HomeMy WebLinkAboutCC Resolution 14117 (Ambulance Cost Recovery)RESOLUTION NO. 14117
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN RAFAEL AUTHORIZING
THE CITY MANAGER TO EXECUTE AGREEMENTS TO ALLOW THE SAN RAFAEL FIRE
DEPARTMENT TO PARTICIPATE IN AN INTERGOVERNMENTAL TRANSFER WITH THE
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES (DHCS) IN ORDER TO
INCREASE THE DEPARTMENT'S REIMBURSEMENT FOR EMS AMBULANCE
TRANSPORT SERVICES PROVIDED TO COUNTY HEALTH PLAN (PARTNERSHIP
HEALTH PLAN) MEMBERS FOR FY 2014-2015.
WHEREAS, the City of San Rafael, through its Fire Department, regularly provides emergency
ambulance transport to persons who are Medi -Cal patients enrolled in managed care plans; and
WHEREAS, the City participates in various governmental programs that provide reimbursement of costs
incurred in providing such emergency services to Medi -Cal patients; and
WHEREAS, pursuant to the authority of Welfare & Institutions Code, sections 14164 and 14301.4,
since 2006 the California Department of Health Care Services (DHCS) has been offering a voluntary rate
range Intergovernmental Transfer Program to allow healthcare providers such as the City of San Rafael
Fire Department to access federal matching funds for reimbursement through their Medi -Cal Managed
Care Health Plan Providers; and
WHEREAS, the City may pursue an Intergovernmental Transfer to DHCS through its Medi -Cal
Managed Care Health Plan Provider, Partnership Health Plan of California (PHC); and
WHEREAS, by participating in the Intergovernmental Transfer Program, the City will receive
reimbursements for a larger proportion of its actual costs for providing emergency ambulance transport to
Medi -Cal patients enrolled in managed care plans; and
WHEREAS, under the Intergovernmental Transfer Program, the funds shall be transferred in accordance
with a mutually agreed upon schedule between the City of San Rafael and DHCS.
NOW, THEREFORE, BE IT RESOLVED, that the City Council does hereby authorize the San Rafael
Fire Department to participate in an Intergovernmental Transfer (IGT) with the California Department of
Health Care Services (DHCS) in order to increase the Department's reimbursement for EMS ambulance
transport services provided to Partnership Health Plan of California members for FY 2014-2015.
BE IT FURTHER RESOLVED, that the City Council hereby authorizes the City Manager to execute
agreements with PHC and DHCS for the San Rafael Fire Department's participation in this program,
subject to final approval as to form by the City Attorney.
BE IT FURTHER RESOLVED, that the City Council does hereby authorize the transfer of funds to
DHCS pursuant to such agreements, in an amount approved by the City Manager and in accordance with
a mutually agreed upon schedule, to be used solely as a portion of the non-federal share of actuarially
sound Medi -Cal managed care capitation rate increases for the Partnership Health Care period of June
30, 2014 through July 1, 2015.
I, ESTHER C. BEIRNE, Clerk of the City of San Rafael, hereby certify that the foregoing
Resolution was duly and regularly introduced and adopted at a regular meeting of the City Council of
said City held on the 16t" day of May, 2016, by the following vote, to wit:
AYES: COUNCILMEMBERS: Bushey, Colin, Gamblin, McCullough & Mayor Phillips
NOES: COUNCILMEMBERS: None
ABSENT: COUNCILMEMBERS: None
ESTHER C. BEIRNE, City Clerk
Jim Schutz
Page 2
If you have any questions regarding this request, please contact Sandra Dixon at
(916) 552-9460.
Sincerely,
A
Jennifer Lopez
Acting Division Chief
Capitated Rates Development Division
Enclosure
cc: Chris Gray, Fire Chief
San Rafael Fire Department
1039 C Street
San Rafael, CA 94901
Carolyn Stewart
Senior Director of Financial Analysis
Partnership HealthPlan of California
4665 Business Center Drive
Fairfield, CA, 94534
Sandra Dixon
Capitated Rates Development Division
Department of Health Care Services
P.O. Box 997413, MS 4413
Sacramento, CA 95899-7413
CONTRACT #14-90625
INTERGOVERNMENTAL TRANSFER ASSESSMENT FEE
This Agreement is entered into between the CALIFORNIA DEPARTMENT OF HEALTH CARE
SERVICES ("State DHCS") and the City of San Rafael with respect to the matters set forth below.
RECITALS
A. This Agreement is made pursuant to the authority of Welfare & Institutions Code, section
14301.4.
THEREFORE, the parties agree as follows:
AGREEMENT
1. Transfer of Public Funds
1.1 The City of San Rafael shall make Intergovernmental Transfer(s) ("IGTs") to State
DHCS pursuant to section 14164 of the Welfare and Institutions Code and paragraph 1.1 of the
Intergovernmental Agreement(s) Regarding the Transfer of Public Funds contract number 14-90595, to be
used as a portion of the non-federal share of actuarially sound Medi -Cal managed care rate range
capitation increases ("non-federal share IGT") to Partnership HealthPlan of California ("PHC") for the
period of July 1, 2014 through June 30, 2015.
