HomeMy WebLinkAboutC-5635 - Media-Cal Ground Medical Transportation Services (GEMT) Supplemental Reimbursement Program Provider Participation Agreement,�i
GEMT Provider Participation Agreement
FY 2010/2014
MEDI-CAL GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES (GEMT)
SUPPLEMENTAL REIMBURSEMENT PROGRAM
PROVIDER PARTICIPATION AGREEMENT
Name of Provider: City of Newport Beach
NPI Provider# 1679579296
ARTICLE 1- STATEMENT OF INTENT
The purpose of this Agreement is to allow participation in the Ground Emergency Medical
Transportation Supplemental Reimbursement Program (GEMT program) by the governmentally
owned or operated provider, named above and hereinafter referred to as Provider, subject to
Provider's compliance with the responsibilities set forth in this Agreement with the California
Department of Health Care Services (DHCS), hereinafter referred to as the State or DHCS, as
authorized in State law pursuant to section 14105.94 of the California Welfare and Institutions
Code.
ARTICLE 2- TERM OF AGREEMENT
A. This Agreement begins on January 30, 2010, and stays in effect until this Agreement is
terminated or the GEMT program ends pursuant to the repeal of State or federal statutory
authority to make payments or claim federal reimbursement.
B. Either party may terminate this Agreement, without cause, by delivering written notice of
termination to the other party at least thirty (30) days prior to the effective date of termination.
C. Failure by Provider to comply with Provider's responsibilities under Article 3 shall constitute a
material breach of this Agreement, which shall result in termination by Provider pursuant to
Paragraph B. Provider may prevent the termination of this Agreement pursuant to this
Paragraph by curing any material breach prior to termination of this Agreement, unless actions
giving rise to the material breach result from not complying with Paragraphs K, L, M, or N of
Article 3.
D. Failure by Provider to comply with Provider's responsibilities under Paragraph 0 of Article 3
shall result in an immediate suspension of this Agreement and initiate termination pursuant to
Paragraph B. Upon suspension, the Provider may not participate in the GEMT program,
Provider's claims identified in Article 4 shall not be reimbursed, and DHCS is no longer subject
to its obligations in Article 4. Provider may reverse the suspension and prevent termination by
complying with Paragraph 0 of Article 3 in its entirety.
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GEMT Provider Participation Agreement
FY 2010/2014
ARTICLE 3- GEMT PROVIDER RESPONSIBILITIES
By entering into this Agreement, the Provider agrees to:
A. Comply with Title XIX of the Social Security Act, as periodically amended; Titles 42 and 45 of
the Code of Federal Regulations (CFR), as periodically amended; The California Medicaid
State Plan, as periodically amended; Chapter 7 (commencing with Section 14000) of the
California Welfare and Institutions (W&I) Code, as periodically amended; Division 3 of Title 22
of the California Code of Regulations (CCR) (commencing with Section 50000), as periodically
amended; State issued policy directives, including Policy and Procedure Letters, as
periodically amended; and federal Office of Management and Budget (OMB) Circular A-87,as
periodically amended.
B. Ensure all applicable State and federal requirements, as identified in Paragraph A of Article 3,
are met in rendering services under this Agreement. It is understood and agreed that failure
by the Provider to ensure all applicable State and federal requirements are met in rendering
services subject to supplemental reimbursement under this Agreement shall be sufficient
cause for the State to deny or recoup payments to the Provider as well as termination of this
Agreement.
C. Submit an annual participation survey to DHCS by July 1 of each state fiscal year to:
Regular U.S. Postal Service Mail: Overnight or Express Mail:
Department of Health Care Services Safety Department of Health Care Services Safety Net
Net Financing, GEMT Program P.O. Box Financing, GEMT Program
997436, MS 4504 1501 Capitol Ave, MS 4504
Sacramento, CA 95899-7436 Sacramento, CA 95814
D. Comply with the following Expense Allowability and Fiscal Documentation requirements:
1) Provider cost report and claim form that are accepted or submitted for payment by the
State shall not be deemed evidence of allowable Agreement costs.
