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Item C45 BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date July 17, 2013 Division: Social Services Bulk Item: Yes X No — Department: Bayshore Manor Staff Contact/Phone- #- Sheryl Graham, 292-45 10 AGENDA ITEM WORDING: Approval for Monroe County Bayshore Manor to re-enroll in a Provider Agreement for participation in the Title XIX Institutional Florida Medicaid Program ITEM BACKGROUND: Bayshore Manor previously housed residents who received services through the Title XIX Institutional Florida Medicaid Program. We need to continue participation in this program in order for eligible future residents to receive services through this program. PREVIOUS RELEVANT BOCC ACTION: At the July 21, 2010 Board of County Commissioner's Meeting, the Board granted approval and authorized execution of the Title XIX Institutional Medicaid Provider Agreement for Monroe County to continue to,participate in a Provider Agreement with the Florida Medicaid Program. CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATIONS:Approval TOTAL COST: N/A INDIRECT COST: N/A BUDGETED: Yes X No DIFFERENTIAL OF LOCAL PREFERENCE: COST TO COUNTY: N/A SOURCE OF FUNDS: Estimate(MA)() REVENUE PRODUCING: Yes-X No—AMOUNT PER MONTH_SZZ56.00 Year$27072.00 APPROVED BY: County Atty OMB/Purchasing Risk Management_&d DOCUMENTATION: Incl rded Not Required DISPOSITION: AGENDA ITEM# Revised 7/09 MONROE COUNTY BOARD OF COUNTY COMMISSIONERS CONTRACT SUMMARY Contract with: Florida Medicaid Contract# Effective Date: , Expiration Date: Contract Purpose/Description: To enable Monroe County to re-enroll in a Provider Agreement for participation in the Title XIX Institutional Florida Medicaid Program Contract Manager: Sheryl Graham 4510 Social Services Stop 1 (Name) (Ext.) (Department/Stop#) for BOCC meeting on 7/17/2013 Agenda Deadline: 7/2/2013 CONTRACT COSTS Total Dollar Value of Contract: $ 0 Current Year Portion: $ 0 Budgeted? Yes❑ N/A Account Codes: - - - Grant: $ 0 - County Match: $ N/A - - - ADDITIONAL COSTS Estimated.Ongoing Costs: $ 0 /yr For: N/A (Not included in dollar value above) (e .maintenance,utilities, janitorial,salaries,etc.) CONTRACT REVIEW Changes Date Out Date In Needed Reviewer Division Director Yes❑ No❑ Risk Management Yes❑No O.M.B./Purchasing 1 1 Yes❑No County Attorney Yes❑N A& Comments: OMB Form Revised 2/27/01 MCI'#2 1/3,111 WHEA FLORIDA AGMY FOR HEALTHCARE ADWRISTRATION RICK SCOTT Better Health Care for all Flo►"ans ELIZABETH DUDEK GOVERNOR SECRETARY 01((96956022 II PRV-9051-D/XX/0196956022/1 MONROE COUNTY BAYSHORE MANOR BAYSHORE MANOR 5200 COLLEGE RD KEY WEST FL 33040-4302 June 4, 2013 Dear Administrator: Your current Institutional Medicaid Provider Agreement for participation in the Title XIX Medicaid Program will expire 08/30/2013. A new Institutional Florida Medicaid Provider Agreement must be signed before 08/30/2013 in order to continue participation in the Medicaid program. Failure to complete this process may result in termination of your provider number. Verify the entity's name and tax id number on the last page of the agreement for accuracy. Please have the provider agreement signed by the facility owner(s) or an authorized representative, and fax to HP Provider Reenrollment at 866-270-1497. Or, mail to: For Regular Mail: For Overnight or Express Delivery: HP Enterprise Services, LLC HP Enterprise Services, LLC Provider Reenrollment Provider Reenrollment PO Box 13800 2671 W Executive Center Cir Ste 100 Tallahassee, FL 32317-3800 Tallahassee, FL 32301-5020 If you have any questions, please call HP Enterprise Services Provider Enrollment at 1-800-289-7799 option 4. Sincerely, Angela Ramsey, Acting Chief a Medicaid Contract Management cc: Provider File Headquarters Medicaid Contract Management 2727 Mahan Drive,MS#22 2562 Executive Center Circle E Tallahassee,Florida 32308 Montgomery g ry Bldg.,Suite 100 AHCA.MyFlorida.com Tallahassee,FL 32301 INSTITUTIONAL MEDICAID PROVIDER AGREEMENT The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions: (1) Discrimination. The parties agree that the Agency for Health Care Administration(agency)may make payments for medical assistance and related services rendered to Medicaid recipients only to a person or entity who has a provider agreement in effect with the agency,who is performing services or supplying goods in accordance with federal, state, and local law,and who agrees that no person shall,on the grounds of sex,handicap, race, color,national origin,other insurance, or for any other reason, be subjected to discrimination under any program or activity for which the provider receives payment from the agency. (2) Qualft of Service. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, of a quality comparable to those furnished by the provider's peers, and within the parameters;permitted by the provider's license or certification. The provider further agrees to bill only for the services performed within the specialty or specialties designated in the provider application on file with the agency. The services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting the claim. (3) Compliance.The provider agrees to fully comply with all-state and federal laws, rules, regulations,' and statements of policy applicable to the Medicaid program, including the Medicaid Provider Handbooks issued by the agency, as well as all federal, state, and local laws pertaining to licensure, if required,and the practice of any of the healing arts. (4) Term and§ignatures. The parties agree that this is a voluntary'agreement between the agency and the provider, in which the provider agrees to furnish services or goods to Medicaid recipients. Provided that all requirements for enrollment have been met,this agreement shall remain in effect for three(3) years from the effective date of the provider's eligibility unless otherwise terminated. With respect,to reenrolling providers,the agreement shall remain in effect for three(3)years from either the date the most recent agreement expires or the date the,provider signs the renewal agreement,which ever date is earlier, unless otherwise terminated. This agreement shall be renewable only by mutual consent. The provider understands-and-agrees that no agency signature is required to make this agreement valid and enforceable. (5) Provider,Responsibilities. The Medicaid provider shall.