1.2 The parties acknowledge that State DHCS will obtain any necessary approvals
from the Centers for Medicare and Medicaid Services ("CMS") pertaining to the acceptance of
non-federal share IGTs and the payment of non-federal share IGT related rate range capitation increases
to PHC.
2. Intereovernmental Transfer Assessment Fee
Template Version 4/2/12 IGT Assessment Fee City of San Rafael / Partnership 05/01/2015
CONTRACT #14-90625
2.1 The State DHCS shall, upon acceptance of non-federal share IGTs pursuant to the
Intergovernmental Agreement(s) Regarding the Transfer of Public Funds, and as described in paragraph I
of this Agreement, exercise its authority under section 14301.4 of the Welfare and Institutions Code to
assess a 20 -percent assessment fee on the entire amount of the non-federal share IGTs to reimburse State
DHCS for the administrative costs of operating the IGT program pursuant to this section and for the
support of the Medi -Cal program.
2.2 The funds subject to the 20 -percent assessment fee shall be limited to non-federal
share IGTs made by the transferring entity, The City of San Rafael, pursuant to the Intergovernmental
Agreement(s) Regarding the Transfer of Public Funds, and as described in paragraph 1 of this Agreement.
2.3 The 20 -percent fee will be assessed on the entire amount of the non-federal share
IGTs pursuant to the Intergovernmental Agreement(s) Regarding the Transfer of Public Funds, and as
described in paragraph I of this Agreement, and will be made in addition to, and transferred separately
from, the transfer of funds pursuant to the Intergovernmental Agreement(s) Regarding the Transfer of
Public Funds.
2.4 The 20 -percent assessment fee pursuant to this Agreement is non-refundable and
shall be wired to State DHCS separately from, and simultaneous to, the non-federal share IGTs pursuant
to the Intergovernmental Agreement(s) Regarding the Transfer of Public Funds, and as described in
paragraph 1 of this Agreement. However, if any portion of the non-federal share IGTs is not expended for
the specified rate increases stated in paragraph 2.2 of the Intergovernmental Agreement(s) Regarding the
Transfer of Public Funds, DHCS shall return a proportionate amount of the 20 -percent assessment fee to
The City of San Rafael.
Template Version 4/2/12 IGT Assessment Fee City of San Rafael /Partnership 05/01/2015
CONTRACT #14-90625
Other Provisions
3.1 This Agreement contains the entire Agreement between the parties with respect to
the 20 -percent assessment fee on non-federal share IGTs pursuant to the Intergovernmental Agreement(s)
Regarding the Transfer of Public Funds, and as described in paragraph 1, and supersedes any previous or
contemporaneous oral or written proposals, statements, discussions, negotiations or other agreements
between the transferring entity and State DHCS. This Agreement is not, however, intended to be the sole
agreement between the parties on matters relating to the funding and administration of the Medi -Cal
program. One or more other agreements may exist between the parties regarding such other matters, and
other agreements may be entered into in the future. This Agreement shall not modify the terms of any
other agreement between the parties.
3.2 Time is of the essence in this Agreement.
3.3 Each party hereby represents that the person(s) executing this Agreement on its
behalf is duly authorized to do so.
4. State Authoritv. Except as expressly provided herein, nothing in this Agreement shall be
construed to limit, restrict, or modify State DHCS' powers, authorities, and duties under federal and state
law and regulations.
5. Approval. This Agreement is of no force and effect until signed by the parties.
Template Version 4/2/12 IGT Assessment Fee City of San Rafael / Partnership 05/01/2015
CONTRACT #14-90625
SIGNATURES
IN WITNESS WHEREOF, the parties hereto have executed this Agreement, on the date of the last
signature below.
The City of San Rafael
M
/4A tin
J \
Jim Schutz, City
City of San Rafael
Date: U
THE STATE OF CALIFORNIA, DEPARTMENT OF HEALTH CARE SERVICES:
By
Date: 4M//
Jennifer Lopez, Acting Division Chief, Capitated Rates Development Division
Template Version 4/2/12 IGT Assessment Fee City of San Rafael / Partnership 05/01/2015
DHCS
11 P
JENNIFER KENT
DIRECTOR
OCT 2 7 2010
Jim Schutz
State of California—Health and Human Services Agency
Department of Health Care Services
City Manager
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
Dear Mr. Schutz:
EDMUND G. BROWN JR.