2) Provider shall maintain for review and audit and supply to the State, upon request,
auditable documentation of all amounts claimed pursuant to this Agreement to permit a
determination of expense allowability.
3) If the allowability or appropriateness of an expense cannot be determined by the State
because invoice detail, fiscal records, or backup documentation is nonexistent or
inadequate, according to generally accepted accounting principles or practices, all
questionable costs may be disallowed and payment may be withheld by the State. Upon
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FY 2010/2014
GEMT Provider Participation Agreement
receipt of adequate documentation supporting a disallowed or questionable expense,
reimbursement may resume for the amount substantiated and deemed allowable.
E. By November 30 of each year:
1) Submit a signed electronic PDF copy of the annual GEMT Cost Report for the prior fiscal
year ending June 30, to: GEMTSubmissionsadhcs.ca.gov
F. Accept payment in full the reimbursement received for services subject to supplemental
reimbursement pursuant to this Agreement.
G. Comply with confidentiality requirements as specified in paragraph (7) of subsection (a) of
section 1396a of Title 42 of the United States Code, 42 CFR 431.300, W&I Code sections
14100.2 and 14132.47, and 22 CCR Section 51009.
H. Submit claims in accordance with 42 CFR 433.51.
Retain all necessary records for a minimum of three (3) years after the end of the quarter in
which the provider submitted its cost reports to DHCS. If an audit is in progress, all records
relevant to the audit shall be retained until the completion of the audit or the final resolution of
all audit exceptions, deferrals, and/or disallowances. Records must fully disclose the name
and Medi-Cal number or beneficiary identification code (BIC) of the person receiving the
services, the name of the provider agency and person providing the service, the date and
place of service delivery, and the nature and extent of the service provided. The Provider
shall furnish said records and any other information regarding expenditures and revenues for
providing services, upon request, to the State and to the federal government.
J. Be responsible for the acts or omissions of its employees and/or subcontractors.
K. Comply with the following requirements pertaining to exclusions. The conviction of an
employee or subcontractor of the Provider, or of an employee of a subcontractor, of any felony
or of a misdemeanor involving fraud, abuse of any Medi-Cal beneficiary, or abuse of the Medi-
Cal program, shall result in the exclusion of that employee or subcontractor, or employee of a
subcontractor, from participation in the GEMT Program. Failure to exclude a convicted
individual from participation in the GEMT Program shall constitute a breach of this Agreement.
L. Comply with the following requirements pertaining to exclusions. Exclusion after conviction
shall result regardless of any subsequent order under section 1203.4 of the Penal Code
allowing a person to withdraw his or her plea of guilty and to enter a plea of not guilty, or
setting aside the verdict of guilty, or dismissing the accusation, information, or indictment.
M. Comply with the following requirements pertaining to exclusions. Suspension or exclusion of
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GEMT Provider Participation Agreement
FY 2010/2014
an employee or a subcontractor, or of an employee of a subcontractor, from participation in
the Medi-Cal program, the Medicaid program, or the Medicare program, shall result in the
exclusion of that employee or subcontractor, or employee of a subcontractor, from
participation in the GEMT program. Failure to exclude a suspended or excluded individual
from participation in the GEMT program shall constitute a breach of this Agreement.
N. Comply with the following requirements pertaining to exclusions. Revocation, suspension, or
restriction of the license, certificate, or registration of any employee, subcontractor, or
employee of a subcontractor, shall result in exclusion from the GEMT program, when such
license, certificate, or registration is required for the provision of services. Failure to exclude
an individual whose license, certificate, or registration has been revoked, suspended, or
restricted from the provision of services may constitute a breach of this Agreement.
