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Home My WebLink AboutC-5635-2 - Public Provider Intergovernmental Transfer Program for Ground Emergency Medical Transportation (GEMT) Services Certification Form for State Calendar Year 2024DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 I, the undersigned, hereby declare and certify on behalf of the City of Newport Beach (the "Public Entity") as follows: As a public administrator, a public officer, or other public individual, I am duly authorized to make this certification. 2. The Public Entity elects to make this intergovernmental transfer (IGT) to the Department of Health Care Service (DHCS) as a voluntary contribution to the non-federal share of Medi-Cal expenditures for purposes of Assembly Bill 1705 (2019) pursuant to Sections 14105.94, 14105.945, 14129, 14129.3, and 14164 of the Welfare and Institutions (W&I) Code. All funds transferred pursuant to this certification qualify for federal financial participation (FFP) pursuant to Section 1903(w) of the Social Security Act and Title 42 of the Code of Federal Regulations, Section 433 Subpart B, and are not derived from impermissible sources such as recycled Medicaid payments, federal money excluded from use as the non-federal share (NFS), impermissible health care -related taxes, or non -bona fide provider - related donations. 3. Voluntary contributions attributable to the period of January 1, 2023, through December 31, 2024, will be made via recurring transfers as indicated on the invoices provided to the Public Entity by DHCS. The voluntary contributions made by the Public Entity may also include adjustments related to the CY 2023 rating period's NFS reconciliation as described in paragraph 7 below. Please note, the total IGT amount at the bottom of this IGT certification will continue to be itemized on your invoice which is sent to you along with this IGT certification form 45-days in advance of the IGT contribution due date. The Public Entity acknowledges that any transfers made pursuant to this certification during this time period are consid- ered an elective IGT made pursuant to W&I Code sections 14105.945 and 14164, to be used by DHCS, subject to paragraph four herein, exclusively as the source for the NFS of ground emergency medical transport public provider supplemental payments in both Medi-Cal fee -for -service payments and the portion of the risk - based capitation rate to Medi-Cal managed care health plans associated with re- imbursement made in accordance with Section 14105.945, subdivision (h)(1) (hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Trans- portation (GEMT) Program, or the PP-GEMT Program), and DHCS costs associ- ated with administering the PP-GEMT Program. 4. DHCS may accept this voluntary contribution to the extent it is able to obtain FFP for the PP-GEMT Program as permitted by federal law. In the event DHCS is unable to obtain FFP for the PP-GEMT Program, or the full payments cannot otherwise be made to and retained by eligible public providers, and, therefore, all or a portion of the transferred amount cannot be used as the NFS of payments, DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 DHCS will notify the Public Entity via e-mail and return the applicable portion of the unused IGT amount. 5. The Public Entity acknowledges that, in accordance with W&I Code section 14105.945, subdivision (h)(2), DHCS shall assess a ten percent (10%) fee on each transfer of public funds to the state to pay for health care coverage and to reim- burse DHCS its costs associated with administering the PP-GEMT Program. 6. The Public Entity acknowledges that the IGT is to be used by DHCS for the filing of a claim with the federal government for federal funds and understands that any misrepresentation regarding the IGT may violate federal and state law. 7. The amount voluntarily transferred to DHCS is based on the estimated Medi-Cal fee -for -service and Medi-Cal managed care non-federal share of ground emer- gency medical transport payments, as referenced in paragraph three herein. Be- cause the amount to be voluntarily transferred to DHCS will be based on an esti- mate, the Public Entity acknowledges that a reconciliation of the voluntary NFS contributions to the actual NFS expenditures will occur. To the degree necessary to fund the NFS for the PP-GEMT Program, amounts due to or owed by Public Entity as a result of the reconciliation may be offset against, or added to, future transfers as applicable and as determined by DHCS. DHCS may accept a volun- tary contribution to the extent it is able to obtain FFP for PP-GEMT payments as permitted by federal law. 8. The Public Entity acknowledges that all records of funds transferred are subject to review and audit upon DHCS' request. The