GOVERNOR
Per Section 14301.4 of the Welfare and Institutions Code, the Department of Health
Care Services (DHCS), upon acceptance of non-federal share Intergovernmental
Transfer(s) (IGT) pursuant to the Intergovernmental Agreement Regarding the Transfer
of Public Funds #14-90595, will assess a 20 -percent fee on the adjusted amount of the
non-federal share IGT pursuant to the Agreement to reimburse DHCS for the
administrative costs pursuant to this section, and for the support of the Medi -Cal
Program. Because the rates were recalculated subsequent to our March 8, 2016 letter
to the health plan, the maximum amount available under agreement #14-90595 is
$243,457.
DHCS is requesting that City of San Rafael transfer the fee in the amount of $48,691 to
DHCS by no later than 7 calendar days after the date of this letter. This fee is in
accordance with the Intergovernmental Transfer Assessment Fee Agreement
#14-90625. The 20 -percent Assessment Fee IGT Agreement is enclosed.
Please transfer the above amount to the following:
Bank of America Sacramento Main
555 Capitol Mall, Suite 1555
Sacramento, CA 95814
For Credit to State of California Account #01482-80005
ABA# 0260-0959-3
For Further Credit to: Department of Health Care Services
Reference: Rafael IGT Assessment Fee Agreement #14-90625
Once the governmental funding entity has transferred the fee to the specified account,
please email Sandra Dixon at Sandra. DixonCLDdhcs.ca.aov with the completed
transaction information.
Capitated Rates Development Division
1501 Capitol Avenue, P.O. Box 997413, MS 4414
Sacramento, CA 95899-7413
Phone (916) 322-5631 Fax (916) 650-6860
www.dhcs.ca.aov
0HICS State of California—Health and Human Services Agency
IN01 Department of Health Care Services
JENNIFER KENT
DIRECTOR
OCT 2 7 2016
Jim Schutz
City Manager
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
Dear Mr. Schutz:
EDMUND G. BROWN JR.
GOVERNOR
Per the Intergovernmental Agreement Regarding Transfer of Public Funds, #14-90595
the Department of Health Care Services (DHCS) is requesting that City of San Rafael
transfer funds in the amount of $243,457 to DHCS by no later than 7 calendar days
after the date of this letter. Pursuant to Section 14164 of the Welfare and Institutions
Code, the funds will be used as a portion of the non-federal share of actuarially sound
Medi -Cal managed care capitation rate range increases for Partnership HealthPlan of
California for the period of July 1, 2014 through June 30, 2015. The Intergovernmental
Agreement Regarding Transfer of Public Funds is enclosed.
Because the rates were recalculated subsequent to our March 8, 2016 letter to the
health plan, the maximum amount available under this agreement has been decreased
by $40,607 from $284,064 to $243,457.
Please transfer the above amount to the following:
Bank of America Sacramento Main
555 Capitol Mall, Suite 1555
Sacramento, CA 95814
For Credit to State of California Account #01482-80005
ABA# 0260-0959-3
For Further Credit to: Department of Health Care Services
Reference: Rafael IGT #14-90595
Once the governmental funding entity has transferred funds to the specified account,
please email Sandra Dixon at Sandra. Dixon (@dhcs.ca. aov with the completed
transaction information.
Capitated Rates Development Division
1501 Capitol Avenue, P.O. Box 997413, MS 4413
Sacramento, CA 95899-7413
Phone (916) 322-5831 Fax (916) 650-6860
www.dhcs.ca.aov
PROFESSIONAL SERVICES AGREEMENT/CONTRACT-
COMPLETION
GREEMENT/CONTRACTCOMPLETION CHECKLIST AND ROUTING SLIP
Below is the process for getting your professional services agreements/contracts finalized and
executed. Please attach this "Completion Checklist and Routing Slip" to the front of your
contract as you circulate it for review and signatures. Please use this form for all professional
services aereernents/contracts (not just those requiring City Council approval).
This process should occur in the order presented below.
Step Responsible
Department
1 City Attorney
2 Contracting Department
3 Contracting Department
4 City Attorney
5 City Manager / Mayor / or
Department Head
6 City Clerk
Description
Review, revise, and comment on draft
agreement.
Forward final agreement to contractor for
their signature. Obtain at least two signed
originals from contractor.
Agendize contractor -signed agreement for
Council approval, if Council approval
necessary (as defined by City Attorney/City
Ordinance*).
Review and approve form of agreement;
bonds, and insurance certificates and
endorsements.
Agreement executed by Council authorized
official.
City Clerk attests signatures, retains original
agreement and forwards copies to the
contracting department.
To be completed by Contracting Department:
Completion
Date
r
Project Manager: Danielle Ferrigno Project Name: IGT
Agendized for City Council Meeting of (if necessary): n 5/1 G 11F(0PPC:F1
check if required
1Y
If you have questions on this process, please contact the City Attorney's Office at 485-3080.
* Council approval is required if contract is over $20,000 on a cumulative basis.
HEALTH PLAN -PROVIDER AGREEMENT
Partnership HealthPlan of California and the City of San Rafael
AMENDMENT 2
;2o /6
This Amendment is made this /kaday of 4"o" , by and between Partnership
HealthPlan of California, a County Organized Health System hereinafter referred to as "PLAN",
and City of San Rafael, hereinafter referred to as "PROVIDER".
