Item C25
I , I'
, I !
BOARD 0 COUNTY l.-PMMISSIO~, ERS
AG A ITEM ISUMMARY I
! I ,
I ':
Meeting Date: 10/18/2006 D' ision: Comm ni Sertices
11
~I aliment: So 'ial S rviJes
1 I I I
S ff Contact P son:] SuJan Scarlet
I I I
AGENDA ITEM WORDING: Appro I for Monro County to rb-~nrol in ~ Provider
Agreement with the Florida Medicaid P ~ am. I . I Ii
I i
Bulk Item: Yes ....2L.
No
ITEM BACKGROUND: See attache.
PREVIOUS RELEVANT BOCC
Commissioners granted approval an
between Monroe County and the Age
Medicaid Program on 3/20/2002.
'CTION: Ithe Monro ~ C \m,' Board of County
thorized ek~cution of, . edicaid, Provider Agreement
I y for Health I' Care Adminfstration! to participate in the
I I
. ,
I
,
No
CONTRACT/AGREEMENTCHAN
STAFF RECOMMENDATIONS: Ap
DOCUMENTATION:
I
I
. I
~UDGETEn: I Yes
, I.
COST TO COUNTY: None SOURCE OF fNDS: , N/A
REVENUE PRODUCING: Yes....2L.1 0 AMOUNT ,~R MQ! TH approx $1000.00
Year approx. $12,000.00. i I . Ii
I I I I i
APPROVED BY: County Atty -4! OMB/Purchasing~11 R~~ iManagement_X~
I : ' i i
LLI' I I
Included j i. Not Required : .
II ·
I
I
TOTAL COST: N/A
DISPOSITION:
i
I
GEND~ ~TEM #
. ,
; :
! II
OK~~rY ~o~~~E
(305) 294-4641
Bayshore Manor
5200 College Road
Key West, FL 33040
To:
I MEMORANDUM
i
I
Monroe County Board of County CO~itioners
Susan Scarlet, Senior Administrator, Bay*ore Manor l
9/8/06 j
Agenda Item for Approval to re-enroll in rovider agreement with Florida edicaid
From:
Date:
Re:
BOA l OF COUNTY COMMISSIONERS
Mayo~ Charles "Sonny" McCoy, District 3
Mayo~ Pro Tern Dixie M. Spehar, District 1
Georg: Neugent, District 2
David i . Rice, District 4
Glenn i alton, District 5
I
I
I
I
The approval of this provider agreement with Flori Medicaid will allow Bayshore,Manor to
continue to serve Medicaid recipients with respite s rvices. The services produce a roximatel
$12,000.00 a year revenue for Bayshore Manor. .
Bayshore Manor has been providing respite serviye through Florida Medicaid since February
The Board of County Commissioners approved the edicaid Non-Institutional Prov der Agree
last on 3/2012002. 1
Attached please ftnd the letter from Florida Mediy. a1~.. requesting the renewal of the. on- Institu
Medicaid Provider Agreement dated August 28,20.6. Also attached fmd ftve copie of the re
for your signature.
Contract with: Florida Medicaid
Contract # _
Effective Date:
Expiration Date:
I SEP 1 2 IU.Ub
,~-42Jia==-
MONROE COUNTY OARD OF COUNTY CO
TRACT SUMMARY
Contract Purpose/Description: .
To enable Monroe County to re-eptj 11 in a Provider Agreemen to accep Medicaid
clients and be reimbursed for thiss . rvice by the Florida Medic id Progr, m.
Contract Manager: Susan Scarlet
4533
(Ext. )
S cial S
N. anor/Sto #9
(Depa
(Name)
for BOCC meeting on
10/18/06
Agenda Deadline: 10/3/06
, ONTRACT COSTS
Total Dollar Valae of Contract: $ .,... J .,.1/ A A Current Year Portion:
Budgeted?YesD NoD ACC~ -_- -
Grant: $ 01 - -_-
County Match: $ N/A . -_-~-
---L-
A DITIONAL COSTS I
For: N/A
(eg. maintenance, utiliti s, janitori
Estimated Ongoing Costs: $Qlyr
(Not included in dollar value above)
Division Director
CIDNTRACT REVIEW
I
Cha~1 ges
~ te . Nee ed .
~.~t.YesDNoIT ~l
~ YeSOlN00 11). C/,I''1I3LC)
I. I
YesO~Nog-
YesONo~
/)_~~:1~
LI'~I.?'() I{'
Risk Mana~men~
tr ~ ~(tJ ~ \.'11~
o .1vI.B .lPurchasing '!.lllL(J1,
County Attorney ~)"
f~/J -D?
