SFY2000 09/08/1999
HOME ANn COMMUNITY nASED WAIVER
REFERRAL AGREEMENT
This Referr~1 Agreement, made this 20 day of July, 1999, shall be in effect for the period of
July 30, 1999 to June 30, 2000 between Alliance for Aging, the Area Agency on Aging for
PI~nning amt Service Area 11; Monroe County In Home Services, the case management agency;
andCuwdlan fY\ec@;CCt\ tYlO1I~ni lf1J(Trv, the Service Provider Agency. The purpose of
this agreement is to promote the development of a coordinated service delivery system to meet
the needs of the aged or disabled adults who are at risk of premature institutionalization.
J. Objectives
I. To maintain ~ climate of cooperation and consultation with and between agencies,
in order to achieve max.imum efficiency and effectiveness.
2. To participate together by means of shared information in the development and
expansion of services.
3. To promote programs and activities designed to prevent the premature
institutionalization of elders and disabled adults.
4. The parties of this Agreement will provide technical assistance and consultation to
each other on matters pertaining to actual service delivery and share appropriate
assessment information and care plans so duplication may not occur.
II. Under this Agreement, the Service Provider Agency ngrees to the following:
1. To accept referrals for the 1915c Home and Community Based Service (HCBS)
Medicaid Waiver from only the above designated case management agency.
2. To provide quality service(s) specified in Section V to the waiver participant.
Provision of service(s) is subject to quality monitoring and/or observation by the
case management agency and/or the Area Agency on Aging.
3. To provide only those services specifically outlined in the Plan of Care or service
authorization suhmitted hy the above designated case management agency.
4. To attach documentation regarding provider qualifications to this agreement; and
to provide, as requested, any information regarding Medicaid Waiver billing,
payment, or waiver participant information, to the Case Management Agency or
Area Agency on Aging. Provider rate increases/decreases must be forwarded to
the Case Management Agency and Area Agency on Aging along with justification
for any increase. If additional services are to he added to this agreement, a
written request to do so must he received hy the Area Agency on Aging and an
amendment must he prepared by the Area Agency on Aging listing the added
service(s). The necessary documentation regarding provider qualifications for the
additional services will he signed, attached to the agreement and forwarded to the
A rea Agency on Aging. ...."':~ 'AINnO:J 30~NOW
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90:1. Wd 91 AON66
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5. To maintain the waiver participant's confidentiality according to 42 CFR
431.301.
6. To immediately report any changes in the waiver participant's condition to the
designated Case Management Agency.
7. To maintain enrolled provider status by renewing applicable licensure,
certification, contract, and/or referral agreements.
8. Include its name, unit rate, and other appropriate information on a list of all
enrolled providers which will be shown to recipient during development of an
individualized plan of care understanding that the recipient reserves the right at all
times to a choice of enrolled providers.
9. To immediately notify the Case Management Agency of staffing shortfalls which
will negatively impact provision of service to Medicaid Waiver recipients.
10. To suhmit claim data for hilling to the Medicaid fiscal agent within 60 days after
services have heen provided or document reasons for delayed submission of
claims. Such documentation shall he available for review by the area agency on
agency or hy the Department of Elder Affairs, upon request.
II. To suhmit claims for hilling to the Medicaid fiscal agent at the agency's usual and
customary rate. It is a violation of federal regulation to bill Medicaid more than
the agency's usual and customary rate.
12. The service provider n~cncy herehy agrees that it will develop and implement a
policy to ensure that its employees, board members, and management, will avoid
any connict of interest or the appearance of a connict of interest when disbursing
or using the funds described in this agreement or when contracting with another
entity which will be paid by the funds described in this agreement. A connict of
interest includes, but is not limited to, receiving, or agreeing to receive, a direct
or indirect benefit, or anything of value from a service provider, client, vendor,
or any person wishing to benefit from the use or disbursement of funds. To avoid
a connict of interest, the service provider agency must ensure that all individuals
make a disclosure to the Area Agency on Aging of any relationship which may be
a connict of interest, within thirty (30) days of an individual's original
appointment or placement on a board, or if the individual is serving as an
incumbent, within thirty (30) days of the commencement of the contract.
III. Under this Agreement, the Area Agency on Aging agrees to the following:
I. To facilitate the enrollment of providers with the Medicaid Fiscal Agent.
2. To provide technical assistance and training to Service Providers.
3. To determine that the case management agency is conducting monitoring of its
service providers.
4. To regularly monitor the Service Providers in accordance with requirem~nts
specified hy the Department of Elder Affairs.