RECITALS:
WHEREAS, PLAN and PROVIDER have previously entered into an Agreement
effective June 1, 2014;
WHEREAS, Section 9.2 of such Agreement provides for amending such
Agreement;
WHEREAS, PLAN has been created by its Boards of Supervisors to negotiate
exclusive contracts with the California Department of Health Care Services and to arrange for
the provision of health care services to qualifying individuals in Marin County and PLAN is a
public entity, created pursuant to Welfare and Institutions Code 14087.54 and County Code
Chapters 7.2, County Code Chapters 34, County Code Chapters 2.40, County Code Chapters 2.0,
8.69, and County Code Chapters 2.0.
WHEREAS, the San Rafael Fire Department is a department of the City of San
Rafael that provides emergency response and transport to San Rafael, Marinwood and other
unincorporated areas of Marin County. The Department's four ambulances provide Advanced
Life Support and Basic Life Support transport and treatment services.The Department responds
to 9-1-1 dispatches and serves all patients regardless of insurance or ability to pay including
Medi -Cal and Medicare beneficiaries.
WHEREAS, PLAN and PROVIDER desire to amend the Agreement to provide
for Medi -Cal managed care capitation rate increases to PLAN as a result of intergovernmental
transfers ("IGTs") from City of San Rafael to the California Department of Health Care Services
("State DHCS") to maintain the availability of Medi -Cal health care services to Medi -Cal
beneficiaries.
NOW, THEREFORE, PLAN and PROVIDER hereby agree as follows:
Attachment D of the Agreement is added to amend the agreement as follows:
IGT MEDI-CAL MANAGED CARE CAPITATION RATE RANGE INCREASES
1. IGT Capitation Rate Ranze Increases to PLAN
A. Pavment
City of San Rafael /Partnership
Should PLAN receive any Medi -Cal managed care capitation rate increases from
State DHCS where the nonfederal share is funded by the City of San Rafael specifically pursuant
to the provisions of the Intergovernmental Agreement Regarding Transfer of Public Funds
("Intergovernmental Agreement") effective for the period July 1, 2014 through June 30, 2015 for
Intergovernmental Transfer Medi -Cal Managed Care Rate Range Increases ("IGT MMCRRIs"),
PLAN shall pay to PROVIDER the amount of the IGT MMCRRIs received from State DHCS, in
accordance with paragraph LE below regarding the form and timing of Local Medi -Cal
Managed Care Rate Range ("LMMCRR") IGT Payments. LMMCRR IGT Payments paid to
PROVIDER shall not replace or supplant any other amounts paid or payable to PROVIDER by
PLAN.
B. Health Plan Retention
(1) Medi -Cal Managed Care Seller's Tax
The PLAN shall be responsible for any Medi -Cal Managed Care Seller's
("MMCS") tax due pursuant to the Revenue and Taxation Code Section 6175 relating to any IGT
MMCRRIs through June 30, 2015. If the PLAN receives any capitation rate increases for
MMCS taxes based on the IGT MMCRRIs, PLAN may retain an amount equal to the amount of
such MMCS tax that PLAN is required to pay to the State Board of Equalization, and shall pay,
as part of the LMMCRR IGT Payments, the remaining amount of the capitation rate increase to
PROVIDER.
(2) The PLAN shall retain a three percent (3%) administrative fee based on
the total amount of the IGT MMCRRIs received from DHCS for PLAN'S administrative costs.
Each provider's share of the 3% fee shall be calculated based on that provider's proportionate
share of the LMMCRR IGT payments made by Plan in the PROVIDER'S County.
(3) PLAN will not retain any other portion of the IGT MMCRRIs received
from the State DHCS other than those mentioned above.
C. Conditions for ReceivinL- Local Medi -Cal Manaeed Care Rate Ranee IGT
Pavments
As a condition for receiving LMMCRR IGT Payments, PROVIDER shall, as of
the date the particular LMMCRR IGT Payment is due:
(1) remain a participating provider in the PLAN and not issue a notice of
termination of the Agreement;
(2) maintain its current emergency response services for PLAN Medi -Cal
beneficiaries.
2
Template Version -1/20/12 The San Rafael Fire Department / Partnership
D. Schedule and Notice of Transfer of Non -Federal Funds
PROVIDER shall provide PLAN with a copy of the schedule regarding the
transfer of funds to State DHCS, referred to in the Intergovernmental Agreement, within fifteen
(15) calendar days of the PROVIDER establishing such schedule with the State DHCS.
Additionally, PROVIDER shall notify PLAN, in writing, no less than seven (7) calendar days
prior to any changes to an existing schedule including, but not limited to, changes in the amounts
specified therein.
