SFY2007 07/19/2006DANNYL. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE: July 24, 2006
TO: Dotti Albury, Administrative Assistant
In -Home Services
FROM: Pamela G. HanctjA_
Deputy Clerk ��f
At the July 19, 2006, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Adult Services Home and Community Based Waiver
Case Management Referral Agreement between the Florida Department of Children and Families
(DCF) District 11 Program Office and Monroe County Board of County Commissioners
(In -Home Services Program).
Enclosed are four duplicate originals of each of the above -mentioned, executed on behalf
of Monroe County, for your handling. Please be sure to return the fully executed "Monroe
County Clerk's Office Originals" and the "Monroe County Finance Department's Originals"
as soon as possible. Should you have any questions please do not hesitate to contact this office.
CC' County Attorney
FinanFe w/o document
File
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HOME AND COMMUNITY BASED WAIVER g~r .-
CASE MANAGEMENT REFERRAL AGREEMENT ~AJ~'~ _
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This Referral Agreement made this IC, day of ~, 200 G,. between the Florida Dep~~ of ~
Children and Families' (DCF) District II Program Office, and Monroe County In-Holi'ie ServiOlll,
hereinafter referred to as "case management agency", details the responsibilities and the expectations
associated with the Medicaid Waiver for State Fiscal Year (SFY) 2006-2007. This Referral
Agreement is in effect from the date of signature, through SFY 2006-2007 for as long as the
Medicaid waiver provider remains enrolled with the State of Florida's Medicaid fiscal agent.
Provider noncompliance, nonperformance, or unacceptable performance under this agreement may
require a corrective action plan addressing the problems identified by state agency Quality
Assurance Reviews. Failure of providers to adhere to the Department of Children and Families'
guidance on eligibility and referral for services may result in recoupment of program funds or
provider dis-enrollment as a Medicaid Waiver program provider.
ADULT SERVICES
The purpose of this agreement is to enable eligible disabled adult participants to receive case
management services from qualified providers with oversight of the quality of care by the Florida
Department of Children and Families' District II Program Office and the Medicaid Waiver Specialist
employed by the Department of Elder Affairs (DOEA). These services are authorized in order that
the participant may remain in the least restrictive setting and avoid or delay nursing home placement
Services and care are to be furnished in a way that fosters the independence of each participant and
facilitates an increased functional capacity. 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
1. 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 disabled adults.
D. To provide technical assistance to and consultation between agencies on matters
pertaining to actual service delivery and share appropriate assessment information and
care plans to avoid duplication.
E. To establish an effective working relationship between the case management agency, the
service provider, and the Florida Department of Children and Families; the case
management agency being responsible for the development of care plans and authorization of
services available under the waiver, the service provider being responsible for the direct
provision of those services to consumers served under the waiver program, and the
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Department being responsible for management and oversight of the waiver program.
II. Under this Agreement, the District (Regional) Program Office agrees to the following:
A. To provide technical assistance and training to the case management agency.
B. To provide or to assist the Medicaid Waiver Specialist in providing annual on site
monitoring of the provider case management agency and, when applicable, conduct the
same monitoring of district DCF staff performing case management activities, using the
approved DOEA Medicaid waiver programmatic monitoring tool.
C. To monitor and project provider expenditures.
D. To conduct telephone screenings on all new referrals requesting services through the
ADA-HCBS Medicaid waiver within the timeftames set forth in the Adult Services Wait
List Policy guidelines, and using the Adult Services Screening for Consideration for
Community-Based Programs.
E. To accept all Budget Entity Team referrals for face-to face assessments.
F.' To complete all initial face-to-face assessments on all pre-screened individuals referred
by the Budget Entity Team for service consideration and program application, using the
Adult Services Client Assessment, CF-AA 3019.
G. To maintain an accurate and current active waiver case list.
H. To maintain a current monthly billing ledger of all provider claims submitted to the
Agency for Health Care Administration, including all corrected claims and adjustments to
claims for Medicaid services that were delivered to consumers being served through this
Agreement.