Public Entity will maintain documentation supporting the allowable funding source of the IGTs. 9. Upon notice from the federal government of a disallowance or deferral related to this IGT, the Public Entity responsible for this IGT shall be the entity responsible for the federal portion of that expenditure. I hereby declare under penalty of perjury under the law of the United States that the foregoing is true and correct to the best of my knowledge. I further understand that the known filing of a false or fraudulent claim, or making false statements in support of a claim, may violate the Federal False Claims Act or other applicable statute and federal law and may be punishable thereunder. DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 Executed on this day of2024 at /r✓ 7✓� ��California. Signature of Authorized Person: Name of Authorized Person: Grace . Leung Title of Authorized Person: City Manager Name of Public Entity: City of Newport Beach NPI of Public Entity: 1679579296 Amount of IGT: $98,888.56 APPROVED AS TO FCi= M: CITY ATTORNEY'S OFFICE Date: C) 1 # # # By: _ V� Aar, n C. Harp, City Atfdrney Attest: Leila i I. Brown, MM , City Clerk Date: U cq��F0 Rio H C S CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES Michelle BaassI Director PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION (PP-GEMT) PROGRAM MANAGED CARE AND FEE FOR SERVICE - INVOICE Provider Information: Due D. 10/15/2024 Provider Name: City Of Newport Beach Payment Details: Year: 2024 Collection #: 4 NPI: 1679579296 Total Amount Due: $98,888.56 Program/Payee Information: Banking Information: Vendor Name: Bank Name: California Department of Health Care Services US Bank Please await Wire Request Memo for payment instructions PP-GEMT Program Email: Payment Methods Accepted: AB1705Pdhcs.ca.gov ACH Wire Transfer Payment Instructions: Attention: Please review, sign, and submit the Intergovernmental Transfer (IGT) Certification form by October 1, 2024, to AB1705@dhcs.ca.gov. IGT Certification forms are required to be submitted prior to each collection due date. Once the IGT Certification form is received, DHCS will send a Wire Request Memo providing payment details and instructions. Please do not send your IGT payment until you have received the Wire Request Memo as payment details are subject to change. DeliveryIGT Non -Federal Share (NFS) Breakdown By DHCS Managed Care (MC) MC NFS #4 $87,005.94 MC Admin Fee #4 $0.00 MC Reconciliation #2 (Jul - Dec 2023) $2,276.30 Fee For Service (FFS) FFS NFS #4 $9,606.32 FFS Admin Fee #4 $0.00 Total* IGT Transfer Amount: $98,888.56 *Any differences are due to rounding. CY 2024 Invoice #1 Invoice Packets Sent 12/1/2023 IGT Certifications Due 1/1/2024 Payment Due 1/15/2024 CY 2024 Invoice #2 Invoice Packets Sent 3/1/2024 IGT Certifications Due 4/1/2024 Payment Due 4/15/2024 CY 2024 Invoice #3 Invoice Packets Sent 5/31/2024 IGT Certifications Due 7/1/2024 Payment Due 7/15/2024 CY 2024 Invoice #4 Invoice Packets Sent 8/30/2024 IGT Certifications Due 10/1/2024 Payment Due 10/1S/2024 DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 I, the undersigned, hereby declare and certify on behalf of the City of Newport Beach (the "Public Entity") as follows: 1. As a public administrator, a public officer, or other public individual, I am duly authorized to make this certification. 2. The Public Entity elects to make this intergovernmental transfer (IGT) to the Department of Health Care Service (DHCS) as a voluntary contribution to the non-federal share of Medi-Cal expenditures for purposes of Assembly Bill 1705 (2019) pursuant to Sections 14105.94, 14105.945, 14129, 14129.3, and 14164 of the Welfare and Institutions (W&I) Code. All funds transferred pursuant to this certification qualify for federal financial participation (FFP) pursuant to Section 1903(w) of the Social Security Act and Title 42 of the Code of Federal Regulations, Section 433 Subpart B, and are not derived from impermissible sources such as recycled Medicaid payments, federal money excluded from use as the non-federal share (NFS), impermissible health care -related taxes, or non -bona fide provider - related donations. 