Comments:
OMB Form Revised 2/27/01 MCP #2
-
==
~
;;;;;;;;;;;;;;;
;;;;;;;;;;;;;;;
JNCA
flORIM AGENCY FOR HEAlTH CARf ,ooMINlSTRATION
The Provider agrees to participate in the ~I . rida Medicaid program undt the foil ing terms and conditions:
(1) Discrimination. The parties agree that t e Agency for Health Care ~dministrai6n (AHCA) may make payments
for medical assistance and related services rendered to Medicaid recipi nts only 0 a person or entity who has a
provider agreement in effect with AHCA; wh is performing services or upplying' oods in accordance with federal,
state, and local law; and who agrees that rg person shall, on the groun s of sex; andicap, race, color, national
origin, other insurance, or for any other reajon, be subjected to discrim nation un' er any program or activity for
which the provider receives payment from, -4HCA.
(2) guality of Service. The provider agrees~hat services or goods bille to the ~. dicaid program must be
medically necessary, of a quality comparabl to those furnished by the provider's peers, and within the parameters
permitted by the provider's license or certin ation. The provider further agrees t bill only for the services
performed within the specialty or specialtie~ designated in the P, rovider apPlicatio, pn file with AHCA. The services
~~aT~~dS must have been actually provided t eligible Medicaid reciPiers by the i rovider prior to submitting the
(3) Compliance. The provider agrees to cO~.?IY with local, state, and fe eral law~i,' as well as rules, regulations, and
statements of policy applicable to the Med,icrid program, including the ledicaid !ro, vider Handbooks issued by
AHCA. I
!
(4) Term and signatures. The parties agre . that this is a voluntary agr ement b ,ween AHCA and the provider, in
which the provider agrees to furnish services or goods to Medicaid recibients. p' vided that all requirements for
enrollment have been met, this agreement hall remain in effect for ten (10) year trom the effective date of the
provider's eligibility unless otherwise termi ated. This agreement shall be rene ble only by mutual consent. The
provider understands and agrees that no A CA signature is required to make thi , agreement valid and enforceable
(5) Provider Responsibilities. The Medicai provider shall: I' ;
(a) Possess at the time of the signing of th~prOVider agreement, and maintain i1g00d standing throughout the
period of the agreement's effectiveness, a v lid professional, occupational, facilit or other license appropriate to
the services or goods being provided, as re uired by law. l
(b) Keep, maintain, and make available in J systematic and orderly ma ner all m: dical and Medicaid-related
records as AHCA requires for a period of atlleast five (5) years. I I
(c) Safeguard the use and disclosure of imf1rmation pertaining to curre t or form I r Medicaid recipients as required
by law. , .
I '
i ! I
(d) Send, at the provider's expense, iegible~CoPies of all Medicaid-relat d inform 't\on to authorized state and
tedera! emp!oye.es, including their agents.,. 'he provider shall give state and fede ai, employees, inciuding their
agents, access to all Medicaid patient recor s and to other information hat can n t, be separated from
Medicaid-related records. 'I I I
(e) Bill other insurers and third parties, in, c1....~ding the Medicare program, before JiI!" ing the Medicaid program, if the
recipient is eligible for payment for health c re or related services from anotheri ~urer or person.
(f) Within 90 days o~ receipt, refund any nilo eys received in error or inJxcess of he amount to which the provider
is entitled from the Medicaid program. '.
(g) To the extent allowed by in and accord~nce with section 768.28, F.S (2001), a d any successor legislation, be
liable for and indemnify, defend, and hold A CA harmless from all c1ai s, suits, j dgments, or damages, including
court costs and attorney's fees, arising out. f the negligence or omissions of the' rovider in the course of providing
services to a recipient or a person believedjto be a recipient. i
NO -INSTITUTIONAL
MEDICAID ROVIDER AGREEMENT
Non-Institutional MPA (Revised July 2006)
F8NP A2 08/06
1 of 3
(h) Accept Medicaid payment as paymenti full, and not bill or collect from the r cipient or the recipient's
responsible party any additional amount e,Xq pt, and only to th'e, extent AHCA per its or requires, co-payments,
coinsurance, or deductibles to be paid by 1h recipient for the services or goods ovided. This includes situations
in which the provider's Medicare coinsurand claims are denied in accordance wi h Medicaid's payment.
(i) Agrees to submit claims to AHCA electr nically and to abide by the t rms of t ,e Electronic Claims Submission
Agreement. ' ,
(6) AHCA Responsibilities. The agency shall:
I
(a) Make timely payment at the established,.lrate for services or goods f rnished t a recipient by the provider upon
receipt of a properly completed claim. ,
(b) Not seek repayment from the provider", i~ any instance in which the
to error in the state's determination of eligibIlity of a recipient.
(7) Termination For Convenience. This agrl',' ement may be terminated
notice by either party.
(8) Ownership. The provider agrees to givel AHCA sixty (60) days writte notice ,fore making any change in
ownership of the entity named in the provid r agreement as the provide. The prvider is required to maintain and
make available to AHCA Medicaid-related r cords that relate to the sale or transf r of the business interest,
practice, or facility in the same manner as tough the sale or transactio had not aken place, unless the provider
enters into an agreement with the purchase of the business interest, pr ctice, or ,acility to fulfill this requirement.
,
(9) Complete Information. All statements ,a Id information furnished by he prosp 'ctive provider before signing the
provider agreement shall be true and compl te. The filing of a materiall incompl te, misleading or false
application will make the application and a,g{eement voidable at the option of AH, : A and is sufficient cause for
immediate termination of the provider from tre Medicaid program and/or revocati I n of the provider number.
(10) Interpretation. This agreement shall n1 be construed against either party 0 the basis of this agreement
having been prepared by one of the parties.
(11) GoverninQ Law. This agreement shall e governed by and construed in acc dance with the laws of the State
of Florida. I
(12) Amendment. This agreement, the appl~cation and other documenj being ex cuted and delivered pursuant
hereto constitute the full and entire agreem,' ~nt and understanding betw en the pa, ies hereto with respect to the
subject matter hereof. No amendment shall1be effective uniess it is in riting and'signed by each party.
(13) Severabiiitv. If one or more of the provisions contained in this agr ement or i,apPiication shall be invalid, illegai
or unenforceable, the validity, legality ande~. forceability of the remainint prOViSiO", " s shall not in any way be
affected or impaired. I . ,i
(14) AQreement.Retention. The parties agr~e tha~ AHCA ~ay .only retai th~ Sig~i ture p~ge" of this .agreement, and
that a copy of thiS standard prOVider agreement Will be maintained by th Dlrecto i of Medicaid, or hiS designee, and
may be reproduced as a duplicate originai f4r any legal purpose and m y also be jentered into evidence as a
business record. I i
(15) FundinQ. This contract is contingent u9~n the availability of funds. '
I
I
]
(j) Agrees to receive payment from AHCA, b Electronic Funds Transfer
deposits funds to the provider's account, t~er the provider agrees that
account. I
2 of 3
Non-Institutional MPA (Revised July 2006)
F8NPB2 08{06
he event that AHCA erroneously
withdraw the funds from the
edicaid'verpayment is attributable soiely
I
se upon thirty (3D) days written
;;;;;;;;;;;;;;;
-
-
-
-
-
-
I . ~ I
The parties concur that this agreement is .',p, il"egal and binding dO, cu, ment and is fll y enforceable in a court of
competent jurisdiction. The signatories her~to represent and warrant t at they t ve read the agreement,
understand it, and are authorized to execl:ltti! it on behalf of their respec ive prine i als or co-owners. This
agreement becomes null and void upon transfer of assets; change of ownership; r upon discovery by ahca of the
submission of a materially incomplete, misl~ading or false provider application L less subsequently ratified or
approved by ahca.
All shareholders (with five percent or greater ownership interest), principals, part I ers and financial custodians are
required to sign this agreement or, a chief executive officer (CEO) or prE sident 0 ~n organization may sign this
agreement in lieu of the above. Failure tq sign the agreement will makE this apf cation, agreement and provider
number voidable by AHCA. . :
IN WITNESS WHEREOF, the undersigned have caused this agreel1l1ent to duly executed under the
penalties of perjury, swear or affirm that the foregoing is true and corre .
(legibly print name of signatory)
Title
Date
Signature
(legibly print name of signatory)
Title
Date
Signature
(legibly print name of signatory)
Title
Date
Signature
(legibly print name of signatory)
Titie
Date
Signature :
(legibly print name of signatory)
Title
Date
Signature
(USE ADDITIONAL PAGES IF NECESSARY
Provider's Name:
MONROE COUNTY
DBA Name:
Tax Identification Number:
National Provider Identifier:
Florida Medicaid
Identification Number:
I (For new applicants this block will
be completed by the fiscal agent.)
676448700
3 of 3
MP A Revised April 2003
F8NPCI06/12/03