E. Form and Timine of Pavments
PLAN agrees to pay LMMCRR IGT Payments to PROVIDER in the following
form and according to the following schedule:
(1) PLAN agrees to pay the LMMCRR IGT Payments to PROVIDER using
the same mechanism through which compensation and payments are normally paid to
PROVIDER (e.g., electronic transfer).
(2) PLAN will pay the LMMCRR IGT Payments to PROVIDER no later than
thirty (30) calendar days after receipt of the IGT MMCRRIs from State DHCS.
F. Consideration
(1) As consideration for the LMMCRR IGT Payments, PROVIDER shall use
the LMMCRR IGT Payments for the following purposes and shall treat the LMMCRR IGT
Payments in the following manner:
(a) The LMMCRR IGT Payments shall represent compensation for
Medi -Cal services rendered to Medi -Cal PLAN members by PROVIDER during the State fiscal
year to which the LMMCRR IGT Payments apply.
(b) To the extent that total payments received by PROVIDER for any
State fiscal year under this Amendment exceed the cost of Medi -Cal services provided to Medi-
cal beneficiaries by PROVIDER during that fiscal year, any remaining LMMCRR IGT Payment
amounts shall be retained by PROVIDER to be expended for health care services. Retained
LMMCRR IGT Payment amounts may be used by the PROVIDER in either the State fiscal year
for which the payments are received or subsequent State fiscal years.
(2) For purposes of subsection (1) (b) above, if the retained LMMCRR IGT
Payments, if any, are not used by PROVIDER in the State fiscal year received, retention of funds
by PROVIDER will be established by demonstrating that the retained earnings account of
PROVIDER at the end of any State fiscal year in which it received payments based on
Template Version -1/20/12 The San Rafael Fire Department / Partnership
LMMCRR IGT Payments funded pursuant to the Intergovernmental Agreement, has increased
over the unspent portion of the prior State fiscal year's balance by the amount of LMMCRR IGT
Payments received, but not used. These retained PROVIDER funds may be commingled with
other City of San Rafael funds for cash management purposes provided that such funds are
appropriately tracked and only the depositing facility is authorized to expend them.
(3) Both parties agree that none of these funds, either from the City of San
Rafael or federal matching funds will be recycled back to the City of San Rafael's general fund,
the State, or any other intermediary organization. Payments made by the health plan to providers
under the terms of this Amendment constitute patient care revenues.
G. PLAN's Oversight Responsibilities
PLAN's oversight responsibilities regarding PROVIDER's use of the LMMCRR
IGT Payments shall be limited as described in this paragraph. PLAN shall request, within thirty
(30) calendar days after the end of each State fiscal year in which LMMCRR IGT Payments
were transferred to PROVIDER, a written confirmation that states whether and how PROVIDER
complied with the provisions set forth in Paragraph 11 above. In each instance, PROVIDER
shall provide PLAN with written confirmation of compliance within thirty (30) calendar days of
PLAN's request.
H. Cooperation Among Parties
Should disputes or disagreements arise regarding the ultimate computation or
appropriateness of any aspect of the LMMCRR IGT Payments, PROVIDER and PLAN agree to
work together in all respects to support and preserve the LMMCRR IGT Payments to the full
extent possible on behalf of the safety net in Marin County.
I. Reconciliation
Within one hundred twenty (120) calendar days after the end of each of PLAN's
fiscal years in which LMMCRR IGT Payments were made to PROVIDER, PLAN shall perform
a reconciliation of the LMMCRR IGT Payments transmitted to the PROVIDER during the
preceding fiscal year to ensure that the supporting amount of IGT MMCRRIs were received by
PLAN from State DHCS. PROVIDER agrees to return to PLAN any overpayment of LMMCRR
IGT Payments made in error to PROVIDER within thirty (30) calendar days after receipt from
PLAN of a written notice of the overpayment error, unless PROVIDER submits a written
objection to PLAN. Any such objection shall be resolved in accordance with the dispute
resolution processes set forth in Section 10.3 of the Agreement. The reconciliation processes
established under this paragraph are distinct from the indemnification provisions set forth in
Section J below. PLAN agrees to transmit to the PROVIDER any underpayment of LMMCRR
IGT Payments within thirty (30) calendar days of PLAN's identification of such underpayment.
4
Template Version -1/20/12 The San Rafael Fire Department / Partnership
J. Indemnification
PROVIDER shall indemnify PLAN in the event DHCS or any other federal or
state agency recoups, offsets, or otherwise withholds any monies from or fails to provide any
monies to PLAN, or PLAN is denied any monies to which it otherwise would have been entitled,
as a direct result of the LMMCRR IGT arising from the Intergovernmental Agreement.
Recovery by PLAN pursuant to this section shall include, but not be limited to, reduction in
future LMMCRR IGTs paid to PROVIDER in an amount equal to the amount of MMCRRI
payments withheld or recovered from PLAN, or by reduction of any other amounts owed by
PLAN to PROVIDER.