3. Voluntary contributions attributable to the period of January 1, 2023, through December 31, 2024, will be made via recurring transfers as indicated on the invoices provided to the Public Entity by DHCS. The voluntary contributions made by the Public Entity may also include adjustments related to the CY 2023 rating period's NFS reconciliation as described in paragraph 7 below. Please note, the total IGT amount at the bottom of this IGT certification will continue to be itemized on your invoice which is sent to you along with this IGT certification form 45-days in advance of the IGT contribution due date. The Public Entity acknowledges that any transfers made pursuant to this certification during this time period are consid- ered an elective IGT made pursuant to W&I Code sections 14105.945 and 14164, to be used by DHCS, subject to paragraph four herein, exclusively as the source for the NFS of ground emergency medical transport public provider supplemental payments in both Medi-Cal fee -for -service payments and the portion of the risk - based capitation rate to Medi-Cal managed care health plans associated with re- imbursement made in accordance with Section 14105.945, subdivision (h)(1) (hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Trans- portation (GEMT) Program, or the PP-GEMT Program), and DHCS costs associ- ated with administering the PP-GEMT Program. 4. DHCS may accept this voluntary contribution to the extent it is able to obtain FFP for the PP-GEMT Program as permitted by federal law. In the event DHCS is unable to obtain FFP for the PP-GEMT Program, or the full payments cannot otherwise be made to and retained by eligible public providers, and, therefore, all or a portion of the transferred amount cannot be used as the NFS of payments, DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 DHCS will notify the Public Entity via e-mail and return the applicable portion of the unused IGT amount. 5. The Public Entity acknowledges that, in accordance with W&I Code section 14105.945, subdivision (h)(2), DHCS shall assess a ten percent (10%) fee on each transfer of public funds to the state to pay for health care coverage and to reim- burse DHCS its costs associated with administering the PP-GEMT Program. 6. The Public Entity acknowledges that the IGT is to be used by DHCS for the filing of a claim with the federal government for federal funds and understands that any misrepresentation regarding the IGT may violate federal and state law. 7. The amount voluntarily transferred to DHCS is based on the estimated Medi-Cal fee -for -service and Medi-Cal managed care non-federal share of ground emer- gency medical transport payments, as referenced in paragraph three herein. Be- cause the amount to be voluntarily transferred to DHCS will be based on an esti- mate, the Public Entity acknowledges that a reconciliation of the voluntary NFS contributions to the actual NFS expenditures will occur. To the degree necessary to fund the NFS for the PP-GEMT Program, amounts due to or owed by Public Entity as a result of the reconciliation may be offset against, or added to, future transfers as applicable and as determined by DHCS. DHCS may accept a volun- tary contribution to the extent it is able to obtain FFP for PP-GEMT payments as permitted by federal law. 8. The Public Entity acknowledges that all records of funds transferred are subject to review and audit upon DHCS' request. The Public Entity will maintain documentation supporting the allowable funding source of the IGTs. 9. Upon notice from the federal government of a disallowance or deferral related to this IGT, the Public Entity responsible for this IGT shall be the entity responsible for the federal portion of that expenditure. I hereby declare under penalty of perjury under the law of the United States that the foregoing is true and correct to the best of my knowledge. I further understand that the known filing of a false or fraudulent claim, or making false statements in support of a claim, may violate the Federal False Claims Act or other applicable statute and federal law and may be punishable thereunder. DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 Executed on this day of , 2024 at , California. Signature of Authorized Person: Name of Authorized Person: Grace Leung Title of Authorized Person: City Manager Name of Public Entity: City of Newport Beach NPI of Public Entity: 1679579296 Amount of IGT: $99,888.56 Attest: Date- APPROVED AS TO FORM: CITY ATTORNEY'S OFFICE Date:_ f�_P-,1;,,/ Z ..7 4 By: ,- Aar . Harp Ci ttorney i PvHCS CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES Michelle Baass I Director PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION (PP-GEMT) PROGRAM MANAGED CARE AND FEE FOR SERVICE - INVOICE Provider Information: Due Date: 1o/1s/zoz4 Provider Name: City Of Newport Beach Payment Details: Year: 2024 Collection #: 4 NPI: 1679579296 Total Amount Due: $98,888.56 Program/Payee information: Banking Information: Vendor Name: Bank Name: California Department of Health Care Services US Bank Please await Wire Request Memo for payment instructions PP-GEMT Program Email: Payment Methods Accepted: AB1705(@dhcs.ca.gov JACH or Wire Transfer Payment Instructions: Attention: Please review, sign, and submit the Intergovernmental Transfer (IGT) Certification form by October 1, 2024, to AB1705@dhcs.ca.gov. IGT Certification forms are