SFY2003 08/21/2002
Clerk oldie
eircul eo on
Danny L. Kolhage
Clerk of the Circuit Court
Phone: (305) 292-3550
FAX: (305) 295-3663
e-mail: phancock@monroe-clerk.com
Memnranduin
TO: Louis Latorre, Director
Social Services Division
ATTN: Margaret Adkins
Nutrition Program
FROM: Pamela G. Haneoh
Deputy Clerk ry
DATE: September 3, 2002
At the August 21, 2002, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Home and Community Based Waiver Referral Agreement between
the Alliance on Aging, Inc., the Area Agency on Aging for Dade and Monroe Counties, and for Planning and
Service Area 11, and the Monroe County Board of County Commissioners (Monroe County Social
Services/Nutrition Program), for Fiscal Year beginning on July 1, 2002 through June 30,2003.
Enclosed are three duplicate originals, executed on behalf of Monroe County, for your
handling. Please be sure that the fully executed "Monroe County Clerk's Original" and the
'.Monroe County Finance Division's Original" are returned to our office as soon as possible.
Should you have any questions please do not hesitate to contact this office.
Cc: County Administrator w/o document
Finance w/o document
County Attorney
Filev'
Marue Coaaty.CIerJts omce o.w II
HOME AND COMMUNITY BASED WAIVER
REFERRAL AGREEMENT
This Referral Agreement, made this 1st day of July, 2002 between Allianc~~;~:g, the Area
Agency on Aging for Planning and Service Area ll.; and Monroe County ") Service
Provider. This Referral Agreement is in effect for a period of time that is equal to the Medicaid
waiver provider's enrollment period with the State of Florida's Medicaid fiscal agent. One 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. Another
purpose of this agreement is to enable eligible elderly participants to receive Home and
Community Based Waiver Services from qualified providers with oversight of the quality of care
by the Medicaid Waiver Specialist employed by the Area Agency on Aging. These services are
authorized in order that the participant may remain in the least restrictive setting and avoid or delay
premature nursing home placement. Services and care are to be furnished in a way that fosters the
independence of each participant to facilitate aging in place. All parties agree that routines of care
provision and service delivery must be consumer driven to the maximum extent possible. All
parties agree to and will treat each participant with dignity and respect.
I. Objectives
A. To maintain a climate of cooperation and consultation with and between agencies,
in order to achieve maximum efficiency and effectiveness.
B. To participate together by means of shared information in the development and
expansion of services.
C. To promote programs and activities designed to prevent the premature
institutionalization of elders and disabled adults.
D. To require the parties of this Agreement to 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.
E. To establish an effective working relationship between the case management
agency that is responsible for the development of care plans and authorization of
services available under the waiver, the service provider that is responsible for the
direct provision of those services to consumers served under the waiver program,
and the Area Agency on Aging that is responsible for management and oversight of
the waiver program.
II. Under this Agreement, the Service provider agrees to the following:
A. To accept referrals for the 1915c Home and Community Based Service (HCBS)
Medicaid Waiver from the enrolled case management agency.
B. To provide quality service(s) to the waiver participant as specified in Section IV.
Provision of service(s) is subject to quality monitoring and/or observation by the
case management agency and/or the Area Agency on Aging and/or the Department
of Elder Affairs.
C. To provide only those services specifically outlined in the Plan of Care and
authorized by the enrolled case management agency.
D. To attach documentation regarding the service provider's 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 Area Agency on Aging along with justification for any increase. If
additional services are to be added to this agreement, a written request to do so must
, be received by the Area Agency on Aging and an amendment must be prepared by
the Area Agency on Aging listing the added service(s). The necessary
documentation regarding provider qualifications for the additional services must be
attached to the agreement.
E. To maintain the waiver participant's confidentiality according to 42 CFR 431.301.
F. To immediately report any changes in the waiver participant's condition to the case
management agency.
G. To maintain enrolled provider status by renewing applicable licensure, certification,
contract, and/or referral agreements and by maintaining all provider qualifications
as contained in the Aged and Disabled Adult Medicaid Waiver under which
services are provided.
H. To include its name and other appropriate information on a list of all enrolled
providers which will be shown to consumer during development of an
individualized plan of care, understanding that the consumer reserves the right at all
times to a choice of enrolled providers.
I. To immediately notify the case management agency of staffing shortfalls which
will negatively impact provision of service to Medicaid Waiver consumers.
J. To submit claim data for billing to the Medicaid fiscal agent after delivery of
services has been accomplished. All services should be billed within 60 days after
services have been provided or document reasons for delayed submission of claims.
Such documentation shall be available for review by the area agency on agency or
by the Department of Elder Affairs, upon request.
K. To submit claims for billing 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.
L. To submit void or adjustment claims no later than 45 days after the error has been
identified by either party. Any error not adjusted or voided within 45 days may be
adjusted or voided by the Area Agency on Aging. The provider's refusal to adjust
or void erroneous claims will result in termination of this agreement.
M. To 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 described in this agreement. A
conflict 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, consumer,
vendor, or any person wishing to benefit from the use or disbursement of funds. To
avoid a conflict of interest, the service provider 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.
N. To adhere to the policies and procedures as outlined in the following manuals
published by the Agency for Health Care Administration: the Aged/Disabled Adult
Waiver Guidelines and the Medicaid Provider Reimbursement Handbook (Non-
Institutional 081), inCluding any and all attachments or updates.
III. Under this Agreement, the Area Agency on Aging agrees to the following:
A. To facilitate the enrollment of providers with the Medicaid Fiscal Agent.
B. To provide technical assistance and training to Service Providers.
C. To notify the case management agency within 48 hours of any approved service
provider rate adjustment.
D. To regularly monitor the Service Providers in accordance with requirements
specified by the Department of Elder Affairs.
IV. Under this agreement, the following services will be delivered by the Service provider
in accordance with the plan of care or service authorization:
Service
Unit Rate
CountylRegion
Served
MONROE
.m0()~~
mDn (2,Of.
mD'1 ecf_
rY)D')f2OF .
A.NUTRITION PROG. MEALS
B. .yeJ2.SLYQL en of2
C. G.Hr.xLP
D. ~rrYl~Q...
E. ~rr.e
$ 5.00
$46 . DD
---4:.1. 00
..J tf:5. aD
.. 2,%.00
V. Termination
In the event this agreement is terminated, the case management agency and the service provider
agree to submit, at the time notice of intent to terminate is delivered, a plan which identifies
procedures to ensure services to consumers will not be interrupted or suspended by the termination.
A. Termination at Will
This agreement may be terminated by any party upon no less than thirty (30)
calendar days notice, without 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.
B. 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.
C. 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 notice 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.
In witness whereof, the parties have caused this ~ page agreement to be executed by their
undersigned officials as duly authorized.
Area ncy on Agin~~erVice provider
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