HomeMy WebLinkAboutC-8085-2A - Health Plan-Provider Intergovernmental Transfer Rate Range Program Agreement 2017HEALTH PLAN -PROVIDER AGREEMENT
INTERGOVERNMENTAL TRANSFER RATE RANGE PROGRAM AGREEMENT
This Agreement is made this' 3 day of lip`( , 2017, by and between
CALOPTIMA, a California public agency hereinafter referred to as 'PLAN", and the City of
Newport Beach, a California municipal corporation and charter city operating through its Fire
Department, hereinafter referred to as "PROVIDER".
RECITALS:
WHEREAS, PLAN is a public agency formed pursuant to California Welfare and
Institutions Code Section 14087.54 and Orange County Ordinance No. 3896 as amended by
Ordinance Nos. 00-8, 05-008, 06-012, 09-001, 11-013, 14-002 and 16-001, and is party to a
Medi -Cal managed care contract with DHCS, entered into pursuant to Welfare and Institutions
Code Section 14087.3, under which PLAN arranges and pays for the provision of covered Medi -
Cal health care services to eligible Medi -Cal members residing in Orange County;
WHEREAS, PROVIDER is a public healthcare provider of emergency
ambulance transport services, which is a covered Medi -Cal health care service, to persons
enrolled with Medi -Cal Managed Care Health Plan Providers, including PLAN;
WHEREAS, PLAN and PROVIDER desire to enter into this Agreement to
provide for Medi -Cal managed care capitation rate increases to PLAN as a result of
intergovernmental transfers ("IGTs") from City of Newport Beach (GOVERNMENTAL
FUNDING ENTITY) to the California Department of Health Care Services ("State DHCS") to
maintain the availability of Medi -Cal health care services to Medi -Cal beneficiaries.
NOW, THEREFORE, PLAN and PROVIDER hereby agree as follows:
IGT MEDI-CAL MANAGED CARE CAPITATION RATE RANGE INCREASES
1. IGT Capitation Rate Ranee Increases to PLAN
A. Payment
Should PLAN receive any Medi -Cal managed care capitation rate increases from
State DHCS where the nonfederal share is funded by the GOVERNMENTAL FUNDING
ENTITY specifically pursuant to the provisions of the Intergovernmental Agreement Regarding
Transfer of Public Funds, 416-93671 ("Intergovernmental Agreement') effective for the periods
of July 1, 2015 through June 30, 2016 and July 1, 2016 through June 30, 2017 for
Intergovernmental Transfer Medi -Cal Managed Care Rate Range Increases ("IGT MMCRRIs"),
PLAN shall pay to PROVIDER the amount of the IGT MMCRRIs received from State DHCS, in
accordance with paragraph LE below regarding the form and timing of Local Medi -Cal
Managed Care Rate Range ("LMMCRR") IGT Payments. LMMCRR IGT Payments paid to
PROVIDER shall not replace or supplant any other amounts paid or payable to PROVIDER by
PLAN. For purposes of this Agreement, the phrase "GOVERNMENTAL FUNDING ENTITY"
shall have the same meaning as in the Intergovernmental Agreement.
B. Health Plan Retention
(1) Medi -Cal Managed Care Seller's Tax
(a) The PLAN shall be responsible for any Medi -Cal Managed Care
Seller's ("MMCS") tax due pursuant to the Revenue and Taxation Code Section 6175 relating to
any IGT MMCRRIs through June 30, 2016. If the PLAN receives any capitation rate increases
for MMCS taxes based on the IGT MMCRRIs, PLAN may retain an amount equal to the amount
of such MMCS tax that PLAN is required to pay to the State Board of Equalization, and shall
pay, as part of the LMMCRR IGT Payments, the remaining amount of the capitation rate
increase to PROVIDER.
(b) This paragraph does not apply to any service months on or after
July 1, 2016.
(2) a. PLAN shall retain 19.68%, from the Medi -Cal managed care rate
increases paid to PLAN by DHCS as described in this Agreement prior to disbursing LMMCRR
IGT Payments to PROVIDER. Such retained funds will be expended by PLAN in support of
Medi -Cal beneficiaries and the Medi -Cal program, in either the State fiscal year received or in
subsequent State fiscal years, to make improvements in one or more of the following areas upon
approval by the CalOptima Board of Directors as follows:
• Community health investments as identified by a member health needs assessment
being conducted in CY 2017. Investment areas may include programs addressing opioid
overuse, homeless health care access, children's mental health, adult mental health,
childhood obesity, strengthening the safety net, children's health, older adult health and
other areas as identified;
• Up to three percent (3%) of the amount retained by CalOptima will be expended
on administration of the IGT program and any programs developed within the community
health investment areas above.
Each provider's share of retained amounts shall be calculated based on the provider's
proportionate share of the LMMCRR IGT payment made by PLAN in Orange County.
b. The amounts referenced in this Agreement are estimates. The parties
understand and agree that the total amount of the Medi -Cal managed care capitation rate
increases paid by DHCS to PLAN may fluctuate as a result of enrollment. The parties further
understand and agree that any such fluctuations will likewise affect the amount to be retained by
the PLAN and the amount payable to PROVIDER by the same percentage as the variance in the
capitation rate increases, if any.
Template Version- 2017
(3) PLAN will not retain any other portion of the IGT MMCRRIs received
from the State DHCS other than those mentioned above.
C. Conditions for Receivin¢ Local Medi -Cal Managed Care Rate Ranee IGT
Payments
As a condition for receiving LMMCRR IGT Payments, PROVIDER shall, as of
the date the particular LMMCRR IGT Payment is due:
(1) continue to provide emergency transport services to PLAN
Members promptly and in a manner which ensures access to care consistent with PROVIDER's
regular business practices for providing such services; and
(2) not discriminate against PLAN Members or in any way impose
limitations on the acceptance of PLAN Members for care or treatment that are not imposed on
other patients of PROVIDER.
D. Schedule and Notice of Transfer of Non -Federal Funds
1. PROVIDER shall provide PLAN with a copy of the schedule regarding the
transfer of funds to State DHCS referred to in the Intergovernmental Transfer Agreement within
fifteen (15) calendar days of establishing such schedule with State DHCS. Additionally,
PROVIDER shall notify PLAN, in writing, no less than seven (7) calendar days prior to any
changes to an existing schedule, including but not limited to, changes to the amounts specified
therein.
2. PROVIDER shall provide PLAN with written notice of the amount and date of
the transfer within seven (7) calendar days after funds have been transferred to State DHCS for
use as the nonfederal share of any IGT MMCRRIs.
E. Form and Timing of Payments
PLAN agrees to pay LMMCRR IGT Payments to PROVIDER in the following
form and according to the following schedule:
(1) PLAN agrees to pay the LMMCRR IGT Payments to PROVIDER using
the same mechanism through which compensation and payments are normally paid to
PROVIDER (e.g., electronic transfer).
(2) PLAN will pay the LMMCRR IGT Payments to PROVIDER no later than
thirty (30) calendar days after receipt of the IGT MMCRRIs from State DHCS.
Template Version- 2017
F. Consideration
(1) As consideration for the LMMCRR IGT Payments, PROVIDER shall use
the LMMCRR IGT Payments for the following purposes and shall treat the LMMCRR IGT
Payments in the following manner:
(a) The LMMCRR IGT Payments shall represent compensation for
Medi -Cal services rendered to Medi -Cal PLAN members by PROVIDER during the State fiscal
year to which the LMMCRR IGT Payments apply.
(b) To the extent that total payments received by PROVIDER for any
State fiscal year under this Agreement exceed the cost of Medi -Cal services provided to Medi -
Cal beneficiaries by PROVIDER during that fiscal year, any remaining LMMCRR IGT Payment
amounts shall be retained by PROVIDER to be expended for health care services. Retained
LMMCRR IGT Payment amounts may be used by the PROVIDER in either the State fiscal year
for which the payments are received or subsequent State fiscal years.
(2) For purposes of subsection (1) (b) above, if the retained LMMCRR IGT
Payments, if any, are not used by PROVIDER in the State fiscal year received, retention of funds
by PROVIDER will be established by demonstrating that the retained earnings account of
PROVIDER at the end of any State fiscal year in which it received payments based on
LMMCRR IGT Payments funded pursuant to the Intergovernmental Agreement, has increased
over the unspent portion of the prior State fiscal year's balance by the amount of LMMCRR IGT
Payments received, but not used. These retained PROVIDER funds may be commingled with
other GOVERNMENTAL FUNDING ENTITY funds for cash management purposes provided
that such funds are appropriately tracked and only the depositing facility is authorized to expend
them.
(3) Both parties agree that none of these funds, either from the
GOVERNMENTAL FUNDING ENTITY or federal matching funds will be recycled back to the
GOVERNMENTAL FUNDING ENTITY'S general fund, the State, or any other intermediary
organization. Payments made by the health plan to providers under the terms of this Agreement
constitute patient care revenues.
G. PLAN's Oversieht Responsibilities
PLAN's oversight responsibilities regarding PROVIDER's use of the LMMCRR
IGT Payments shall be limited as described in this paragraph. PLAN shall request, within thirty
(30) calendar days after the end of each State fiscal year in which LMMCRR IGT Payments
were transferred to PROVIDER, a written confirmation that states whether and how PROVIDER
complied with the provisions set forth in Paragraph 1.17 above. In each instance, PROVIDER
shall provide PLAN with written confirmation of compliance within thirty (30) calendar days of
PLAN's request.
Template Version- 2017
H. Cooperation Among Parties
Should disputes or disagreements arise regarding the ultimate computation or
appropriateness of any aspect of the LMMCRR IGT Payments, PROVIDER and PLAN agree to
work together in all respects to support and preserve the LMMCRR IGT Payments to the full
extent possible on behalf of the safety net in Orange County.
I. Reconciliation
Within one hundred twenty (120) calendar days after the end of each of PLAN's
fiscal years in which LMMCRR IGT Payments were made to PROVIDER, PLAN shall perform
a reconciliation of the LMMCRR IGT Payments transmitted to the PROVIDER during the
preceding fiscal year to ensure that the supporting amount of IGT MMCRRIs were received by
PLAN from State DHCS. PROVIDER agrees to return to PLAN any overpayment of LMMCRR
IGT Payments made in error to PROVIDER within thirty (30) calendar days after receipt from
PLAN of a written notice of the overpayment error, unless PROVIDER submits a written
objection to PLAN. Any such objection shall be resolved in accordance with the dispute
resolution process set forth in Section I.H. The reconciliation processes established under this
paragraph are distinct from the indemnification provisions set forth in Paragraph 1.J below.
PLAN agrees to transmit to the PROVIDER any underpayment of LMMCRR IGT Payments
within thirty (30) calendar days of PLAN's identification of such underpayment.
J. Indemnification
PROVIDER agrees to and acknowledges the following:
(1) PLAN has no obligation to make any payments hereunder until PLAN has
received IGT MMCRRIs from State DHCS;
(2) that PLAN is not responsible for State DHCS payments to PLAN, including
any mathematical calculations made by DHCS;
(3) PLAN is not responsible for the timing of the payments from DHCS to PLAN
(including the conditions precedent to the timing of such payments which includes the timing of
DHCS submission to CMS and/or CMS review and approval). In addition, PLAN and
PROVIDER agree and acknowledge that nothing herein is intended to create an obligation on the
part of PLAN to agree to delays in capitation payment(s) from State DHCS in order to
accommodate this IGT; and
(4) In the event of any dispute or legal action arising under this Agreement, the
prevailing party shall not be entitled to attorneys' fees.
Template Version- 2017
2. Term
The term of this Agreement shall commence on July 1, 2015 and shall terminate
on September 30, 2019.
SIGNATURES
HEALTH PLAN: CalOptima Date: 5-25'--1)
By: Michael Schrader, Chief Executive Officer
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
Date: %
By:
Aaron C. Harp
City Attorney
ATTEST:
Date:
By: ol►
Leilani I. Brown
City Clerk
Template Version- 2017
CITY OF NEWPORT BEACH,
a California municipal corporation and
charter city operating through its Fire
Department
Date:
LM
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