IV. Under this ARreement, the Cnse Mnnngement Agency nRrees to the following:
I. The case management agency shall suhmit written referral to service provider
agency with at least 24 hours notice. The case management agency may refer
recipients to any qualified service provider agency. The referral will contain, at a
minimum:
a. Name
b. Address (with directions if not easily accessible)
c. Pertinent information regarding recipient's health or disabilities and living
situation.
d. Detailed service authorization including frequency, duration, and specific tasks
to be performed.
2. Maintain case records in accordance with the Aged and Disabled Adult Medicaid
Waiver Coverage and Limitations Handbook.
3. Evaluate quality of services and service documentation as provided by service
provider agency.
4. Accept financial responsibility for service claims found out of compliance if they
are the result of a failure by the Case Management Agency to update, renew, or
terminate the service authorization.
5. To monitor service provider agencies billings to ensure spending is within
allocated spending limits.
6. To monitor service provider agencies for adherence to authorized case plans and
with in authorized rates.
7. The case management agency hereby agrees that it will develop and implement a
policy to ensure that its employees, board members, and management, will avoid
any conflict of interest or the appearance of a conflict of interest when disbursing
or using the funds descrihed in this agreement or when contracting with another
entity which will be p"id by the funds described in this agreement. A conflict of
interest includes, but is not limited to, receiving, or agreeing to receive, a direct
or indirect henefit, or anything of value from a service provider, client, vendor,
or "ny person wishing to benefit from the use or disbursement of funds. To avoid
" conflict of interest, the case management agency must ensure that all individuals
make a disclosure to the Area Agency on Aging of any relationship which may be
a conflict of interest. within thirty (30) days of an individual's original
appointment or placement on a board, or if the individual is serving as an
incumbent, within thirty (30) days of the commencement of the contract.
V. Under this 3~reement, the following services will he delivered by the Service
Provider ^~ency in 3ccordmlce with the plan of C3re or service authorization:
Service
Unit Rate
County IRegion
Served
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3.
4.
5.
VI. Termhmtiol1
In the event this agreement is terminated. the case management agency and the service provider
agency agree to submit. at the time notice of intent to terminate is delivered, a plan which
identities procedures to ensure services to clients will not be interrupted or suspended by the
termination.
I. Termination at Will
This agreement may he terminated by any party upon no les!! thAn thirty (30)
calendar days notice, withont cause, unless a lesser time is mutually agreed upon
by both parties. in writing. Said notice shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery.
2. Termination Because of Lack of Funds
In the event funds to finance this agreement become unavailable, the area agency
may terminate this agreement upon no less than twenty-four (24) hours notice in
writing to the other party. Said notice shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery. The area agency shall be
. the final authority as to the availability of funds.
3. Termination for Breach
Unless a breach is waived by the area agency in writing, or the parties fail to cure
the breach within the time specified by the area agency, the area agency may, by
written ttotice to the parties, terminate the agreement upon no less than twenty-
four (24) hours notice. Said notice shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery.
VII. In witness whereof, the l)flr'ties Imve cnnsNI this five pn~e ~~reement to he executed
by their ul1(lersi~ned ornci~ls ~s duly authorized.
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Area Agency on A~ing
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GUARDIAN MEDICAL MONITORING
1 ROOO \V. Ei~ht Mile nom), Sotlthfield, MI 4R075 . I-RRR-349-2400
1-88&-349-2400
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This oriel' expires Oclohcr I. 1999.
lIealth Care for the New Millenniunl
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CERTIFICATE OF LIABILITY INSURANC~JM,~6 OA~E~7~o;';;19
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ONLY AND COt-WERS NO RIGHTS urON TilE CERTIFICATE
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EXI'II1ATIOfl nA 11' TlIFPF.nE, TIll' 1<;~UlIlG ItlSUflF.11 Will ENDEIIVOR TO !Mll
Monroe Couty In Home Servic~s 30 DAY~ WflITlHI NOTICE 10 THE CEflTlElCAlF' HOlDER flAMED TO T"E
Dee Simpson --.---
5100 College Rd PSB, Wing III I EET. ""I E^,lUflF 10 on ~o SIIAIL IMPO~F. NO nA1IGATION Ofl UAIlIUTY OF
Key West Fl. 330-10 _-^NY_ KItID.IJPON THE ItlSUI1ER. ITS AGEN'.AW.d?J,J
-- I Glenn n Warsh
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(III 'I'D 7<; S (7/97)
ACORD CORPORATION 1988