K. Remittance Information
The IGT -funded payments made by the PLAN pursuant to this Amendment only,
shall be mailed to the PROVIDER at the address set forth below:
Mark Moses, Finance Director
City of San Rafael
1400 Fifth Ave
San Rafael, Ca 94901
2. Term
The term of this Amendment shall commence on July 1, 2014 and shall terminate
on September 30, 2017.
All other terms and provisions of said Agreement shall remain in full force and effect so that all
rights, duties and obligations, and liabilities of the parties hereto otherwise remain unchanged;
provided, however, if there is any conflict between the terms of this Amendment and the
Agreement, then the terms of this Amendment shall govern.
5
Template Version -1/20/12 The San Rafael Fire Department / Partnership
SIGNATURES
A
HEALTH PLAN: Date: DQ -03 -X11
By: Elizabeth Gibboney, CEO, Partnership Healt04hPlan f California
' r
PROVIDER: Date: / 114
By: Jim SchutU Manager
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
6
Template Version -1/20/12 The San Rafael Fire Department / Partnership
PROFESSIONAL SERVICES AGREEMENT/CONTRACT
COMPLETION CHECKLIST AND ROUTING SLIP
Below is the process for getting your professional services agreements/contracts finalized and
executed. Please attach this "Completion Checklist and Routing Slip" to the front of your
contract as you circulate it for review and signatures. Please use this form for all twofessional
services aereem e nts/co n tracts (not just those requiring City Council approval).
This process should occur in the order presented below.
Step Responsible Description
Department
1 City Attorney Review, revise, and comment on draft
agreement.
2 Contracting Department Forward final agreement to contractor for
their signature. Obtain at least two signed
originals from contractor.
Contracting Department
4 City Attorney
5 City Manager / Mayor / or
Department Head
6 City Clerk
Agendize contractor -signed agreement for
Council approval, if Council approval
necessary (as defined by City Attorney'City
Ordinance*).
Review and approve form of agreement;
bonds, and insurance certificates and
endorsements.
Agreement executed by Council authorized
official.
City Clerk attests signatures, retains original
agreement and forwards copies to the
contracting department.
To be completed by Contracting Department:
Completion
�Date
ted'
Project ManagerU� J(C Y1 1 +/j (! Project Name: /1 916h_ PVbV1(� G 1� � _
Agendized for City Council Meeting of (if necessary): FPPC: ❑ , check if required
If you have questions on this process, please contact the City Attorney's Office at 485-3080.
* Council approval is required if contract is over $20,000 on a cumulative basis.
Partnership HealthPlan of California
FY 2014/15 Rate Range IGTs - DRAFT
Column A
Column B
Column D
Column E
Column F Column G
Column H
Column I
Column J
Column K
Column L
Column M
Column N
Column O
Column P
Headroom - Net Maximum
Cost of
% Allocation
Net new
County
Entity
Entity Type
PHC ID #
of MCO and Provider
Services
PHC
of unmet
Provider
DHCS Admin
Payment From
Provider's Net
funds as a %
Admin Contribution
Provided
Reimbursement
Unmet Cost
costs
Contribution
Fee
PHC
New Funds
Unmet Cost
51.5%
20%
Marin
Marin County H&HS
County
13710
$ 2,410,221
$
88,918
$
2,321,303
32.0%
$ 863,131
$
172,626
$
1,679,366
$
643,608
27.73%
Marin
Novato Fire
Fire District
11196
$ 466,185
$
38,369
$
427,816
5.9%
$ 159,075
$
31,815
$
309,507
$
118,617
27.73%
Marin
San Rafael Fire
Fire District
23551
$ 981,274
$
87,464
$
893,810
12.3%
$ 332,346
$
66,469
$
646,634
$
247,819
27.73%
Marin
Southern Marin Fire
Fire District
13690
$ 534,570
$
22,009
$
512,561
7.1%
$ 190,586
$
38,117
$
370,816
$
142,113
27.73%
Marin
Marin General Hospital
Hospital
2513
$ 3,100,977
$
3,100,977
42.7%
$ 1,153,038
$
230,608
$
2,243,427
$
859,781
27.73%
TOTAL Marin