required to be submitted prior to each collection due date. Once the IGT Certification form is received, DHCS will send a Wire Request Memo providing payment details and instructions. Please do not send your IGT payment until you have received the Wire Request Memo as payment details are subject to change. Managed Care (MC) MC NFS #4 $87,005.94 MC Admin Fee #4 $0.00 MC Reconciliation #2 (Jul - Dec 2023) $2,276.30 Fee For Service (FFS) FFS NFS #4 $9,606.32 FFS Admin Fee #4 $0.00 Total* IGT Transfer Amount: $98,888.56 ces are due to rounding. CY 2024 Invoice tt1 Invoice Packets Sent 12/1/2023 IGTCertificationsDue 1/1/2024 Payment Due 1/1S/2024 CY 2024 Invoice Jt2 Invoice Packets Sent 3/1/2024 IGT Certifications Due 4/1/2024 Payment Due 4/1S/2024 CY 2024 Invoice tt3 Invoice Packets Sent 5/31/2024 IGTCertificationsDue 7/1/2024 Payment Due 7/iS/2024 Invoice Packets Sent 8/30/2024 CY 2024 IGTCertificationsDue 10/1/2024 Invoice 94 Payment Due 10/SS/2024 DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 I, the undersigned, hereby declare and certify on behalf of the City of Newport Beach (the "Public Entity") as follows: 1. As a public administrator, a public officer, or other public individual, I am duly authorized to make this certification. 2. The Public Entity elects to make this intergovernmental transfer (IGT) to the Department of Health Care Service (DHCS) as a voluntary contribution to the non-federal share of Medi-Cal expenditures for purposes of Assembly Bill 1705 (2019) pursuant to Sections 14105.94, 14105.945, 14129, 14129.3, and 14164 of the Welfare and Institutions (W&I) Code. All funds transferred pursuant to this certification qualify for federal financial participation (FFP) pursuant to Section 1903(w) of the Social Security Act and Title 42 of the Code of Federal Regulations, Section 433 Subpart B, and are not derived from impermissible sources such as recycled Medicaid payments, federal money excluded from use as the non-federal share (NFS), impermissible health care -related taxes, or non -bona fide provider - related donations. 3. Voluntary contributions attributable to the period of January 1, 2023, through December 31, 2024, will be made via recurring transfers as indicated on the invoices provided to the Public Entity by DHCS. The voluntary contributions made by the Public Entity may also include adjustments related to the CY 2023 rating period's NFS reconciliation as described in paragraph 7 below. Please note, the total IGT amount at the bottom of this IGT certification will continue to be itemized on your invoice which is sent to you along with this IGT certification form 45-days in advance of the IGT contribution due date. The Public Entity acknowledges that any transfers made pursuant to this certification during this time period are consid- ered an elective IGT made pursuant to W&I Code sections 14105.945 and 14164, to be used by DHCS, subject to paragraph four herein, exclusively as the source for the NFS of ground emergency medical transport public provider supplemental payments in both Medi-Cal fee -for -service payments and the portion of the risk - based capitation rate to Medi-Cal managed care health plans associated with re- imbursement made in accordance with Section 14105.945, subdivision (h)(1) (hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Trans- portation (GEMT) Program, or the PP-GEMT Program), and DHCS costs associ- ated with administering the PP-GEMT Program. 4. DHCS may accept this voluntary contribution to the extent it is able to obtain FFP for the PP-GEMT Program as permitted by federal law. In the event DHCS is unable to obtain FFP for the PP-GEMT Program, or the full payments cannot otherwise be made to and retained by eligible public providers, and, therefore, all or a portion of the transferred amount cannot be used as the NFS of payments, DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 DHCS will notify the Public Entity via e-mail and return the applicable portion of the unused IGT amount. 5. The Public Entity acknowledges that, in accordance with W&I Code section 14105.945, subdivision (h)(2), DHCS shall assess a ten percent (10%) fee on each transfer of public funds to the state to pay for health care coverage and to reim- burse DHCS its costs associated with administering the PP-GEMT Program. 