- (a) Possess at the time of the signing of the provider agreement, and maintain in good standing throughout the period of the agreement's effectiveness,a valid professional, occupational,facility or other license pertinent to the services or goods being provided, as required by the state or locality in which the provider is located,and the Federal Government, if applicable. (b) Maintain in a systematic and orderly manner all medical and Medicaid-related'records the agency requires and determines are relevant to the services or goods being provided. (c) Retain all medical and Medicaid-related records for a period of five(5)years to satisfy all necessary inquiries by the agency. (d) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients and comply with all state and federal laws pertaining to confidentiality of patient information. (e) Send, at the provider's expense, all Medicaid-related information,which may be in.the form of records, logs,documents, or computer files,and other information pertaining to services or goods billed to the Medicaid program, including access to all patient records and other provider information if the provider cannot easily separate records for Medicaid patients from other records to the Attorney General, the Federal Government,and the authorized agents of each of these entities. (f) Bill other insurers and third parties,including the Medicare program, before billing the Medicaid> program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other state and federal requirements in this regard. (g) Report and refund any moneys received in error or in excess of the amount to which the provider is entitled from the Medicaid program within ninety(90)days of receipt. MPA Institutional(March 2013) 1 of 4 (h) Be liable for and indemnify, defend, and hold the agency harmless from all claims, suits,judgments, or damages, including court costs and attorneys fees,arising out of the negligence or omissions of the provider in the course of providing services to a recipient or a person believed to be a recipient to the extent allowed by in and accordance with section 768.28, F.S. (2001), and any successor legislation,' (i) Provide proof of liability insurance at the option of the agency and maintain such insurance in effect for any period during which services of goods are furnished to Medicaid recipients. 6) Accept Medicaid payment as payment in full,and not bill or collect from the recipient or the recipient's responsible party any additional amount except, and only to the extent the agency permits or requires, co-payments, coinsurance, or deductibles to be paid by the recipient for the services or;goods'provided. This includes situations in which the provider's Medicare coinsurance claims are denied in accordance with Medicaid policy: (k) Comply with all of the requirements of Section 6032 (Employee Education About False Claims Recovery)of the Deficit Reduction Act of 2005, if the provider receives or earns five million dollars or greater annually under the State plan: (1) Submit,within thirty-five(35)days of the date on a request by the Secretary or the Medicaid agency, full and complete information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the twelve(12)month period ending on the date of the request; and any significant business transactions between the provider and any wholly owned supplier, or between the,provider and any subcontractor, during the five(5)year period ending on the date of the request. (m)`Employ only individuals who may legally work in the United States, either U.S. citizens or foreign citizens who are authorized to work in the U.S, in compliance with the Immigration Reform and Control Act of 1986 which prohibits employers from knowingly hiring illegal workers. (n) Utilize the U.S. Department of Homeland Security's E-Verify Employment Eligibility Verification system to verify the employment eligibility of all persons employed by the provider during the term of this Contract to perform employment duties within Florida and all persons(including subcontractors)assigned by the provider to perform work pursuant to this Contract. The provider shall include this provision in all subcontracts it enters into for the performance of work under this Contract. (o) Attest that all statements and information furnished by the prospective provider before signing the provider agreement shall be true and complete. The filing of a materially incomplete, misleading or false application'will make the application and agreement voidable at the option of the agency and is sufficient cause for immediate termination of the provider from the Medicaid program and/or revocation of the provider number. (p) Agree to notify the agency of any changes to the information furnished on the Florida Medicaid Provider Enrollment Application`including changes of address, tax identification number,'group affiliation, depository bank account;and principals. For this purpose,principals includes partners or shareholders of five(5)percent or more,officers, directors, managers,financial records custodian, medical records custodian, subcontractors, and individuals holding signing privileges on the depository account,and other affiliated person. (q) Agree to notify the agency within five(5)business days after suspension or disenrollment from Medicare. Failure to notify may result in sanctions imposed pursuant s. 409.908'(24)and the provider may required to return funds paid to the provider during the period of time that the provider was suspended or disenrolled as a Medicare provider. (r) Search the List of Excluded Individuals/Entities(LEIE), located at hftp:L/www.oig.hhs.ggv/fraud/exclusions.asp, and the Agency's final order database, located at http://apps.ahca,mygorida.com/dM web, monthly