10/13/1999 CL i/ek "S 04.2"G ZNAL
s
HOME AND COMMUNITY BASED WAIVER
REFERRAL AGREEMENT
This Referral Agreement, made this 30 day of June, 1999, shall be in effect for t� piio o •
July 1, 1999 to June 30, 2000 between Alliance for Aging, the Area Agency on gktbEforn rn
Planning and Service Area 11; Monroe County Social Services, the case manager 4ilE agen -
and Staff Builders, the Service Provider Agency. The purpose of this agreement 9 rode to
the development of a coordinated service delivery system to meet the needs of theepor = x
disabled adults who are at risk of premature institutionalization. . '= rTi
i • c.
Objectives c` rr ' as o
1. To maintain a climate of cooperation and consultation with and between agencies,
in order to achieve maximum 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 agrees 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 submitted by 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 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 will be signed, attached to the agreement and forwarded to the
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Area Agency on Aging.
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 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 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, 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 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 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 shall 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 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 described in this agreement or when contracting with another
entity which will be paid 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 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 authorization:
Service Unit Rate County/Region
Served
1. FER•OIJAL CARE 5.00 MONROE
2. I" JoMEAAAKE g. ' 4.50
3. ESPiTE 4 4. 50
-i� C F WS Ic A L.)
4. RISK OUGTteJl 5 S. 00
5. ESN AT 4 1 , S. 60
c4PAJJION `l S. Oo
VI. Termination
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
identifies procedures to ensure services to clients will not be interrupted or suspended by the
termination.
1. 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.
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 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 Service Provider Agency
A.414 f_/AAIA41.40
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Signature
AL) Ramona Frischman
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