Program as a condition of receiving supplemental
reimbursement pursuant to that Section; and
WHEREAS, Metro Fire has been designated by the agreement attached as Exhibit A,
to recover the administrative and implementation costs required to be paid by eligible
providers under Section 14105.94; and
WHEREAS, Metro Fire will incur administrative and other costs in connection with
billing GEMT Transporters for costs, and has assumed the risk of payment, or non- payment
of the costs from GEMT Transporters.
NOW THEREFORE, Metro Fire and GEMT Transporter enter into this Agreement for
the purpose of setting forth the agreement for payment of administrative costs by GEMT
Transporter to Metro Fire, under the following terms and conditions.
Page 1 of 6
PARTIES
Metro Fire is a designated agency for the collection of costs related to the GEMT
Supplemental Medi -Cal Reimbursement Program. GEMT Transporter is an eligible provider
of GEMT services as described in Section 14105.94.
This Agreement shall be effective and commence as of July 1, 2011, and shall
terminate on June 30, 2014. However, GEMT Transporter acknowledges and agrees that
cost reports are subject to audit by the State for a period of thirty-six (36) months from the
date of submission of the reports by GEMT Transporter to the State. During that period of
time, State administrative costs as defined in Section 14105.94 will continue to be incurred by
the State for which GEMT Transporter agrees to pay to Metro Fire pursuant to Paragraphs IV
and V, below. GEMT Transporter agrees to pay its transporter share of administrative costs
pursuant to Paragraph V, whether this Agreement is terminated by its term, or in the event
GEMT Transporter elects to terminate the Agreement, or in the event that Metro Fire
terminates the Agreement.
i
Where there has been a need for Metro Fire to provide services essential to the initial
start-up of the GEMT program in the State and where such services have been provided prior
to the date of execution of this agreement, both Parties agree that the calculation, and
payment, of services under this Agreement shall begin as of July 1, 2011.
IV. SCOPE OF SERVICES AND RESPONSIBILITIES
Metro Fire shall provide the following services:
A. Advance of GEMT administration costs to the State on behalf of GEMT
Transporter as provided by SPA 09-024.
B. Assistance to the State GEMT program on behalf of GEMT Transporter
including:
1. Cost Report development.
2. Information resources to the State and Federal governments.
3. P ro g ra m development to expand the scope of eligible costs.
C. Assistance to GEMT Transporter including:
1. Program guidance via telephone.
2. Ombudsman services when needed.
3. Advocate for reimbursements.
4. Government relations.
Page 2 of 6
GEMT Transporter shall provide the following services:
A. Accurate reports of transports eligible under the GEMT program.
B. Accurate recordkeeping and retention of records for a period of not less than
seven (7) years.
C. Provide all records upon request for audit purposes.
V. PAYMENT TERMS
GEMT Transporter agrees to pay Metro Fire its GEMT Transporter share of the State
administrative costs as defined in Section 14105.94. GEMT Transporter's share shall be
based upon the administrative costs per fee-for-service Medi -Cal transport, multiplied by
GEMT Transporter's number of fee-for-service Medi -Cal transports for each reporting period.
The administrative costs per fee-for-service Medi -Cal transport shall be determined by the
State based on the total administrative costs of the State in administering the GEMT
Supplemental Medi -Cal Reimbursement Program divided by the total number of fee-for-
service Medi -Cal transports statewide by all participating transporter agencies for each
reporting period. In addition, GEMT Transporter shall compensate Metro Fire one percent
(1%) of GEMT Transporter's gross State Supplemental Reimbursement of GEMT Services
under Section 14105.94 for each reporting period for Metro Fire's program services,
administrative services, expansion of program for future reimbursements, contracting
services, other expenses, cost of advancing funds for the State, and the risk of non-payment.
A. Metro Fire shall notify GEMT Transporter, via email, the amount due under
Paragraph V of this Agreement once the amount is determined.
B. All amounts due under this Agreement shall be paid via an ACH electronic
debit transaction initiated by Metro Fire no sooner than thirty (30) days after
the first e-mail notification is sent to GEMT Transporter.