to determine whether any employee or contractor has been excluded. Providers will notify the Agency immediately any exclusion information discovered'. Civil monetary penalties may be imposed against Medicaid providers and managed care entities who employ or enter into contracts with excluded individuals or entities to provide items or services to Medicaid recipients. (6) Agency Responsibilities. The agency shall: (a) Make timely payment at the established rate for services or goods furnished to a recipient by the provider upon receipt of a properly completed claim. (b) Not seek repayment from the provider in any instance in which the Medicaid overpayment is attributable solely to error in the state's determination of eligibility of a recipient. (7) Change of('ownership. A Medicaid provider agreement may be revoked, at the option of the agency, as the result of a change of ownership of any facility, association, partnership, or other entity named as the provider in the provider agreement. MPA institutional(March 2013) 2 of 4 (a) If the provider sells or transfers a business interest or practice that substantially constitutes the entity named as the provider in the provider agreement, or sells or transfers a facility that is of substantial importance to the entity reamed as the provider in the provider agreement,the provider is required to maintain and make available to the agency Medicaid-related records that relate to the sale or transfer of the business interest, practice, or facility in the same manner as though the sale or transaction had not taken place, unless the provider enters into an agreement with the purchaser of the business interest, practice, or facility to fulfill this requirement: (b) In the event of a change of ownership, the transferor remains liable for all outstanding overpayments, administrative fines, and any other moneys owed to the agency before the effective date of the change of ownership. In addition to the continuing liability of the transferor,the transferee is liable to the agency for all outstanding overpayments identified by the agency on or before the effective date of the change of ownership. The term"outstanding overpayment"includes any amount identified in a preliminary audit report issued to the transferor by the agency on or before the effective date of the change of ownership. In the event of a change of ownership for a skilled nursing facility or intermediate care facility,the Medicaid provider,agreement shall be assigned to the transferee if the transferee meets all other Medicaid provider qualifications. In the event of a change of:ownership involving a skilled nursing facility licensed under part 11 of chapter 400, liability for all outstanding overpayments,administrative fines, and any moneys owed to the agency before the effective date of the change of ownership shall be determined in accordance with s.400.179. (c) At least 60 days before the anticipated date of the change of ownership, the transferor shall notify the agency of the intended change of ownership and the transferee shall submit to the agency a Medicaid provider enrollment application. If a change of ownership occurs without compliance with the notice requirements of this subsection, the transferor and transferee shall be jointly and severally liable for all overpayments, administrative fines, and other moneys due to the agency, regardless of whether the agency identified the overpayments, administrative fines, or other moneys before or after the effective date of the change of ownership. The agency may not approve a transferee's Medicaid provider enrollment application if the transferee or transferor has not paid or agreed in writing to a payment plan for all outstanding overpayments, administrative fines, and other moneys due to the agency. This subsection does not preclude the agency from seeking any Other legal or equitable remedies available to the agency for the recovery of moneys owed to the Medicaid program. In the event of a change of ownership involving a skilled nursing facility licensed under part 11 of chapter 400, liability for all outstanding overpayments, administrative fines, and any moneys owed to the agency before the effective date of the change of ownership shall be determined in accordance with s.400.179 if the Medicaid provider enrollment application for change of ownership is submitted before the change of ownership. (8) Termination for Convenience. This agreement may be terminated without cause upon thirty(30)days written notice by either party. (9) Interpretation. When interpreting this agreement, it shall be neither construed against either party nor considered which party prepared the agreement. (10) ;Governing Law. This agreement shall be governed by and construed in accordance with the laws of the State of Florida and both parties concur that this agreement is a legal and binding document and is fully enforceable in a court of competent jurisdiction. (11) Amendment. This agreement, application and supporting documents constitute the full and entire agreement and understanding between the parties with respect to their relationship. No amendment is effective unless it is in waiting and signed by each party. (12) Severability. If one or more of the provisions contained in this agreement or application shall be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired. (13) Agreement Retention. The parties agree that the agency may only retain the signature page of this agreement, and that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record. (14) Funding. This contract is contingent upon the availability of funds. (15) Assignability. The parties agree that neither may assign their rights under this agreement without the express written consent of the other. A chief executive officer(CFO), president, or administrator may sign this agreement in lieu of all principals. Failure to sign the agreement will make the agreement and provider number voidable by the agency. MPA Institutional(March 2013) 3 of 4 The signatory hereto represents and