0. Enter into a separate agreement with a host entity in order to satisfy the requirements in
subdivision (d) of section 14105.94 of the W&I Code where the host entity will collect the
payments from Provider in order to pay DHCS for its administrative costs, which are the
costs incurred by DHCS pursuant to its responsibilities described in Article 4. If Provider is the
host entity, then it shall enter into a separate agreement with DHCS to pay the administrative
costs incurred in processing the claims of the GEMT program invoiced through the separate
agreement. If Provider is the host entity and contracts with at least one other provider for
purposes of participating in the GEMT program, then it shall enter into an agreement with
other such providers participating in the GEMT program to collect payments from the other
providers for DHCS's administrative costs incurred in processing the other provider's claims
under the GEMT program.
ARTICLE 4- STATE RESPONSIBILITIES
By entering into this Agreement, the State agrees to:
A. Lead the development, implementation, and administration for the GEMT program and ensure
compliance with the provisions set forth in the California Medicaid State Plan.
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.
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GEMT Provider Participation Agreement
FY 2010/2014
447-Payments For Services.
E. Complete the audit and settlement process of the interim reconciliations for the claiming period
within three (3) 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 GEMT 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 CFR 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 program. Accounting records shall include
continuous time logs for identified staff that record time spent in the following areas: the GEMT
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.
Designate a person to act as liaison with Provider in regard to issues concerning this
Agreement. This person shall be identified to Provider's contact person for this Agreement.
J. Provide a written response by email or mail to Provider's contact person within thirty (30) days
of receiving a written request for information related to the GEMT program.
K. Provide program technical assistance and training related to the GEMT program to provider
personnel after receiving a written request from Provider contact person.
ARTICLE 5 -PROJECT REPRESENTATIVES
A. The project representatives during the term of this Agreement will be:
Department of Health Care Services
Provider
Name: Faye Borton
City of Newport Beach
Unit: Quality Assurance Fee
Telephone: (949)644-3106
Telephone: (916) 552-9113
Fax (949)644-3120
Fax: (916) 552-8651
Email: sposter@nbfd.net
Email: GEMT@dhcs.ca.00v
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GEMT Provider Participation Agreement
B. Direct all inquiries to:
FY 2010/2014
Department of Health Care Services Provider: City of Newport Beach
Section: Medi-Cal Supplemental Payments Telephone: (949) 644-3106
Unit: Quality Assurance Fee Fax: (949) 644-3120
Attention: Email: sposter@nbfd.net
GEMT Supplemental Reimbursement Program
Address: 1501 Capitol Avenue, MS 4504
P.O. Box 997436
Sacramento, CA 95899-7436
Telephone: (916) 552-9113
Fax: (916) 552-8651
Email: GEMT@dhcs.ca.gov
C. Either party may make changes to the information above by giving written notice to the other
party. Said changes shall not require an amendment to this agreement.
ARTICLE 6- GENERAL PROVISIONS
A. This document constitutes the entire Agreement between the parties. Any condition,
provision, agreement or understanding not stated in this Agreement shall not affect any rights,
duties, or privileges in connection with this Agreement.
B. The term "days" as used in this Agreement shall mean calendar days unless specified
otherwise.
C. The State shall have the right to access, examine, monitor, and audit all records, documents,
conditions, and activities of the Provider and its subcontractor related to the services provided
pursuant to this Agreement.
D. No covenant, condition, duty, obligation, or undertaking made a part of this Agreement shall
be waived except by amendment of the Agreement by the parties hereto, and forbearance or
indulgence in any other form or manner by either party in any regard whatsoever shall not
constitute a waiver of the covenant, condition, duty, obligation, or undertaking to be kept,
performed, or discharged by the party to which the same may apply; and, until performance or
satisfaction of all covenants, duties, obligations, or undertakings is complete, the other party
shall have the right to invoke any remedy available under this Agreement, or under law,
notwithstanding such forbearance or indulgence.
E. None of the provisions of this Agreement are or shall be construed as for the benefit of, or
enforceable by, any person not a party to this Agreement.
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GEMT Provider Participation Agreement FY 2010/2014
ARTICLE 7 -AMENDMENT PROCESS
A. Should either party, during the term of this Agreement, desire a change or amendment to the
terms of this Agreement, such changes or amendments shall be proposed in writing to the
other party, who will respond in writing as to whether the proposed amendments are accepted
or rejected. If accepted and after negotiations are concluded, the agreed upon changes shall
be made through a process that is mutually agreeable to both the State and the Provider. No
amendment will be considered binding on either party until it is approved in writing by both
parties. Replacing the Project Representative does not require an amendment to this
agreement and may be updated with written notice sent to the other party. Written notice may
include email.
ARTICLE 8- AVOIDANCE OF CONFLICTS OF INTEREST BY THE PROVIDER
A. The State intends to avoid any real or apparent conflict of interest on the part of the Provider,
subcontractors, or employees, officers, and directors of the Provider or subcontractors. Thus,
the State reserves the right to determine, at its sole discretion, whether any information,
assertion, or claim received from any source indicates the existence of a real or apparent
conflict of interest; and, if a conflict is found to exist, to require the Provider to submit
additional information or a plan for resolving the conflict, subject to the State's review and prior
approval.
B. Conflicts of interest include, but are not limited to:
1) An instance where the Provider or any of its subcontractors, or any employee, officer, or
director of the Provider or any subcontractor has an interest, financial or otherwise,
whereby the use or disclosure of information obtained while performing services under the
contract would allow for private or personal benefit or for any purpose that is contrary to
the goals and objectives of the contract.
2) An instance where the Provider's or any subcontractor's employees, officers, or directors
use their positions for purposes that are, or give the appearance of being, motivated by a
desire for private gain for themselves or others, such as those with whom they have family,
business or other ties.
C. If the State is or becomes aware of a known or suspected conflict of interest, the Provider will
be given an opportunity to submit additional information or to resolve the conflict. A Provider
with a suspected conflict of interest will have five (5) working days from the date of notification
of the conflict by the State to provide complete information regarding the suspected conflict. If
a conflict of interest is determined to exist by the State and cannot be resolved to the
satisfaction of the State, the conflict will be grounds for terminating the contract. The State
may, at its discretion upon receipt of a written request from the Provider, authorize an
extension of the timeline indicated herein.
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GEMT Provider Participation Agreement FY 2010/2014
ARTICLE 9 - FISCAL PROVISIONS
Reimbursement under this Agreement shall be made in the following manner:
A. Upon the Provider's compliance with all provisions pursuant to W&I Code section14105.94
and this Agreement, and upon the submission of a cost report and claim form based on valid
and substantiated information, the State agrees to process the cost report and claim form for
reimbursement.
B. Transfer of funds is contingent upon the availability of federal financial participation. If, in the
event federal financial participation funds for a service period are not available for all of the
supplemental amounts payable to GEMT providers due to the application of a federal limit or
for any other reason, both of the following shall apply:
1) The total amounts payable to GEMT providers for the service period shall be reduced to
reflect the amounts for which federal financial participation is available.
2) The amounts payable to each GEMT provider for the service period shall be equal to the
amounts computed under Article 3 multiplied by the ratio of the total amounts for which
federal financial participation is available.
C. Provider shall certify the certified public expenditure from the Provider's General Fund, or from
any other funds allowed under federal law and regulation, for Title XIX funds claimed for
reimbursement pursuant to W&I Code section 14105.94. The State shall deny payment of any
invoice submitted under this Agreement, if it determines that the certification is not adequately
supported for purposes of FFP. The following certification statement shall be made on each
Summary Invoice submitted to the State for payment for the performance of services:
"I, certify under penalty of perjury as follows: Public funds for services provided have been
expended as necessary for federal financial participation, pursuant to the requirements of Section
1903(w) of the Social Security Act and 42 C.F.R. § 433.50, et seq. for allowable costs. The
expenditures claimed have not previously been, nor will be, claimed at any other time to receive
federal funds under Medicaid or any other program. The provider acknowledges that the
information is to be used for claiming federal funds and understands that misrepresentation of
information constitutes a violation of federal and State law. The provider acknowledges that all
funds expended pursuant to W&I Code section 14105.94 are subject to review and audit by the
Department of Health Care Services. The provider acknowledges that it understands that DHCS
must deny payments for any claim submitted under W&I Code section 14105.94, if it determines
that the certification is not adequately supported for purposes of federal financial participation. That
I am the responsible person of the subject fire department I agency and am duly authorized to sign
this certification and that, to the best of my knowledge and information, each statement and amount
in the accompanying schedules are to be true, correct, and in compliance with section 14105.94
of the California Welfare and Institutions Code."
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GEMT Provider Participation Agreement
FY 2010/2014
ARTICLE 10- RECOVERY OF OVERPAYMENTS
A. Provider agrees that when it is established upon audit that an overpayment has been made,
the Department shall recover such overpayment in accordance with section 51047 of Title 22
of the California Code of Regulations.
B. The State reserves the right to select the method to be employed for the recovery of an
overpayment.
C. Overpayments may be assessed interest charges, and may be assessed penalties, in
accordance with W&I Code Sections 14171(h) and 14171.5.
ARTICLE 11 -BUDGET CONTINGENCY CLAUSE
A. It is mutually agreed that if the State Budget Act of the current year and/or any subsequent
years covered under this Agreement does not appropriate sufficient funds for the GEMT
program, this Agreement shall be of no further force and effect. In this event, the State shall
have no liability to pay any funds whatsoever to Provider or to furnish any other considerations
under this Agreement and Provider shall not be obligated to perform any provisions of this
Agreement.
B. If funding for any state fiscal year is reduced or deleted by the State Budget Act for purposes
of this GEMT program, the State shall have the option to either cancel this Agreement, with no
liability occurring to the State, or offer an agreement amendment to Provider to reflect the
reduced amount.
ARTICLE 12- LIMITATION OF STATE LIABILITY
A. Notwithstanding any other provision of this Agreement, the State shall be held harmless from
any federal audit disallowance and interest resulting from payments made by the federal
Medicaid program as reimbursement for claims providing services pursuant to W&I Code
section 14105.94, for the disallowed claim, less the amounts already remitted to the State
pursuant to W&I Code section 14105.94.
B. To the extent that a federal audit disallowance and interest results from a claim or claims for
which the Provider has received reimbursement for services, the State shall recoup from the
Provider, upon written notice, amounts equal to the amount of the disallowance and interest in
that fiscal year for the disallowed claim. All subsequent claims submitted to the State
applicable to any previously disallowed claim, may be held in abeyance, with no payment
made, until the federal disallowance issue is resolved, less the amounts already remitted to
the State pursuant to W&I Code section 14105.94.
Page 9 of 11
ARTICLE 13- AGREEMENT EXECUTION
The undersigned hereby warrants that s/he has the requisite authority to enter into this Agreement on behalf
of Newport Beach Fire Department and thereby bind the above named provider to the terms and conditions
of the same.
Provider Authorized Repre ignature
Print Name
,FKe
Title NEWPORT BEACH FIRE DEPARTMW
P.O. BOX 1768
NEWPORT BEACH, CA 92658-8915
Address
SEP 2 7 201�
D
Delrtme of e aa're Services
Authorized Representative's Signature
Stacy Fox
Print Name
Chief, Medi-Cal Supplemental Payments Section
Title
Name of Department
Address
Io-IST;
Date
CA Dept. of Health Care Services
1501 Capitol Avenue, MS 4504
Sacramento, CA 95814
Page 11 of 11
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed on the dates written below.
APPROVED AS TO FORM:
CITY �00N Y'S OFFICE
Date:
B
roparp
City Attorney
ATTEST: q-�O-
By:
City Clerk
V 2
.a�
r'141pOR `P
CITY OF NEWPORT BEACH,
A California municipal corporation
Date: 01k"0 tUP,
By:
Dave iff
City Manager
[END OF SIGNATURES]