C. GEMT Transporter shall complete a Direct Payment Authorization Form
authorizing Metro Fire to initiate the debit payment of the amounts due to
Metro Fire pursuant to this Agreement.
It is the responsibility of GEMT Transporter to keep the Direct Payment
Authorization Form up to date with the most current financial institution
information.
D. Non-payment by GEMT Transporter due to insufficient funds or other reasons
will result in a termination of the Agreement pursuant to Paragraph XII.
Any breach of this Paragraph V may be cured by: 1) having the amount
due plus additional bank fees incurred by Metro Fire (if any) available in
the financial institution named on the
Form; and 2) the successful completion
additional banking fees.
Page 3 of 6
Direct Payment Authorization
of the debit transaction including
E. The State will not provide GEMT supplemental reimbursements to GEMT
Transporter without this valid and executed Agreement with Metro Fire for
Recovery of Administrative Costs for Implementation and Recovery of GEMT
Payments.
VL REIMBURSEMENT COSTS ACKNOWLEDGMENT
GEMT Transporter acknowledges and agrees that the compensation paid to Metro
Fire pursuant to this Agreement is intended to cover the costs for administering the
supplemental reimbursement program under Section 14105.94. The compensation payable
to Metro Fire is approved by the State, pursuant to the agreement between the State and
Metro Fire as set forth in Exhibit A. GEMT Transporter hereby agrees to waive any claim,
action, or challenge to the payment method for the collection of costs under Section
14105.94(d), as set forth in this Agreement.
Vill. DISPUTE RESOLUTION
In the event of a dispute between the Parties to this Agreement as to any issue arising
under this Agreement, the Parties agree to meet and negotiate in good faith to resolve such
dispute. This shall not limit the Parties' right to pursue any available remedies at law or in
equity.
VIII. MUTUAL INDEMNIFICATION
It is agreed that GEMT Transporter shall defend, hold harmless and indemnify
Metro Fire and its officers, employees, and agents from any and all claims, liability,
loss or expense (including reasonable attorneys' fees) for injuries or damage to any person
and/or any property which arise out of the terms and conditions of this Agreement and the
negligent or intentional acts or omissions of GEMT Transporter and its officers, employees or
agents. It is further agreed that Metro Fire shall defend, hold harmless and indemnify GEMT
Transporter and its officers, employees, and agents from any and all claims, liability, loss or
expense (including reasonable attorneys' fees) for injuries or damage to any person and/or
any property which arise out of the terms and conditions of this Agreement and the
negligent or intentional acts or omissions of Metro Fire and its officers, employees, or
agents.
IX. SEVERABILITY
If any term, condition, or provision of this Agreement is held by a court of competent
jurisdiction to be invalid, void, or unenforceable, the remaining provisions will nevertheless
continue in full force and effect, and shall not be affected, impaired or invalidated in any way.
Notwithstanding the previous sentence, if a decision by a court of competent jurisdiction
invalidates, voids, or renders unenforceable a term, condition, or provision in this Agreement
that is included in the purpose of this Agreement then the Parties to this Agreement shall
either amend this Agreement pursuant to Paragraph X, or it shall be terminated.
Page 4 of 6
X. AMENDMENT AND WAIVER
Except as provided herein, no alteration, amendment, variation, or waiver of the
terms of this Agreement shall be valid unless made in writing and signed by both Parties.
Waiver by either Party of any default, breach or condition precedent shall not be construed
as a waiver of any other default, breach or condition precedent, or any other right
hereunder.
XI. INTERPRETATION
This Agreement shall be deemed to have been prepared equally by both Parties,
and the Agreement and its individual provisions shall not be construed or interpreted more
favorably for one Party on the basis that the other Party prepared it.
XII. TERMINATION
Either Party may terminate this Agreement upon thirty (30) days written notice to the
other Party. Notice shall be deemed served on the date of mailing. GEMT Transporters
responsibility for administrative costs incurred by the State associated with transporter
costs reports and/or the State's audit of those costs shall survive the termination of the
Agreement.
XIII. PRIOR AGREEMENTS
This Agreement constitutes the entire agreement between Metro Fire and GEMT
Transporter regarding the subject matter of this Agreement. Any prior agreements,
whether oral or written, between Metro Fire and GEMT Transporter regarding the subject
matter of this Agreement are hereby terminated effective immediately upon full execution
of this Agreement.
XIV. INTEGRATION CLAUSE
This Agreement and any exhibits attached hereto shall constitute the entire
agreement between the Parties to it and supersede any prior or contemporaneous
understanding or agreement with respect to the services contemplated, and may be
amended only by a written amendment executed by both Parties to this Agreement.
XV. CONTROLLING LAW
The validity of this Agreement and its terms or provisions, as well as the rights and
duties of the Parties hereunder, the interpretation and performance of this Agreement shall
be governed by the laws of the State of California.
Page 5 of 6
SACRAMENTO METROPOLITAN-FFFEE DISTRICT
Signature:
Name: Scott Clough
Title:. Assistant Chief
Date: -7 -1 -z
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
Date: ) - 4-1 q
By:
Aaron C.[Harp
City Attorney
ATTEST: �, 1
Date:
By:
Leilani I. Brown
City Clerk
GEMT TRANSPORTER: CITY OF
NEWPORT BEACH,
a California municipal corporation
Date: rEB 0 6 204
By:
Scott Poster
Fire Chief
ZRORN A
[END OF SIGNATURES]
Attachments: Exhibit A — Agreement with the California Department of Health Care
Services for Administrative Services Related to Medi -Cal
Ground Emergency Medical Transportation Services
Supplemental Reimbursement Program, dated November
18, 2013
Page 6 of 6
EXHIBIT A
D>41l—�t)c959-�A.
AGREEMENT WITH THE CALIFORNIA DEPARTMENT OF HEALTH CARE
SERVICES FOR ADMINISTRATIVE SERVICES RELATED TO MEDI-CAL
GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES
SUPPLEMENTAL REIMBURSEMENT PROGRAM
1. Parties
The parties to this Agreement with the Califomia Department of Health Care Services
for Administrative Services Related to Medi -Cal Ground Emergency Medical
Transportation Services Supplemental Reimbursement Program (Agreement) are the
Sacramento Metropolitan Fire District (SMFD), in its capacity as the host entity, and the
California Department of Health Care Services (Contractor).
As authorized by California Welfare and Institutions Code section 14105.94, SMFD acts
as the administrative agency for the Medi -Cal Ground Emergency Medical
Transportation Services (GEMT) Supplemental Reimbursement Program on behalf of
all publicly owned and operated GEMT providers in California participating in the
program.
Contractor is the single state agency responsible for administering the California
Medical Assistance Program ("Medi—Cal") pursuant to California Welfare and
Institutions Code section 14100.1.
2. Term of the Agreement
Subject to the provisions of this Agreement, the term of this Agreement shall be from
July 1, 2011, through and including, June 30, 2014.
3. Maximum Payable Amount
In full consideration of Contractor's performance of the services described in Schedule
A and the conditions in Provision 6., the amount that SMFD shall be obligated to pay for
services rendered for the term of this Agreement shall not exceed $250,000 each State
Fiscal Year (SFY) beginning SFY 2011-12. The State Fiscal Year begins on July 1st
each year and ends on June 30th.
The maximum payable amount shall be further subject to annual limits not to exceed:
$100,000 -for July 15t, 2011, through and including June 30th, 2012.
$125,000 - for July 1st, 2012, through and including June 30th, 2013.
$250,000 - for July 1st, 2013, through and including June 30th, 2014,
4. Purpose of the Agreement.
The purpose of this Agreement is for Contractor to perform the administrative services
related to administering the GEMT supplemental reimbursement program as described
in Schedule A, attached hereto and incorporated by reference herein. Further, the
purpose of this agreement is to designate SMFD as the host entity that will collect
administrative costs, as defined in Welfare and Institutions Code section 14105.94(d),
pursuant to written contracts between SMFD and eligible providers. The eligible
providers are required to enter into written contracts by the Provider Participation
Agreement, which are entered into between the eligible providers and the Contractor.
The Provider Participation Agreement between the eligible providers and the Contractor
requires the eligible providers to satisfy their responsibilities for reimbursing the
Contractor for its administrative costs by conditioning their participation in the
supplemental payment program and their receipt of such supplemental funds upon
entering into the written reimbursement contracts between SMFD and the eligible
providers for the payment of Contractor's administrative costs, the subject of this
Agreement. It is understood by both SMFD and Contractor that payments set forth
under this Agreement are for the purpose of reimbursing Contractor for all direct and
indirect expenses related to performing these activities.
6. Contact Persons.
Any notice, request, demand or other communication required or permitted hereunder,
shall be deemed to be properly given when deposited in the United States mail, postage
prepaid, and addressed:
In the case of SMFD, to
GEMT Coordinator
Sacramento Metropolitan Fire District
Attn: Scott Clough, Assistant Chief
10545 Armstrong Avenue
Mather, CA 95655
Or to such person or address as SMFD may, from time to time, furnish in writing to
Contractor.
In the case of Contractor, to:
California Department of Health Care Services
Safety Net Financing Division
Attn: Stacy Fox, Medi -Cal Supplemental Payments Section
1501 Capitol Avenue, MS 4504
P.O. Box 997436
Sacramento, CA 95899-7436
Or to such person or address as Contractor may, from time to time, furnish in writing to
SMFD.
6. Payment Terms and Invoicing.
A. SMFD shall compensate Contractor for services listed in Schedule A, as
authorized by Provision 7 of this agreement, within forty-five (45) days of receipt
of an invoice from Contractor,
B, Failure by SMFD to timely compensate Contractor pursuant to paragraph A shall
constitute material breach of this Agreement by SMFD, which shall result in
termination by Contractor pursuant to Provision 9. SMFD may cure such breach
by rendering immediate payment of the amount owed to Contractor prior to the
termination of this Agreement pursuant to Provision 9.
C. In no event shall payment be made by SMFD for any invoice or portion thereof
exceeding the Agreement amount specified in Provision 3. Payment for any
services rendered by Contractor exceeding the Agreement amount shall require
an amendment to this Agreement pursuant to Provision 8. Services rendered by
Contractor shall cease until an amendment is executed.
D. Contractor shall submit annual invoices to SMFD no sooner than forty-five (45)
days following the close of each SFY. Contractor's invoice shall include the
supplemental form identifying the following summarized categories of costs for
the period billed: salary, benefits, operating expenses, and total costs.
E. SMFD shall not be obligated to pay Contractor for the services covered by any
invoice if Contractor presents the invoice to SMFD more than one (1) year after
this Agreement terminates.
F. Payments shall be sent to Contractor at the following address:
California Department of Health Care Services
Safety Net Financing Division
Attn: Medi -Cal Supplemental Payments Section
1501 Capitol Avenue, MS 4504
P.Q. Box 997436
Sacramento, CA 95899-7436
7. Scooe of Work
In consideration of the payments hereinafter set forth, Contractor shall perform the
activities related to administering the GEMT supplemental reimbursement program as
described in Schedule A, attached hereto and incorporated by reference herein. It is
understood by both SMFD and Contractor that payments set forth under this Agreement
are for the purpose of reimbursing Contractor for all direct and indirect expenses related
to performing these activities. Should the scope of work or services to be performed
under this Agreement conflict with Contractor's responsibilities as the single agency for
Medicaid in California (Medi -Cal), the single state agency responsibilities shall take
precedence.
8. Amendments.
Amendments to this Agreement shall be made only by a written agreement signed by
the parties to this Agreement, and if required by State law, by approval of the California
Department of General Services.
9. Termination.
This Agreement may be terminated by any party upon written notice given at least thirty
(30) calendar days prior to the termination date. Notice shall be addressed to the
respective parties as identified in Provision 5 of this Agreement. SMFD shall be
obligated to pay for all services duly performed by Contractor until the termination date.
10. General Provisions.
A. Indemnification. It is agreed that SMFD shall defend, hold harmless, and
indemnify Contractor, its officers, employees, and agents from any and all claims
liability, loss or expense (including reasonable attorney fees) for injuries or
damage to any person and/or any property which arise out of the terms and
conditions of this Agreement and the negligent or intentional acts or omissions of
SMFD, its officers, employees, or agents.
B. Severability. If any term, condition, or provision of this Agreement is held by a
court of competent jurisdiction to be invalid, void, or unenforceable, the remaining
provisions will nevertheless continue in full force and effect, and shall not be
affected, impaired or invalidated in any way. Notwithstanding the previous
sentence, if a decision by a court of competent jurisdiction invalidates, voids, or
renders unenforceable a term, condition, or provision in this Agreement that is
included in the purpose of this Agreement then the parties to this Agreement
shall either amend this Agreement pursuant to Provision B. Or it shall be
terminated.
C. Records.
1) Upon written notice, Contractor agrees to provide to SMFD or any federal
or State department having monitoring or reviewing authority, access to
and the right to examine and audit its applicable records and documents
for compliance with relevant federal and State statutes, rules and
regulations, and this Agreement.
2) Contractor shall maintain and preserve all records relating to this
Agreement for a period of three (3) years from the termination date of this
Agreement, or until audit findings are resolved, whichever is greater.
D. Compliance with Applicable Laws. All services to be performed by Contractor
pursuant to this Agreement shall be performed in accordance with all applicable
federal and State laws, including, but not limited to:
1) The Americans with Disabilities Act of 1990, as amended;
2) Section 504 of the Rehabilitation Act of 1973, as amended;
3) Title 42, United States Code (U.S.C.) § 1396 at seq.;
4) Welfare and Institutions Code (W&I), § 14000 et seq;
5) Government Code § 53060;
6) The California Medicaid State Plan;
7) Laws and regulations including, but not limited to licensure, certification,
confidentiality of records, quality assurance, and nondiscrimination.
E. Controlling law. The validity of this Agreement and its terms or provisions, as
well as the rights and duties of the parties hereunder, the interpretation and
performance of this Agreement shall be governed by the laws of the State of
California.
F. Integration Clause. This Agreement and any exhibits attached hereto shall
constitute the entire agreement among the parties to it and supersedes any prior
or contemporaneous understanding or agreement with respect to the services
contemplated, and may be amended only by a written amendment executed by
both parties to this Agreement.
G. Provider Participation Agreement. This Agreement does not alter, amend, or
override any of the eligible provider's obligations and SMFD's obligations
contained in the Provider Participation Agreement. The Provider Participation
Agreement is an agreement between the Contractor and each of the eligible
providers, including SMFD in its capacity as an eligible provider. The Provider
Participation Agreement provides the terms and conditions for the eligible
providers to participate in the supplemental payment program. Such terms and
conditions include, but are not limited to, (i) the requirement that the eligible
providers reimburse SMFD for their share of the administrative costs incurred by
the Contactor in administering the supplemental payment program authorized in
section 14105.94(d), and (ii) the term that the Contractor shall immediately and
automatically without prior notice cease making supplemental payments and
initiate a recovery effort against an eligible provider that fails to pay its
administrative costs pursuant to the terms of the Provider Participation
Agreement.
The persons signing this Agreement on behalf of SMFD and Contractor, as applicable,
represent and warrant that he or she is an individual duly authorized and having
authority to sign on behalf of, and approve for, SMFD or Contractor, as applicable, and
is authorized and designated to enter into and approve this Agreement on behalf of
SMFD or Contractor, as applicable.
SACRAMENven�jll LITAN FIRE DISTRICT
Signature:Name: Kurt�
Title: Fire Chief
Date:
SACRAMENTQ-AhET POLITAN FIRE DISTRICT
Signaturq-,-'�
Name: S gh
Title: Assistant Chief
Date: '//Z/i3
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
ContractMa agemen Unit
Signature e�
Name:La-t-,tNn L6 A-P-C
Title: CC'S
Date: Z bll��;
CALIFORNIA DEPARTMENT OF GENERAL SERVICES
Office of Legal Services
Signature:
Name:
Title:
Date:
APPROVED
i
--r T OF GENERA..
k�ltlk� z
SCHEDULE A
SCOPE OF WORK
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES JULY 1, 2011 - JUNE 30,
2014
Contractor agrees to:
A. Lead the development, implementation, and administration for the GEMT
program and ensure compliance with provision set forth in SPA 09-024.
B. Submit claims for federal financial participation (FFP) based on expenditures for
GEMT services that are allowable expenditures under federal law.
C. On an annual basis, submit any necessary materials to the federal government to
provide assurances that claims for FFP will include only those expenditures that
are allowable under federal law.
D. Reconcile certified public expenditure (CPE) invoices with supplemental
reimbursement payments and ensure that the total Medi -Cal reimbursement
provided to eligible GEMT providers will not exceed applicable federal upper
payment limit as described in 42 C.F.R. 447 -Payments For Services.
E. Complete the audit and settlement process of the interim reconciliations for the
claiming period within three years of the postmark date of the cost report and
conduct on-site audits as necessary.
F. Calculate the actual costs for administrative accounting, policy development, and
data processing maintenance activities, including the indirect costs related to the
Medi -Cal Ground Emergency Medical Transportation Services (GEMT)
supplemental reimbursement program provided by its staff based upon a cost
accounting system which is in accordance with the provisions of Office of
Management and Budget Circular A-87 and 45 Code of Federal Regulations
Parts 74 and 95.
G. Maintain accounting records to a level of detail which identifies the actual
expenditures incurred for personnel services which includes salary/wages,
benefits, travel and overhead costs for Contractor's staff, as well as equipment
and all related operating expenses applicable to these positions to include, but
not limited to, general expense, rent and supplies, and travel cost for identified
staff and managerial staff working specifically on activities or assignments
directly related to the GEMT supplemental reimbursement program. Accounting
records shall include continuous time logs for identified staff that record time
spent in the following areas: the GEMT supplemental reimbursement program,
general administration.
H. Ensure that an appropriate audit trail exists within Contractor records and
accounting system and maintain expenditure data as indicated in this Agreement.
I. Designate a person to act as liaison with SMFD in regard to issues concerning
this Agreement. This person shall be identified to SMFD's contact person for this
Agreement.
Provide a written response by email or mail to SMFD's contact person within
thirty (30) days of receiving a written request for information related to the GEMT
supplemental reimbursement program.
K. Provide accounting, and program technical assistance, and training related to the
GEMT supplemental reimbursement program to SMFD personnel after receiving
a written request from SMFD contact person.
4 "" Sacramento Metropolitan Fire Metro Fire
WIL 10545 Armstrong Ave., Suite #200, Mather, CA 95655 (916) 859-4300 Fax (916) 859-3700
KURT P. HENKE
Fire Chief SACRAMENTO METROPOLITAN FIRE DISTRICT
DIRECT PAYMENT AUTHORIZATION FORM
I authorize the Sacramento Metropolitan Fire District to initiate electronic debit entries to our
organization's
❑ Checking account (or) ❑ Savings account
for payment of our annual GEMT administration fee. I acknowledge that the origination of ACH
transactions to my account must comply with the provisions of U.S. law. This authority will
remain in effect for future annual GEMT administration fees until I have cancelled it in writing.
FINANCIAL INSTITUTION NAME
FINANCIAL INSTITUTION CITY AND STATE
ACCOUNT NUMBER
ROUTING NUMBER
YOUR EMAIL ADDRESS
YOUR TELEPHONE NUMBER
ORGANIZATION NAME:
PRINTED NAME:
SIGNATURE
TITLE:
DATE
Mail completed form to: Sacramento Metropolitan Fire District
Attention: Accounts Receivable
10545 Armstrong Ave, Suite 200
Mather, CA 95655