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SFY2000 09/08/1999 1 • HOME AND COMMUNITY BASED WAIVER REFERRAL Al This Referral Agreement, made this 15 day of July, 1999, shall be in effect for the period of July 30, 1999 to June 30, 2000 between Alliance for Age, the Area Agency on Aging for Planning and Service Area 11; Monroe County In and HOME CARE MEDICAL SERVICES � Rome Services, the case mamgement agency; agreement is to promote the develo meat of a Smite Provider Agency. The Pub of this aged or P meted service ��' system to meet the needs of the a g disabled adults who are at risk of premature institutionalization. I. Objectives 1. To maintain a climate of cooperation and consultation with and between a encies efficiency and effectiveness. in order to achieve maximum e g ctiveness. 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 technical assistance and consultation to each other on matters pertaining to actual service delivery and share f appropriate assessment information and care P Plans so duplication may not occur. H. Under this Agreement, the Service provider Agency agrees to the following 1. To accept referrals for the 1915c Home and Community Medicaid Waiver from only the above designated case l3ased �� (HCBS) 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 submitted by the above designated case management agency. 4. To attach documentation regarding provider to provide, as qualifications to this agreement; and requested, any information regarding Medicaid Waiver biting, - payment, or waiver participant information, to the Case Management Agency or Area Agency on Aging. Provider late increases /decreases must be forwarded to the Case Management Agency and Area Agency • ' for any increase. H additional s g �' on Aging along with justification 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 necessary documentation service(s). The regarding lam' 1 ` Ill for the a ditionalII services will be signed, attached to the ., ; ,:: ( . :.r ded to the Agency on Aging. , , i r 90 : I , Rd 8 I AON 66 080338 803 0311.3 • • 5. To maintain the waiver participant's confidentiality according to 42 CF 431.301. 6. To immediately report any changes in the waiver designs tea Case Management Agency. crpaut�s the 7. To maintain enrolled provider status h �` g applicable licensnre, certification, contract, and/or refeaal 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 individualized plan of care understanding times to a choice of enrolled providers that the recipient reserves the rig ght t at all • . 9. To immediately notify the Case Management Agency of staffing shortfalls which will negatively impact provision of service to Medicaid Waiver recipients. 10. To submit claim data for billing to the Medicaid fiscal agent 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. • 11. 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. 12. The service provider 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 described in this agreement or when contracting with another entity which will be paid by the fiords described in this agreement A cantlict of interest includes, but is not limited b, 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 conflict 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 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. III. Under this Agreement, the Area Agency on Aging agrees to the following: 1. To facilitate the enrollment of providers with die 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 requirements • specified by the Department of Elder Affairs. IV. Under this Agreement, the Case Management Agency agrees to the following: 1 . The case management agency shag submit 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 note sly 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 sevvice 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 described in this agreement or when contracting with another entity which will be paid by the fiords 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, client, vendor, or any person wishing to benefit from the use or disbursement of funds. To avoid a• 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 . - agreement, the following services will be delivered by the Service Provider Agency in accordance with the plan of care or service alit her ization: Service Unit Rate Cannty/Region Served 1. ALL b•A..7 _ 3. ` Milk 4. v Li i 1 " • W. Termination In the event this agreement is terminated, the case management g agency and the service provider agency agree to submit, at the time notice of intent to terminate is delivered, a plan which identifies procedures to ensure services to clients will not be interrupted or suspended by the termination. • 1. Termination at Will This went 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. 2 . Termination Because of Lack of Fimds 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 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. • • • • VII. In witness whereof, the parties have caused this five page agreement to be executed by their undersigned officials as duly authorized. Case Management Agency ` Provider Agency signature print name print mane de d `7 7 air ieftesirot is i ATMs ` ' `', CERK Area Agency on Aging s C • •- 4 A S'141 p v �\ .ture / DE e , e �� SC,t1 Q-h Print e_5, den Title ��-3 -qt • Date • • APPR • ' AS TO FORM AND GAL SUFFICIEN /• .. L DATE 7 EA7;