warrants that they have read the agreement, understand it, and are authorized to execute it on behalf of their respective principals. This agreement becomes null and void upon transfer of assets; change of ownership; or upon discovery by the agency of the submission of a materially incomplete, misleading or false provider application unless subsequently ratified or approved by the agency. IN WITNESS WHEREOF,the undersigned representative has caused this agreement to be duly executed under the penalties of perjury and now affirms that the foregoing is true and correct, (Legibly print name of signatory) Tide I Signature :gate Please Complete The Fallowing Information: "Provider's Name: MONROE COUNTY BAYSHORE MANOR DBA Name: momt 'De CUut1- 1 500 AL5ufVicLs18Ay:500PE MAI' og, Tax Identification Number: 596000749 l National Provider Identifier: Florida Medicaid Identification:Number: 1401599 (For new applicants the Medicaid ID will be entered by the fiscal agent upon approval of the application.) Taxonomy Code: (Optional) Effective Date of This Agreement: 9'1112013 Termination Date of This Agreement: ,3l .20 AMOE COLIN AT-;r`rt VCY PEDRO . MER ADO ASSISTANT LIN D `I t 13 MPA Institutional(March 2013 4 of 4 Backgrounde0 Background Screening Each applicant seeking to participate in the Medicaid program must submit a complete set of fingerprints for each person declared on an initial or renewal application for the purpose of conducting a criminal history record check. Details of the requirements are documented in the Florida Medicaid Provider Enrollment Guide for Completing Application located in the Enrollment forms section in the public Web Portal at the following URL: http://mymedicaid-tlorida.com under Public Web Portal >Enrollment. In an effort to streamline the background screening process,AHCA is now encouraging providers to use vendors offering electronic fingerprint scanning services. This process avoids the traditional fingerprint card process where finger prints are"rolled"in ink onto an FBI fingerprint card and mailed hard copy with a check for processing. This improves accuracy with fewer rejections (no ink smudges)and improves timeliness of the background investigation (BI) process. This enhancement to the process allows providers to enroll without mailing any hard copy documentation. Rather, with electronic scanning of fingerprints handled by approved vendors,applicants may submit their application and all remaining supporting documents through the online Enrollment Wizard located at the following URL: http://mymedicaid-floridacom,under Public Web Portal >Enrollment>Enrollment Wizard. The following provides detailed information on how to take advantage of this new option: Level of Screening Required Provider applicants to Florida Medicaid require a Level 2 screening which involves a fingerprint check of state and federal criminal history information'conducted through the Florida Department of Law Enforcement(FDLE)and the Federal Bureau of Investigation(FBI). Submission of Fingerprints All provider applicants are encouraged to submit their fingerprints electronically. Forms of Electronic Screening The most common form of electronic screening involves use of a LiveScan device which is a type of equipment used to directly capture fingerprints through a scanning function. Persons being screened place their hands directly on the scanner for reading. Fingerprint scanning using a LiveScan device provides faster results and generally costs less than hard card scanning as there is less handling involved. LiveScan capture also produces a better quality print, so has a lower rejection rate of illegible prints(no ink smudging, etc). There are several options for LiveScan capture, including: • LiveScan vendors approved to submit fingerprint requests through the Florida Department of Law Enforcement;(FDLE). These vendors generally require advanced online reservations or appointments`and charge a fee for use of the LiveScan in addition to the FDLE screening fee of $40.50. LiveScan devices are available at specific locations or through mobile services where the vendor will either come to the provider location(based on certain volumes and fees)or another pre-arranged location. LiveScan vendors are independent businesses and each must be contacted in advance to determine fees, services, and enrollment requirements. For more information regarding LiveScan vendors, see Florida LiveScan Vendor List for contact information, locations and pricing,and the FDLE LiveScan Site. The Florida LiveScan Vendor List'is available at the following URL: http://ahca.myflorida.com, under Medicaid Health Quality Assurance> Licensing and Regulation. 1 Background Screening Quick Reference Guide Quick Reference Guide Background Screening • The Agency for Health Care Administration has contracted with Cogent Systems to provide electronic fingerprint services for health care providers licensed through the Agency.Cogent Systems has statewide locations and will provide LiveScan services for a screening fee of$40.50 plus a processing fee of$11.00 per transaction for a total screening fee of$51.50 per individual. The fee is due at time of screening unless other payment arrangements have been made with Cogent. For a list of Cogent locations,visit the Cogent Web site at the following URL: http:/twww.cogentid.com/fl/kidex—ahca.htm. Please note, this process is specifically set up for license related activities for AHCA's Health Quality and Assurance division responsible for provider licensing.This is a different division and process than AHCA's Medicaid Enrollment process. This is important to understand should applicants choose to work with Cogent for capture of their fingerprints for Medicaid provider'enrollment purposes. To ensure the results of your screening are delivered to Florida Medicaid and not to AHCA's Division of Health Quality Assurance, be sure to use the correct account number,or ORI, assigned to Florida Medicaid. The ORI which should be used for Medicaid Enrollment and Re-Enrollment is FL922413Z. • LiveScan devices(machines)may purchased/leased by providers who wish to handle their own fingerprint capture. Several businesses offer machines(sale or lease); however, it is important to assure that any selection is approved for submission through FDLE, and all requirements of fingerprint submission are met. For more information visit the AHCA's background screening page at the following URL: http//ahca.myflorida.com, under Health Quality Assurance> Licensing and Regulation>Background Screening. LiveScan Requirements Please have the fallowing information available at the time of screening: • A valid picture ID • Indicate the AHCA#,which is either: the Application Tracking Number(ATN), for new applicants and associated parties; or, • the Medicaid Provider ID,for renewing applicants and associated parties. • All information regarding the the person to be screened, including: • Full Name • Address • Social Security Number • Date of Birth • Race • Sex • Height • Weight NOTE: Incomplete information may result in rejection of screening requests. Please communicate to the LiveScan vendor your screening is for Florida Medicaid Provider Enrollment and should be submitted on behalf of Florida Medicaid at ORI FL922013Z. Cost of Screening FDLE charges$40.50 for a Level 2 background screen ($24.00 for the state portion and $16.50 for the national portion). The additional cost of electronic screening varies based on the vendor chosen. Total cost= $40.50+electronic print processing fee 2 Background Screening Quick Reference Guide an�r PROVIDER REENROLLMENT APPLICATION This application is to he submitted for the purposes of establishing continuing eligibility to receive direct or Indirect payment for services rendered to recipients of the Florida Medicaid Program.(See the Provider Re-enrollment Application Guide available at www.mymedicald-florida.com for full instructions.) Provider ID: 1401599 Provider Name: MONROE COUNTY BAYSHORE MANOR Doing Business As(D1B1A): (Optional) MOW 94)c G! uU '1'y So aAt.SERd i�(E5� ��HDk� A1�1►JD� Tax ID: FEIN 596000749 Name �j l�kEfZ L RANAM Telephone Number Area Code E-Mail Address {'ay131r - ©OV tr t triefti ':iete fla,iy`; eft�rilbr1 ="` o ❑ Yes D9 No Previous Provider Name Provider Number Federal Tax ID Date of CHOW It s t dot thw �1 victual Litt c�1 � c of � � recordsT rr a(s �. A w��up � �nei �., st [ds� � � r� r�� � ssAnd r�dks T'TiWs ': tc .'� ".�: tom 0 E f� � r �: � '� �. :..� .;:.f, Name Title *Relationship *SSN *DOB License# *%Owner (`denotes required field) (see notes below) (rf applicable) cowlly 6vvc-Ammcw7- NOTE:Select one or more from the following list when indicating each owner and operator's relationship to the applicant Owner,Partner,Shareholder,Sub-Contractor,Officer,Director,ManagingEmployee,Financial Records Custodian(FRC),Medical Records Custodian(MRC),EFT Authorized individual,Spouse,Parent Child;or Sitifing. DEFINITIONS: Officers are deemed to be officers of the corporation or company-such as the President or Vice President,directors are members of the company's board of directors;and, managing employees are members of the company's management team:If you have a'Director of Therapy Services'or'Director of Clinical Services,"these persons would quality as managing employees for Medicaid purposes. Visit www.mymedicaid-flotida.com or call 1-800-289-7799,Option 4 for assistance. Provider to:74uiovv 4.,QW0dtaS anC#{ j9EtCatQ1'S Hj3tfit Answer; alt 'cols;a-f;of this que ch any reWired documentation. Have you,or any of the individuals listed in#3 above ever a) Been convicted of a felony,had adjudication withheld on a felony,pled nolo ❑ Yes No contenders to a felony,or entered into a pre-trial agreement for a felony? 1f yes,list the name(s)of the individuals(s)and provide a copy of the administrative complaint and final disposition. Name: b) Had any disciplinary action taken against any business or professional license held ❑ Yes jpq No In this or any other state or surrendered a license In this or any state? If yes,fist the name(s)of the individuaf(s)and the date of the action. Provide a copy of the final disposition. Attach documentation from the proper authorities that approved the reinstatement of the license. Name: Date: c) Been denied enrollment,been suspended or excluded from Medicare or Medicaid in ❑ Yes No any state,or been employed by a corporation,business or professional association that has ever been suspended or excluded from Medicare or Medicaid in any state? If yes,list the name(s)and provider number(s)of the individual(s)and provide a copy of any documents related to the suspension or exclusion. Name: Provider Number: d) Had suspended payments from Medicare or Medicaid In any state,or been employed ❑ Yes No by a corporation,business or professional association that ever had suspended payments from Medicare or Medicaid in any state? If yes,list the names)and provider numbers)of the individuals)and provide a copy of any documents related to the suspended payments. Name: Provider Number. e) Owes money to Medicaid or Medicare that has not been paid? ❑ Yes CK No If yes,list the name(s)and provider number(s)of the individual(s)and provide a copy of any documentation related to the debt. Name: Provider Number: f) Have ownership in any other Medicaid enrolled business? ❑ Yes No If yes,list the name and Medicaid provider number of the other Medicaid enrolled business. Attach additional pages if necessary. Name: Provider Number. Cet`tlficau"S ment "l understand that the filing of materially incomplete or false information with this enrollment request is a third degree felony under Section 409.920(2)(0,Florida Statutes and is sufficient cause for termination from the Florida Medicaid Program;that false claims;statements,documents,or concealment of material facts may be prosecuted under applicable federal and state laws;that I am responsible for the information presented on this application and that the information is true,accurate,and complete; and,that it is my responsibility to notify Medicaid's fiscal agent of any future Changes to the information on this application including,but not limited to,a change of address,gawp aAStiation,ownership,officers,directors,tax identification number,or EFT bank account. Furthermore,I agree to abide by the provisions of the provider agreement from the date it is effective per Section 409.907(g)(a),Florida Statutes. Signature of Provider or Registered Agent Date M Iyd R, Name of Provider or Registered Agent Title If (Please Type or Print Legibly) CVfEYORN Keep a copy of the application and all required documentation for your files and mail originals to: rdEORM For Regular Mail: For Ovemight or Express Delivery: HP Enterprise Services HP Enterprise Services PEDRO Prowler Enrollment Provider Enrollment AS O N ATTORNEY PO Box 13800 2671 W Executive Center Cir Ste 100 f [/Iy Tallahassee,FL 32317-3800 Tallahassee,FL 32301 [date Visit www.mymedicaid-florida.com or call 1-800-289-7799,Option 4 for assistance. AHCA Form 2200-0004(May 2010) APPLICATION Page 2 BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: July 2 i 20 i 0 Division: Community Services Bulk Item: Yes x No Department: BWhore Manor Staff Contact Person/Phone#: Trish Barker AGENDA ITEM WORDING: Approval for Monroe County;Bayshore Manor to re-enroll in a Provider Agreement for participation in the rMeXIX Institutional Florida Medicaid Program ITEM BACKGROUND: Bayshore Manor currently houses two residents who receive services through the Title=Institutional Florida Medicaid Program We need to come participation in this program In order for resident lets to continue PREVIOUS RELEVANT BOCC ACTION:At the July 18,2W Board of County Commissioner's,Meeting the Board granted approval and authorized execution on the Title XIX Institutional Medicaid Provider Agreement for Monroe County to continue to participate in a Provider Agreement with the Florida Medicaid Program CONTRAMAGREEN ENT CHANGES: N/A ` STAFF RECOMMENDATIONS: Approval DIFFERENTIAL OF LOCAL PREFERENCE: COST TO COUNTY: N/A SOURCE OF FUNDS: REVENUE PRODUCING: Yes— No_._ AMOUNT PER MONTH 556.0estimated AMOUNT PER YEAR 6672.00(estimate) APPROVED BY: County Atty x OMB/Purchasing x Risk Management—x— DOCUMENTATION: Included x Not Required DISPOSITION: AGENDA ITEM # BACK 1 8 MCA CAB COUNTY BOARD OF COt)N CCU SSIONT-R.S CONTRACT SU-11WMARY Contrawith- Florida Medicaid Contract Effective Date- Expiration Date- Contract Purpose/Description: _ To enable Monroe County to re-enroll in a Provider Agreement for participation in the Title XIX Institutional Florida Medicaid Program ContractManager: Patricia Barker 4533 Social Service Bayshore Manor S 9 (Name) (Ext.) (Department/Stop for BOCC meeting can July 21201 _Ends line. duly 21 CONTRACT COSTS Total Dollar Value q Contract- Current Year Portion: Budgeted? A unt C - -�_ r t: County Match: NIA - ADDITIONAL COSTS Estimate Ongoing Costs; "Or For: N/A (Not included in dollar value above) ( a maintenance,utilities, ° salaries,etc.) CONTRACT REVIEW Changes Date Out Division Director— � YesEl N ° ° � i dRen' i a C . I.B�Pes urc i i�s in County Attorney _ Nd �. Comments- OXIB Form Revised 2127101 MCP# Z_ INSTITUTIONAL MEDICAID PROVIDER AGREEMENT r The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions: (i}Discrimination The parties agree that the Agency for Health Care Administration(;AHCA)may make payments for medical assistance and related services rendered to Medicaid recipients only to;a person or entity who has a provider agreement in effect wtih AHCA:who is Ong services or supplying goods in aeoordance with federal,slime,and kxW ism and-who agrees-that-no-person shak,on the grounds of_ sex,handicap,race,color,national origin,other insurance,or for any other reason,be subjected to ckscximir ation under any program or activity for which the provider receives payment from AHC"k (2)ggft of Senrice.The plovider agrees dud Services ot goods billed to the Medicaid piogarn nKist medically necessary,of a quality comparable to those furnished by the providers peers,and within the pwarneters permitted by the provider's license or certification.The provider further agrees to bill only for the services performed within the sir or specialties wed in the prr vkW application on file with AHCk The provider must deliver the services or goods to eligible Medicaid recipients to receive payment from AHCA. (3)Cos.The provkW aces to comply with local,state,and federal lags,as well as rues, regulations,and statements of policy applicable to the Medicaid program,irx1uding the Medicaid Provider Handbooks issued by AHCA. (4);Term and sigruatures.The parties agree that this is a voluntary agreement between AHCA and the provk W in which the provider agrees to furnish services or goods to Medicaid recipients_ Provided that all requirements fvr enrollment are met and remain in effect,this agreement shall remain in effect for three(3)years from the effe&Ave date of the provkWs eligibility unless otherwise terminated.This agreement is renewable only by mutual consent.The provider understands and agrees that no AHCA signature is required to make this agreernent valid and enable.This agreement shalt be accepted and entered into by AHCA upon the assignment of aE provider number and effective date as provided for herein. (5)ProviderResponsibilities The Medicaid provider shall: (a)possess at the time of the signing of the provid agreement,and main in good standing throughout the period of the agreenumrs effectiveness,a valid professional,occupational,facility or other license appropriate to the services or goods_provided,as requited by law (b)Keep,maintain,and slake available In a systematic and orderly manner all medical and Medicaid-related records as AHCA requires for a period of at least five(5)years. (c)Safeguard the Use and discloswe of won pertaining to current or former Medicaid recipients as required by law- (d)Send,upon request or as required by applicable handbooks and at the provider's expense, legible Copies of aA M+etl d-related information to authorized state and federal employees, their agents.The provider shall cam're state and federal employees,including their agents,access to all Medicaid patient records and to other information that is inseparable from mid-related records. (e)Bill other i nsums and third parties,ind"M the Medicare program,bellx'e being the Medicaid program,if the rent is eligible for payment for health care or related services from another insurer or p - (f)Refund any moneys received from the Medicaid program in error or in excess of the amount to which the provider isertt#ied within 90 days of receipt. (g)se ki3le for and indemnify,defend,and hold!AHCA harmless from as claims, suits,judgments,or damages,including court casts and atlomey's fees,arising out of the negligence or ornissions of the proffer in the course of providing services to a recent or a person believed to be a recipient to the extent allowed by in and accordance with won 76828, F.S.