$ 5,249,750 $ 2,698,176
$ 7,493,228
$
236,760
$
7,256,468
100.0%
$ 2,698,176
$
539,635
$
5,249,750
$
2,011,939
27.73%
Mendocino
Mendocino County H&HS
County
23731
$ 1,430,077
$
35,390
$
1,394,687
59.5%
$ 1,301,284
$
260,257
$
2,529,442
$
967,902
69.40%
Mendocino
Coast Life Sup. Dist
Fire District
9875
$ 180,490
$
19,868
$
160,622
6.9%
$ 149,865
$
29,973
$
291,308
$
111,470
69.40%
Mendocino
Covelo FPD
Fire District
11309
$ 61,068
$
7,849
$
53,219
2.3%
$ 49,655
$
9,931
$
96,519
$
36,933
69.40%
Mendocino
Mendocino Coast District Hospital
Hospital
3163
$ 735,012
$
735,012
31.4%
$ 685,788
$
137,158
$
1,333,038
$
510,093
69.40%
TOTAL Mendocino
$ 4,250,307 $ 2,186,591
$ 2,406,646
$
63,107
$
2,343,539
100.0%
$ 2,186,591
$
437,318
$
4,250,307
$
1,626,398
69.40%
Napa
Napa County H&HS
County
17785
$ 2,507,709
$
323,356
$
2,184,353
100.0%
$ 2,158,447
$
431,689
$
4,195,734
$
1,605,597
73.50%
TOTAL -Napa
$ 4,195,734 $ 2,158,447
$ 2,507,709
$
323,356
$
2,184,353
100.0%
$ 2,158,447
$
431,689
$
4,195,734
$
1,605,597
73.50%
R8 Del Norte
Del Norte County HHS
County
32646
$ 751,830
$
-
$
751,830
4.9%
$ 598,239
$
119,648
$
1,156,296
$
438,409
58.31%
R8 Humboldt
Humboldt County HHS
County
4843
$ 2,790,205
$
45,307
$
2,744,898
17.9%
$ 2,184,144
$
436,829
$
4,221,586
$
1,600,613
58.31%
R8 Humboldt
Jerold Phelps Hospital
Hospital
6039
$ 494,447
$
494,447
3.2%
$ 393,437
$
-
$
760,447
$
367,011
74.23%
R8 Lake
Kelseyville FPD
Fire District
12284
$ 271,878
$
97,712
$
174,166
1.1%
$ 138,586
$
-
$
267,863
$
129,277
74.23%
R8 Lake
Lake County
County
27637
$ 535,364
$
15,258
$
520,106
3.4%
$ 413,854
$
82,771
$
799,910
$
303,286
58.31%
R8 Lake
Lake County Fire
Fire District
14419
$ 558,747
$
172,060
$
386,687
2.5%
$ 307,691
$
-
$
594,715
$
287,024
74.23%
R8 Lake
Lakeport Fire
Fire District
11920
$ 169,427
$
70,821
$
98,606
0.6%
$ 78,462
$
-
$
151,654
$
73,192
74.23%
R8 Lake
Northshore Fire
Fire District
17652
$ 478,373
$
67,621
$
410,752
2.7%
$ 326,840
$
-
$
631,726
$
304,887
74.23%
R8 Lake
South Lake County FPD
Fire District
8948
$ 383,844
$
26,971
$
356,872
2.3%
$ 283,967
$
-
$
548,861
$
264,894
74.23%
R8 Lassen
Lassen County HHS
County
30930
$ 420,068
$
14,428
$
405,640
2.6%
$ 322,772
$
64,554
$
623,864
$
236,538
58.31%
R8 Modoc
Surprise Valley Hospital
Hospital
7213
$ 205,126
$
205,126
1.3%
$ 163,221
$
-
$
315,479
$
152,258
74.23%
R8 Modoc
Modoc County HHS
County
32311
$ 276,137
$
15,216
$
260,921
1.7%
$ 207,618
$
41,524
$
401,290
$
152,149
58.31%
R8 Modoc
Modoc Med Center
Hospital
14584
$ 1,320,739
$
1,320,739
8.6%
$ 1,050,926
$
-
$
2,031,264
$
980,338
74.23%
R8 Shasta
Shasta County HHS
County
2420
$ 3,341,394
$
213,243
$
3,128,151
20.4%
$ 2,489,103
$
497,821
$
4,811,019
$
1,824,096
58.31%
R8 Shasta
Mayers Memorial Hospital
Hospital
4317
$ 1,156,958
$
1,156,958
7.5%
$ 920,604
$
-
$
1,779,373
$
858,769
74.23%
R8 Siskiyou
Siskiyou County HHS
County
30929
$ 492,774
$
27,665
$
465,109
3.0%
$ 370,092
$
74,018
$
715,326
$
271,216
58.31%
R8 Trinity
Trinity County HHS
County
35688
$ 1,002,957
$
176
$
1,002,781
6.5%
$ 797,923
$
159,585
$
1,542,252
$
584,744
58.31%
R8 Trinity
Trinity Hospital
Hospital
3080
$ 1,473,514
$
1,473,514
9.6%
$ 1,172,491
$
-
$
2,266,228
$
1,093,738
74.23%
TOTAL - Rural 8
$ 23,619,155 $ 12,219,968
$ 16,123,782
$
766,479
$
15,357,303
100.0%
$ 12,219,968
$
1,476,749
$
23,619,155
$
9,922,438
64.61%
Solano
Solano County H&HS
County
$ 7,308,287
$
80,555
$
7,227,732
84.5%
$ 7,215,341
$
1,443,068
$
13,980,763
$
5,322,354
73.64%
Solano
Vacaville City Fire
Fire District
2272
$ 1,426,081
$
100,100
$
1,325,981
15.5%
$ 1,323,707
$
264,741
$
2,564,874
$
976,425
73.64%
TOTAL Solano
$ 16,545,636 $ 8,539,048
$ 8,734,367
$
180,655
$
8,553,712
100.0%
$ 8,539,048
$
1,707,810
$
16,545,636
$
6,298,779
73.64%
Column A Column B Column D Column E Column F
Column G
Column H
Column I Column J Column K Column L.
