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Home My WebLink AboutC-5635-4 - Public Provider Intergovernmental Transfer Program for Ground Emergency Medical Transportation (GEMT) Services Certification Form for State Calendar Year 2026P44 H C S CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES Michelle Baass I Director PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION PROGRAM INTERGOVERNMENTAL TRANSFER CERTIFICATION FORM STATE CALENDAR YEAR 2026 I, the undersigned, hereby declare and certify on behalf of 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 (NFS) 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 NFS, impermissible health care -related taxes, or non -bona fide provider - related donations. 3. Voluntary contributions attributable to the period of January 1, 2024, through December 31, 2026, 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 calendar year (CY) 2024 and CY 2025 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 considered 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 California Department of Health Care Services Capitated Rates Development Division 1501 Capitol Avenue, P.O. Box 997413 Sacramento, CA 1 95899-7413 MS 4413 1 www.dhcs.ca.gov State of California ' \ Gavin Newsom, Governor 7 California Health and Human Services Agency PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION PROGRAM INTERGOVERNMENTAL TRANSFER CERTIFICATION FORM STATE CALENDAR YEAR 2026 Medi-Cal fee for service (FFS) payments and the portion of the risk -based capitation rate to Medi-Cal managed care health plans associated with reimbursement made in accordance with Section 14105.945, subdivision (h)(1) (hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Transportation (GEMT) Program, or the (PP-GEMT Program), and DHCS costs associated 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, 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 state law in W&I Code section 14105.945, subdivision (h)(2) authorizes DHCS, upon obtaining any necessary approvals, to assess a ten percent (10%) fee on each transfer of public funds to the state to pay for health care coverage and to reimburse DHCS its costs associated with administering the PP-GEMT Program. The Public Entity acknowledges that while DHCS is not assessing this fee currently pending federal approval, DHCS has not waived its right to assess the administrative fee under state law upon obtaining any necessary federal approvals. 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 FFS and Medi-Cal managed care NFS of ground emergency medical transport payments, as referenced in paragraph three herein. Since the amount to be voluntarily transferred to DHCS will be based on an estimate, 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 California Department of Health Care Services Capitated Rates Development Division 1501 Capitol Avenue, P.O. Box 997413 Sacramento, CA 1 95899-7413 MS 4413 1 www.dhcs.ca.gov State of California Gavin Newsom, Governor California Health and Human Services Agency PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION PROGRAM INTERGOVERNMENTAL TRANSFER CERTIFICATION FORM STATE CALENDAR YEAR 2026 and as determined by DHCS. DHCS may accept a voluntary 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. Executed on this -`ILI 7 — day of 20 nt ,�x�l drp� &*<4/ , California. Signature of Authorized Person: �.�Q w Name of Authorized Person: Sei mone J U g iS Title of Authorized Person: Name of Public Entity: NPI of Public Entity: City Manager CITY OF NEWPORT BEACH 1679579296 Amount of IGT: $126,8S8.98_ 'r 1OVED AS TO FORM: ATTORNF---'Y'§ OFFICE Date: 12124Z<- By: !i` 0 a on C. Harp, City Attorney ti4 12 titi /aer California Department of Health Care Services Capitated Rates Development Division 1501 Capitol Avenue, P.O. Box 997413 Sacramento, CA 1 95899-7413 MS 4413 1 www.dhcs.ca.gov Attest: City Clerk State of California 6 Gavin Newsom, Governor W' California Health and Human Services Agency P&HCS 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 �Entity Information: - 1/16/2026 Entity Name: City Of Newport Beach Payment Details: Year: 2026 Contribution #: 1 NPI: 1679579296 Total Amount Due: $126,858.98 I Program/Payee Information: Banking Information: Vendor Name: Bank Name: California Department of Health Care Services US Banl< Please await Wire Request Memo for payment instructions PP-GEMT Program Email: Payment Methods Accepted: AB1705(c@dhcs.ca.gov fACH or Wire Transfer Payment Instructions: Attention: Please review, sign, and submit the Intergovernmental Transfer (IGT) Certification form by January 2, 202.6, 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. are due to Managed Care (MC) MC NFS #1 $ 113,403.72 Fee For Service (FFS) FFS NFS #1 $ 13,455.26 Total* IGT Transfer Amount: $ 126,858.98 CY 2026 Invoice #1 Invoice Packets Sent 12/2/2025 IGT Certifications Due 1/2/2026 Payment Due 1/16/2026 CY 2026 Invoice #2 Invoice Packets Sent 3/3/2026 IGT Certifications Due 4/3/2026 Payment Due 4/17/2026 CY 2024 FFS Recon #1 Date of Service Jan - Jun 2024 CY 2025 MC Recon #1 Date of Service TBD CY 2026 Invoice #3 Invoice Packets Sent 6/2/2026 IGT Certifications Due 7/3/2026 Payment Due 7/17/2026 CY 2026 Invoice #4 Invoice Packets Sent 9/1/2026 IGT Certifications Due 10/2/2026 Payment Due 10/16/2026 CY 2024 FFS Recon #2 Date of Service Jul - Dec 2024 CY 2025 MC Recon #2 Date of Service TBD