1. To notifY, on a timely basis, the Adult Services Central Office budget staff of all waiver
service terminations, service increase requests and atypical monthly expenditure trends
with regards to the terms of this Agreement.
J. To complete and submit the Provider Monthly Report Form, CF-AA 1119, to Central
Office the 20th day of the month immediately following the month being reported on.
III. Under this Agreement, the Case Management Agency agrees to the following:
A. Adhere to the Department of Children and Families' guidance on eligibility and referral for
services, as established through the Aged and Disabled Adult (ADA) Waiver Handbook
policy and the ADA Waiver format 1915(c).
B. Assign qualified case managers in accordance with the Aged and Disabled Adult
Medicaid Waiver Handbook to provide case management under the Medicaid Home and
Community Based Waiver for Aged and Disabled Adults.
C. Explain to each individual requesting consideration for ADA-HCBS Medicaid waiver
services that the Medicaid waiver program maintains a centralized Waiting List on which
the individual will be placed according to his or her score received through the Adult
Services Screening for Consideration for Community Based Services.
D. Supply all new disabled adult referrals (individuals requesting Aged and Disabled Adult
Home and Community Based Waiver services) with the name of a DCF Adult Services
counselor and the phone number to the nearest DCF Adult Services unit for the individual
to pursue service consideration and program screening.
E. Maintain and permit district access to:
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1. A current and accurate log of all Medicaid waiver claims, activities and payments by
individual consumer;
2. A listing of each Medicaid waiver consumer served by full name, Social Security ID
and Medicaid ill;
3. Current (within one year) Consumer Care Plans indicating present authorized
service(s) and cost analysis by service on each waiver consumer serviced through this
contract; and,
4. Current log of consumer terminations of service (if applicable) with cost analysis of
the terminated consumer's unexpended care plan budget, date of termination and
reason for termination.
F. Develop and implement the Plan of Care, which must be signed by the consumer, that
specifically outlines:
1. The consumer's health conditions and treatments;
2. Challenges and impediments to the consumer's daily living functionality identified by
the assessment and to be addressed with the Plan of Care;
3. Service(s) authorized;
4. The frequency and intensity of the arranged service interventions;
5. Service gaps;
6. Expected outcomes to be achieved;
7. Cost analysis, by service, of those service units authorized for consumer delivery; and,
8. The formal and informal support persons (agencies) responsible for delivering both
the DCF funded services authorized by the case manager and all other non-DCF
funded services.
G. Reevaluate the Plan of Care at least every six months.
H. Minimally reassess the client annually or more often if significant changes in the client's
situation warrant, with the Adult Services Client Assessment Instrument and amend the
Plan of Care accordingly. Make the required changes to authorized services and/or
service providers as needed.
I. Adhere to the policies and procedures as outlined in the following manuals published by
the Agency for Health Care Administration: Aged and Disabled Adult Waiver Guidelines
and the Medicaid Provider Reimbursement Handbook (Non-Institutional 081), including
any and all attachments or updates.
J. Provide to the District (Regional) Program Office, by the 15th of each month, a completed
Provider Monthly Report Form, CF-AA 1119, which is a detailed expenditure report
showing the number of clients served, defined units and type of services provided, cost of
each service unit, number of units of service provided, totaled monthly cost of services
delivered, and a year to date total cost of services delivered. This report will also include
the number of active clients at the beginning of the month, the number added and deleted
during the month, and the final count at the end of the month.
K. Refer clients to the qualified direct service provider as selected by the client, whenever
reasonable and possible.
L. Issue written service authorizations to subcontracted service providers with at least 24
hours notice. The authorization will contain at a minimum:
1. Client's name;
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2. Client's address (with directions ifnot easily accessible);
3. Pertinent information regarding client's health or disabilities and living situation; and,
4. Detailed service description including frequency, duration and specific tasks to be
performed.
M. Evaluate quality of services and service documentation by the subcontracted service
provider.
N. Hold the Department of Children and Families harmless from 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 a client care plan or service
authorization.
O. Perform semi-annual administrative monitoring of subcontracted service providers for
adherence to authorized care plans and authorized reimbursement rates.
P. 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, consumer, 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 provider staff, volunteers, and
board members bound by this service agreement make a disclosure to the undersigned
provider of any relationship which may be a conflict of interest, within thirty (30) days of
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.
Q. Follow-up with the undersigned on all billing errors identified by the Agency for Health
Care Administration and/or the district DCF office to ensure that all void or adjustment
claims are submitted no later than 45 days after each billing error has been identified by
either party. Any provider error not adjusted or voided within 45 days may be adjusted or
voided by the Florida Department of Children and Families' District (Regional) Program
Office. The provider's refusal to adjust or void erroneous claims will result in termination
of this agreement.
R. If required by 45 CFR Parts 160, 162, and 164, the following provisions shall apply [45
CFR 164.504(e)(2)(ii)]:
(a) The provider hereby agrees not to use or disclose protected health information
(PHI) except as permitted or required by this Agreement, state or federal law.
(b) The provider agrees to use appropriate safeguards to prevent use or disclosure of
PHI other than as provided for by this Agreement or applicable law.
(c) The provider agrees to report to the department any use or disclosure of the
information not provided for by this Agreement or applicable law.
(d) The provider hereby assures the department that if any PHI received from the
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department, or received by the provider on the department's behalf, is furnished
to provider's subcontractors or agents in the performance of tasks required by
this Agreement, that those subcontractors or agents must first have agreed to the
same restrictions and conditions that apply to the provider with respect to such
information.
(e) The provider agrees to make PHI available in accordance with 45 C.F.R. 164.524.
(t) The provider agrees to make PHI available for amendment and to incorporate any
amendments to PHI in accordance with 45 C.F.R. 164.526.
(g) The provider agrees to make available the information required to provide an
accounting of disclosures in accordance with 45 C.F.R. 164.528.
(h) The provider agrees to make its internal practices, books and records relating to
the use and disclosure of PHI received from the department or created or
received by the provider on behalf of the department available for purposes of
determining the provider's compliance with these assurances.
(i) The provider agrees that at the termination ofthis Agreement, iffeasible and
where not inconsistent with other provisions of this Agreement concerning
record retention, it will return or destroy all PHI received from the department or
received by the provider on behalf of the department, that the provider still
maintains regardless of form. If not feasible, the protections of this Agreement
are hereby extended to that PHI which may then be used only for such purposes
as make the return or destruction infeasible.
(j) A violation or breach of any of these assurances shall constitute a material breach
of this Agreement.
S. Adhere to the Adult Services' Preliminary In-house Procedures for transferring a Medicaid
waiver consumer and the consumer's budget from one district to another at the consumer's
request.
IV. The following services will be delivered by the Service provider in accordance with the plan of
care or service authorization:
Service Unit Rate
A.Home Delivered Meals $5.00/meal
a.personal Care $45.UU/an hour
C.Homemaking $ 35.00/an hour
D.Case Management $45.00/an hour
E.
County/Region Served
Monroe
Monroe
Monroe
Monroe
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V. Termination
In the event this agreement is terminated, the case management agency agrees 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 either 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 Florida Department of
Children and Families 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 Florida Department of
Children and Families shall be the final authority as to the availability of funds.
C. Termination for Breach
Unless a breach is waived by the Florida Department of Children and Families in writing, or
the parties fail to cure the breach within the time specified by the Florida Department of
Children and Families, the Florida Department of Children and Families 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 6 page agreement to be executed by their
undersigned officials as duly authorized.
Florida Department Of Children
and Families District II
Program Office 2
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MONROE COUNTY ATTORNEY
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