Column M Column N Column O Column P
Headroom - Net
Maximum
Cost of
% Allocation
Net new
County Entity Entity Type PHC ID # of MCO and
Provider
Services
PHC of unmet Provider
DHCS Admin Payment From Provider's Net funds as a %
Admin
Contribution
Provided
Reimbursement Unmet Cost costs Contribution
Fee PHC New Funds Unmet Cost
Sonoma
Sonoma County H&HS
County
11709
$
8,953,334
$
73,741
$
8,879,593
84.0%
$ 6,438,432
$
1,287,686
$
12,490,681
$
4,764,563
53.66%
Sonoma
Bodega Bay Fire
Fire District
8482
$
72,392
$
5,564
$
66,828
0.6%
$ 48,456
$
9,691
$
94,005
$
35,858
53.66%
Sonoma
City of Petaluma Fire
Fire District
8714
$
394,195
$
43,691
$
350,504
3.3%
$ 254,144
$
50,829
$
493,044
$
188,071
53.66%
Sonoma
Cloverdale Fire
Fire District
2005
$
115,388
$
26,740
$
88,648
0.8%
$ 64,277
$
12,855
$
124,699
$
47,566
53.66%
Sonoma
Sonoma Valley Fire
Fire District
10239
$
376,599
$
46,489
$
330,110
3.1%
$ 239,357
$
47,871
$
464,357
$
177,129
53.66%
Sonoma
Healdsburg District Hospital
Hospital
1874
$
-
$
-
0.0%
$ -
$
-
$
-
$
-
#DIV/0!
Sonoma
Sonoma Valley Hosp
Hospital
3283
$
850,229
$
850,229
8.0%
$ 616,485
$
123,297
$
1,195,993
$
456,211
53.66%
TOTAL -Sonoma
$
14,862,780 $
7,661,151 $
10,762,136
$
196,225
$
10,565,911
100.0%
$ 7,661,151
$
1,532,230
$
14,862,780
$
5,669,398
53.66%
Yolo
Yolo County H&HS
County
10721
$
3,045,262
$
39,308
$
3,005,954
100.0%
$ 3,735,846
$
747,169
$
7,257,358
$
2,774,343
92.29%
TOTAL - Yolo
$
7,257,358 $
3,735,846 $
3,045,262
$
39,308
$
3,005,954
$ 3,735,846
$
747,169
$
7,257,358
$
2,774,343
92.29%
Grand Total
$
75,980,719 $
39,199,227 $
51,073,131
$
1,805,890
$
49,267,241
$ 39,199,227
$
6,872,601
$
75,980,719
$
29,908,892
60.71%
" Cost reports not yet received
** New entity added 3/2/16
ROUTING SLIP / APPROVAL FORM
INSTRUCTIONS: Use this cover sheet with each submittal of a staff report before approval
by the City Council. Save staff report (including this cover sheet) along
with all related attachments in the Team Drive (T:) --> CITY COUNCIL
AGENDA ITEMS 4 AGENDA ITEM APPROVAL PROCESS 4 [DEPT -
AGENDA TOPIC]
Agenda Item #
Date of Meeting: 5/16/2016
From: Danielle Ferrigno
Department: Fire Department
Date: 5/6/2016
Topic: Ambulance Service Cost Recovery
Subject: RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN RAFAEL
AUTHORIZING THE CITY MANAGER TO EXECUTE AGREEMENTS TO ALLOW THE SAN
RAFAEL FIRE DEPARTMENT TO PARTICIPATE IN AN INTERGOVERNMENTAL TRANSFER
WITH THE CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES (DHCS) IN ORDER TO
INCREASE THE DEPARTMENT'S REIMBURSEMENT FOR EMS AMBULANCE TRANSPORT
SERVICES PROVIDED TO COUNTY HEALTH PLAN (PARTNERSHIP HEALTH PLAN)
MEMBERS FOR FY 2014-2015.
Type: ® Resolution ❑ Ordinance
❑ Professional Services Agreement ❑ Other: Staff Report
APPROVALS
® Finance Director
Remarks: Approved - MM 5/6
® City Attorney
Remarks: LG -Approved 5/9/16
® Author, review and accept City Attorney / Finance changes
Remarks: DF -Approved 5/9/16
F City Manager
Remarks:
FOR CITY CLERK ONLY
File No.:
Council Meeting:
Disposition: