HomeMy WebLinkAboutC-5635-1 - Public Provider Intergovernmental Transfer Program for Ground Emergency Medical Transportation (GEMT) Services Certification Form for State Calendar Year 2023DEPARTMENT OF HEALTH CARE SERVICES
PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR
GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES
CERTIFICATION FORM FOR STATE CALENDAR YEAR 2023
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 au-
thorized to make this certification.
2. The Public Entity elects to make this intergovernmental transfer (IGT) to the De-
partment 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 Wel-
fare 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 Med-
icaid payments, federal money excluded from use as the non-federal share, im-
permissible health care -related taxes, or non -bona fide provider -related donations.
3. Voluntary contributions attributable to the period of January 1, 2023, through De-
cember 31, 2023, will be made via recurring transfers as indicated on the invoices
provided to the Public Entity by DHCS. 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
non-federal share of ground emergency medical transport public provider supple-
mental 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
reimbursement made in accordance with Section 14105.945, subdivision (h)(1)
(hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Trans-
portation (GEMT) Intergovernmental Transfer (IGT) Program, or the PP-GEMT
IGT Program), and DHCS costs associated with administering the PP-GEMT IGT
Program.
4. DHCS may accept this voluntary contribution to the extent it is able to obtain FFP
for the PP-GEMT IGT Program as permitted by federal law. In the event DHCS is
unable to obtain FFP for the PP-GEMT IGT 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 non-federal share of
payments, DHCS will notify the Public Entity via e-mail and return the applicable
portion of the unused IGT amount, no later than 90 days after such notification.
5. The Public Entity acknowledges that, in accordance with W&I Code section
14105.945, subdivision (h)(2), upon CMS approval, DHCS shall assess a ten per-
cent (10%) fee on each transfer of public funds to the state to pay for health care
DEPARTMENT OF HEALTH CARE SERVICES
PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR
GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES
CERTIFICATION FORM FOR STATE CALENDAR YEAR 2023
coverage and to reimburse DHCS its costs associated with administering the PP-
GEMT IGT 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 Public Entity acknowledges that all records of funds transferred are subject
to review and audit upon DHCS' request. The Public Entity will maintain docu-
mentation supporting the allowable funding source of the IGTs.
8. 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 fore-
going 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 %y day of Nov , 2023 at WewPoaT RN4c+l , California.
Signature of Authorized Person: 15"
Name of Authorized Person: Grace K. eung
APPROVED AS TO FORM:
Title of Authorized Person: City Manager CITYATTOLHayrp,'City
OFFINameof Public Entity: City of Newport Beach By- nCAttorr
NPI of Public Entity: 1679579296
Amount of IGT: $129,133.17 Attest:
S
Leilani 1. Brown, MMC, City Clerk
Date:
DEPARTMENT OF HEALTH CARE SERVICES
PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR
GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES
CERTIFICATION FORM FOR STATE CALENDAR YEAR 2023
I, the undersigned, hereby declare and certify on behalf of City of Newport Beach (the
"Public Entity") as follows:
As a public administrator, a public officer, or other public individual, I am duly au-
thorized to make this certification.
2. The Public Entity elects to make this intergovernmental transfer (IGT) to the De-
partment 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 Wel-
fare 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 Med-
icaid payments, federal money excluded from use as the non-federal share, im-
permissible health care -related taxes, or non -bona fide provider -related donations.
3. Voluntary contributions attributable to the period of January 1, 2023, through De-
cember 31, 2023, will be made via recurring transfers as indicated on the invoices
provided to the Public Entity by DHCS. 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
non-federal share of ground emergency medical transport public provider supple-
mental 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
reimbursement made in accordance with Section 14105.945, subdivision (h)(1)
(hereafter, the AB 1705 Public Provider (PP) Ground Emergency Medical Trans-
portation (GEMT) Intergovernmental Transfer (IGT) Program, or the PP-GEMT
IGT Program), and DHCS costs associated with administering the PP-GEMT IGT
Program.
4. DHCS may accept this voluntary contribution to the extent it is able to obtain FFP
for the PP-GEMT IGT Program as permitted by federal law. In the event DHCS is
unable to obtain FFP for the PP-GEMT IGT 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 non-federal share of
payments, DHCS will notify the Public Entity via e-mail and return the applicable
portion of the unused IGT amount, no later than 90 days after such notification.
5. The Public Entity acknowledges that, in accordance with W&I Code section
14105.945, subdivision (h)(2), upon CMS approval, DHCS shall assess a ten per-
cent (10%) fee on each transfer of public funds to the state to pay for health care
DEPARTMENT OF HEALTH CARE SERVICES
PUBLIC PROVIDER INTERGOVERNMENTAL TRANSFER PROGRAM FOR
GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES
CERTIFICATION FORM FOR STATE CALENDAR YEAR 2023
coverage and to reimburse DHCS its costs associated with administering the PP-
GEMT IGT 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 Public Entity acknowledges that all records of funds transferred are subject
to review and audit upon DHCS' request. The Public Entity will maintain docu-
mentation supporting the allowable funding source of the IGTs.
8. 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 fore-
going 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 13th day of June, 2023 at Newport Beach, California.
Signature of Authorized Person:
Name of Authorized Person: Grace VLeung
Title of Authorized Person: City Manager APPROVED AS TO FORM:CITYATTOfT
OFFICE
Name of Public Entity: City of Newport Beach
Date: y3
NPI of Public Entity: 1679579296
Amount of IGT: $134,477.47
Attest:
�' /�111' '0�1 #
Lailani I. Brr n, M C, City Clerk
Date. IAZ2023
By. v
2 C. 4pityAttorney
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