6. The Public Entity acknowledges that the IGT is to be used by DHCS for the filing of a claim with the federal government for federal funds and understands that any misrepresentation regarding the IGT may violate federal and state law. 7. The amount voluntarily transferred to DHCS is based on the estimated Medi-Cal fee -for -service and Medi-Cal managed care non-federal share of ground emer- gency medical transport payments, as referenced in paragraph three herein. Be- cause the amount to be voluntarily transferred to DHCS will be based on an esti- mate, the Public Entity acknowledges that a reconciliation of the voluntary NFS contributions to the actual NFS expenditures will occur. To the degree necessary to fund the NFS for the PP-GEMT Program, amounts due to or owed by Public Entity as a result of the reconciliation may be offset against, or added to, future transfers as applicable and as determined by DHCS. DHCS may accept a volun- tary contribution to the extent it is able to obtain FFP for PP-GEMT payments as permitted by federal law. 8. The Public Entity acknowledges that all records of funds transferred are subject to review and audit upon DHCS' request. The Public Entity will maintain documentation supporting the allowable funding source of the IGTs. 9. Upon notice from the federal government of a disallowance or deferral related to this IGT, the Public Entity responsible for this IGT shall be the entity responsible for the federal portion of that expenditure. I hereby declare under penalty of perjury under the law of the United States that the foregoing is true and correct to the best of my knowledge. I further understand that the known filing of a false or fraudulent claim, or making false statements in support of a claim, may violate the Federal False Claims Act or other applicable statute and federal law and may be punishable thereunder. DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 Executed on this day of 2024 at , California. Signature of Authorized Person: Name of Authorized Person: Grace /eung Title of Authorized Person: City Manager Name of Public Entity: City of Newport Beach NPI of Public Entity: 1679579296 Amount of IGT: $99,716.91 APPROVED AS TO FORM: CITY ATTORNEY'S OFFICE Date; .6g Ao l 2 q By. A r n C. Harp, City Attorney Attest: r� Leilani 1. B6rown, M C, City Clerk Date: ►4HCS CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES Michelle Baass I Director PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION (PP-GEMT) PROGRAM MANAGED CARE AND FEE FOR SERVICE - INVOICE Provider Information: Due Date: 7/is/zoza Provider Name: City Of Newport Beach Payment Details: Year: 2024 Collection #: 3 NPI: 1679579296 Total Amount Due: $99,716.91 Program/Payee Information: 'Banking Information: Vendor Name: Bank Name: California Department of Health Care Services US Bank Please await Wire Request Memo for payment instructions PP-GEMT Program Email: Payment Methods Accepted: AB1705Ca@dhcs.ca.aov ACH or Wire Transfer Payment Instructions: Attention: Please review, sign, and submit the Intergovernmental Transfer (IGT) Certification form by July 1, 2024, to AB1705@dhcs.ca.gov. IGT Certification forms are required to be submitted prior to each collection due date. Once the IGT Certification form is received, DHCS will send a Wire Request Memo providing payment details and instructions. Please do not send your IGT payment until you have received the Wire Request Memo as payment details are subject to change. IGT Non -Federal Share [INFS) Breakdown By DHCS Delivery System Care (MC) MC NFS #3 $86,965.42 MC Admin Fee #3 $0.00 MC Reconciliation #1 (Jan - Jun 2023) $3,146.15 Fee For Service (FFS) FFS NFS #3 $9,605.34 FFS Admin Fee #3 $0.00 Total* IGT Transfer Amount: $99,716.91 *Any differences are due to rounding. Invoice Packets Sent 12/1/2023 CY 2024 IGT Certifications Due 1/1/2024 Invoice #1 Payment Due 1/15/2024 Invoice Packets Sent 3/1/2024 CY 2024 IGT Certifications Due 4/1/2024 Invoice It2 Payment Due 4/15/2024 Invoice Packets Sent 5/31/2024 CY 2024 IGT Certifications Due 7/1/2024 Invoice #3 Payment Due 7/15/2024 CY 2024 Invoice #4 Invoice Packets Sent 8/30/2024 IGT Certifications Due 10/1/2024 Payment Due 10/15/2024 DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 I, the undersigned, hereby declare and certify on behalf of the City of Newport Beach (the "Public Entity") as follows: 1. As a public administrator, a public officer, or other public individual, I am duly authorized to make this certification. 2. The Public Entity elects to make this intergovernmental transfer (IGT) to the Department of Health Care Service (DHCS) as a voluntary contribution to the non-federal share of Medi-Cal expenditures for purposes of Assembly Bill 1705 (2019) pursuant to Sections 14105.94, 14105.945, 14129, 14129.3, and 14164 of the Welfare and Institutions (W&I) Code. All funds transferred pursuant to this certification qualify for federal financial participation (FFP) pursuant to Section 1903(w) of the Social Security Act and Title 42 of the Code of Federal Regulations, Section 433 Subpart B, and are not derived from impermissible sources such as recycled Medicaid payments, federal money excluded from use as the non-federal share (NFS), impermissible health care -related taxes, or non -bona fide provider - related donations. 3. Voluntary contributions attributable to the period of January 1, 2023, through December 31, 2024, will be made via recurring transfers as indicated on the invoices provided to the Public Entity by DHCS. The voluntary contributions made by the Public Enty may also include adjustments related to the CY 2023 rating period's NFS reconciliation as described in paragraph 7 below. Please note, the total IGT amount at the bottom of this IGT certification will continue to be itemized on your invoice which is sent to you along with this IGT certification form 45-days in advance of the IGT contribution due date. The Public Entity acknowledges that any transfers made pursuant to this certification during this time period are consid- ered an elective IGT made pursuant to W&I Code sections 14105.945 and 14164, to be used by DHCS, subject to paragraph four herein, exclusively as the source for the NFS of ground emergency medical transport public provider supplemental payments in both Medi-Cal fee -for -service payments and the portion of the risk - based capitation rate to Medi-Cal managed care health plans associated with re- imbursement made in accordance with Section 14105.945, subdivision (h)(1) (hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Trans- portation (GEMT) Program, or the PP-GEMT Program), and DHCS costs associ- ated with administering the PP-GEMT Program. 4. DHCS may accept this voluntary contribution to the extent it is able to obtain FFP for the PP-GEMT Program as permitted by federal law. In the event DHCS is unable to obtain FFP for the PP-GEMT Program, or the full payments cannot otherwise be made to and retained by eligible public providers, and, therefore, all or a portion of the transferred amount cannot be used as the NFS of payments, DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 DHCS will notify the Public Entity via e-mail and return the applicable portion of the unused IGT amount. 5. The Public Entity acknowledges that, in accordance with W&I Code section 14105.945, subdivision (h)(2), DHCS shall assess a ten percent (10%) fee on each transfer of public funds to the state to pay for health care coverage and to reim- burse DHCS its costs associated with administering the PP-GEMT Program. 6. The Public Entity acknowledges that the IGT is to be used by DHCS for the filing of a claim with the federal government for federal funds and understands that any misrepresentation regarding the IGT may violate federal and state law. 7. The amount voluntarily transferred to DHCS is based on the estimated Medi-Cal fee -for -service and Medi-Cal managed care non-federal share of ground emer- gency medical transport payments, as referenced in paragraph three herein. Be- cause the amount to be voluntarily transferred to DHCS will be based on an esti- mate, the Public Entity acknowledges that a reconciliation of the voluntary NFS contributions to the actual NFS expenditures will occur. To the degree necessary to fund the NFS for the PP-GEMT Program, amounts due to or owed by Public Entity as a result of the reconciliation may be offset against, or added to, future transfers as applicable and as determined by DHCS. DHCS may accept a volun- tary contribution to the extent it is able to obtain FFP for PP-GEMT payments as permitted by federal law. 8. The Public Entity acknowledges that all records of funds transferred are subject to review and audit upon DHCS' request. The Public Entity will maintain documentation supporting the allowable funding source of the IGTs. 9. Upon notice from the federal government of a disallowance or deferral related tc this IGT, the Public Entity responsible for this IGT shall be the entity responsible for the federal portion of that expenditure. I hereby declare under penalty of perjury under the law of the United States that the foregoing is true and correct to the best of my knowledge. I further understand that the known filing of a false or fraudulent claim, or making false statements in support of a claim, may violate the Federal False Claims Act or other applicable statute and federal law and may be punishable thereunder. DEPARTMENT OF HEALTH CARE SERVICES PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES CERTIFICATION FORM FOR STATE CALENDAR YEAR 2024 Executed on this 20414 day of rYl�` 2024 at AA� f of � (fit, California. Signature of Authorized Person: — &�= 1-� --- Name of Authorized Person: Grace K. 6�91 Title of Authorized Person: City Manager Name of Public Entity: City of Newport Beach NPI of Public Entity: 1679579296 Amount of IGT: $95,999.34 APPROVED AS TO FORM: CITY ATTO ET iGB on C. Harp, City Attorney Attest: C f Leilani 1. Brc.wm, NAM , City Clerk On,te: _. 19 i