(2001),and any successor legislation. (h)Accept Medicaid payment as payment in W.and not big or collect from the recipient or the recipient's responsible party any aidd tionai anxxint except to the extent AHCA permits or requires,co-payments, coinsurance,or deductiibles wig recipients'pay for the services or goods provided': This includes situations in which the providWs ire coirmrance dads are denied in accordance with Medicaid's payment. MPA tr ons1 Rewh ed February 2007 &_C� 3 &/ 8 y. n �. • s • ..i � r ,m,� _ .:, � .� * �.�. • t 4 i •: - •_ _ � s •- • _ � s e _ _ .. a �: a ,;a ;. - s � - • � e:. - - s ,. .s -_+ a .. �. � � � �_ g � a«. ,. # �. M ..� �. B is .. '# • ! .. i � � a- s - s � � * }. _� __ - � � s� ass a w� ;~ � r •., � . s- f 4. f". � _. _� ...r ♦ Y {► .. ;. • # ..` i�#b:. f ♦: f." # t 4 fir. s i 3Y a � � # 0 "! •.. # f ! ! {1 (14)Agr r .E9191 tion. The parties agree that AHCA may only retain the signature pace of this agreement,and that a copy of this standard provider agreement is maintained by the Director of Medicaid,or his designee, and reproduced as a duplicate original for any purpose and usable as evidence in any legal proceeding. (15)FUnding.This contract is contingent upon the availability of funds. (16)hgggnabiti ,The parties agree that neither may assign their rights under this agreement without the express written consent of the tamer. THE PARTIES CONCUR THAT THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS FULLY ENFORCEA13LE IN A COURT OF COMPETENT JURISDICTION. IT,AND IS AUTHORIZED TO EXECUTE IT ON BEHALF OF HIS OR HER RESPECTIVE PRINCIPALS. IN WITNESS WHEREOF,the undersigned representative of the above executed this agreement under (legibly txir►t name of svriatory) Title Suture rate X RO __ , # -ORi: I u n � TORNEY Please Complete The Following Information: Provider's Name: IViL'NROE COUNTY SAYSHORE MANOR DBA Name: Tax Identification Number: 596000749 National Provider Identifier; Florida Medicaid Identification Number: 1401599 (For new applicants the Medicaid ID wifl be supplied by the fecal agent upon approval of the a " fion.) Taxonomy Cods; (Optional) Effective Elate of This Agreement: j Termination Elate of This Agreement: MPA Institutional Revised February 2007 INSTITUTIONAL MEDICAID PROVIDER AGREEMENT soma" "HEKM CAFt The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions: oy yiscrimunadon. The parties agree that the Agency for Health-care Adrninistra (AHCAY may ice payments-for _ medical assistance and related services rendered to Medicaid recipients only to a person or entity who has a provider agreement in effect with AHCA;who is performing services or-supplying goods in accordance with federal,state, and k)cal if Sex ho natiortal for any other reason,.be subjected to discrimination under , ' or any program or activity for which the provider receives payment from AHCA (2) QuaW of Service. The provider agrees VW services or goods billed to the MeoCaid program must be medically necessary,of a quality comparable to those firrnished by the provkWs peers,and within the parameters permitted by the provider's license or cep. The provider funnier agrees to bill only for the services performed within the specialty or specialties designated in the provider application on file with AHCA The provider must deliver the services or goods to= eligible-Medicaid recipients to receive payment from AHCA. (3) Comoliance. The provider gees to comply with tonal,state,and federal laws,as well as rules, regulations, and statements of poky apple to the Medicaid program, including the Medicaid Provider Handbooks issued by AHCA (4) Term and Wires. The parties agree that this is a voluntary agreement between AHCA and the provider, in which the provider agrees to furnish services or goods to Medicaid recipients. Provided that ad requirements for enrollment are met and remain in effect, this agreement shall remain in effect for three(3)years from the effective date of the provider's eligibilityunlewotherwise.terminated. This agreement is renewable only by mutual consent. The provider understands and agrees that no AHCA signature is required to make this agreement valet and enforceable. This agreement shall be accepted and entered into by AHCA upon the assignment of a pravider number and effective date as provided for herein. (5)_Provider Responsibilities._The Medicaid Provider shall. (a) Possess at the time of the sign of the provider agreement,and maintain in good standing throughout the period of the agreement's effectiveness, a vat-professional,occupational,facility or other license appropriate to the services or goods provided, as required by law. (b) Keep, maintain, and make available in a systematic and orderly manner all medical and Medicaid-related records as AHCA requires for a period of at least trv+e(5)years. (c) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients as required by law. (d) Send, upon request or as required by awe handbooks and at the provider's expense, legible copies of all Med1cmd4elarted information to authorized state and federal employees,Ong their agents. The provider shall give state and federal employees, including their agents, access to all Medicaid patient records and to other information that is inseparable from Medicaid-related records. (e) Bil other insurers and third parties, inchiding the Medicare program,before billing the Medicaid program, if the recipient is edible for payment for health care or related services from another insurer or person. (f) Refund any moneys received from the Medicaid program in error or in excess of the amount to which the provider is entitled within 90 days of receipt. MPA molt dowl Rewsed Febrn 2W7 1 Cif 3. (g) Be liable for and inde€rinify,defend,and hold AHCA harmless from all c lairrns, suits,Judgments,or damages,i0clud ng court costs and attorneys fees,arising out of the negligence or omissions of the provider in ttte course of providing services to a recipientor a person�th be a r ient to the exert allowed by in and accordance with section n 768.28, F.S. (2WI),and any successor kokc a on. (h) Accept Medicaid payment as payment in full,and not big or collect from the recpient or the recipients responsible party any additional amount exOW to fire extent AHCA permits or requires.co-payments,coinsurance,or deductibles will recipients'pay for the services or goods provided. This includes situations in which the provider's Medicare coinsurance claims are denied in accordance with Medicaid's payment (#) Submit claim to AHCA electronitally wW to abide by-the terms of tie-FCC C S Submission n Agreement. U) Receive payment f m AHCA by tic Funds Transfer XFT). In the event that AHCA erroneously deposits funds (k) Comply with all of the requirements of Section 6032(Employee Education About False Claims Recovery)of the Deficit Reduction Act of 2005, g the provider receives or earns five million dogs or greater annually under the State clan. (6) AHCA R onsibili` . AHCA (a) is required to make timelyr payment at the esU baled raft for services or goods furnished to a recipient by the provider upon receipt of a property completed dam (b) Will not seek repayment from the provider in any instance in which the Medicaid overpayment Is' attributable solely to error in the states determination of eligibility of a recipient (7) Termination For Converi ence. This agreement is terminable upon thirty(30)days'writient notice with or without cause by either party. (g) Owner;a The provider agrees to give AHCA sixty(60)clays written notice before making any change in ownership of the entity named in the provk(er agreement as the provider. The provider is required to maintain and make available to AHCA Medicaid refated records that relate to the sale or transfer of the Mess interest practice,or facility in the Same manner as thcxigh the sate or transaction had not taken place, unless the provider enters into an agreement with the Purchaser of the business interest,Rract`0e or facility to h M ttm raquuwnent. Nursing-facilities,have the option to assign this agreement to the new provider as a result of she,lease,or any other change in operational ownership subject to all terms and conditions under whtifi the agreement was originally issued. in the event of a charge in Hospital ownership, the new provider agrees to assume all liabilities due from previous providers to the agency,regardless of when the liabilities are identified. in order to participate in the Medicaid program: (9) Comcilete MMMM.• The P(VAd"is MQWW to furnish true and complete statements and information to AHCA before signing the provider agreement. The provider is obligated to inform AHCA in writing of any change in the statements and information prior to the change. The filing of a imaterigiilyi incomplete,misleading or false application;will matte the application and agreement voidable at the AHCA's option and is suffictent muse Immediate termination of the of Um (10)-interrxetation. When interpreting this agreement, it stead be neither cxy blued against either party nor considered which party Prepay the agreement 01) Owe r_rnft Law. The parties consent to governance by and hterpretation of their agreement in accordance with the State of Florida's laws. (12) Amendme nt This agreement, application and supporting documents constitute the full and entire agreement and understandkV between the parties with respect to theW reia#ionsttsn. No amendment is effective unless it is in writing and signed by each party. (13) SeverabiCtty. If one or more of the pions contained in this agreement or application are declared invalid, then the other provisions remain valid. MPA b stitucional Revised February 2007 2 of 3 (14) Agreement Retention. The parties agree that AHCA may only retain the signature page of this agreement, and that a copy of this standard provider agreement is maintained by the Director of Medicaid, or his designee, and reproduced as a duplicate original for any purpose and usable as evidence in any legal proceeding. Ll§) Fundinct. This contract is contingent upon the availability of funds. (18) Assignability, The parties agree that neither may assign their rights under this agreement without the express written consent of the other. -_ THE PARTIES CONCUR THAT THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS FULLY ENFORCEABLE!N A COURT a_F_COMPETENT JURISDICTI©N. ------ THE SIGNATORY REPRESENTS THAT HE OR SHE HAS READ THE AGREEMENT, UNDERSTANDS IT, AND IS AUTHORIZED TO EXECUTE IT ON BEHALF OF HIS OR HER RESPECTIVE PRINCIPALS. IN WITNESS WHEREOF,the undersigned representative of the above executed this agreement under the Penalty of perjury and now affirms that the foregoing is true and correct. Mario DiGennaro Mayor July 18, 2007 (f "y"nameofsignatory) Tide Sgrtatex+s Date ems }MONROE COUNTY aTT,)gNEY APP€ t/EDA'S T° FORW- iF-3 � ZO t ASSISTANT CQLINT) A7 .OP-NEY atr� f, Please Complete The Following Information: Provider's Name: Bayshore Manor DBA Name: Tax Identification Number. Florida Medicaid kfentifleation Number. 140159900 (For new gV#cants the hbdicaFd ID wad be Vedby the fiscal aaent�� �t of tt e _ National Provider Identifier:(Regwreco Taxonomy Code: (opeomW Effective Date of This Agreement: 911/2007 Termination Date of This Agreement: 8/31/2010 MPA fnstiMiorW Revised Februarys 2007 1 of 3