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FD Intergovernmental Transfer 2016 DHCSCONTRACT # 16-93710 INTERGOVERNMENTAL TRANSFER ASSESSMENT FEE This Agreement is entered into between the CALIFORNIA DEPARTMENTOF HEALTH CARE SERVICES ("State DI ICS") and the City of San Rafael (GOVERNMENTAL FUNDING ENTITY) 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 GOVERNMENTAL FUNDING ENTITY 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 16-93679, 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 HEALTH PLAN (Partnership HealthPlan of California) for the periods of July 1, 2015 to June 30, 2016 and July 1, 2016 to June 30, 2017. 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 HEALTH PLAN. 2. Int_ eMovernmental Transfer Assessment Fee CONTRACT # 16-93710 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 1 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, GOVERNMENTAL. FUNDING ENTITY, 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 1 of this Agreement, and will be made in addition to, and transferred separately from, the transfer of funds pursuant to the Intergovermnental 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, DIICS shall return a proportionate amount of the 20 -percent assessment fee to the GOVERNMENTAL, FUNDING ENTITY. CONTRACT 4 16-93710 3. 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 GOVERNMENTAL FIJNDING 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 fitture. 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 Authority. 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. S. Approval. This Agreement is of no force and effect until signed by the parties. 3 CONTRACT # 16-93710 SIGNATURES IN WI FNESS WHEREOF, the parties hereto have executed this Agreement, on the date of the last signature below. I HE CITY OF SAN RAFAEL By: /' 1 /�-�=�� Date: _ --��G - � 7 Jim Schutz City g, Mana erCi of San Rafael City 1400 Fifth Avenue San Rafael, CA 94901 Approved As To Form: c=� City Attorney, City 6f San`Rafael THE STATE OF CALIFORNIA, DEPARTMENT OF HEALTH CARE SERVICES: By: _� ` ' Date: 1 Jennifer Lopez, Acting Division Chief, Capitated Rates Development Division 4 DHCS State of California—Health and Human Services Agency IN01 Department of Health Care Services JENNIFER KENT DIRECTOR APIA 0 2 2018 Chris Gray, Fire Chief The City of San Rafael Fire Department 1600 Los Gamos Drive Suite #345 San Rafael, CA 94903 Dear Mr. Gray: 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 #16-93679 will assess a 20 -percent fee on the entire 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. DHCS is requesting that the City of San Rafael transfer the fee in the amount of $50,394 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 #16-93710 for the period of July 1, 2016 through June 30, 2017. 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: 2016-17 San Rafael IGT Assessment Fee Agreement #16-93710 Once the governmental funding entity has transferred the fee to the specified account, please email Sandra Dixon at Sandra. Dixon(Pdhcs.ca. cloy with the completed transaction information. Capitated Rates Development Division 1501 Capitol Avenue, P.O. Box 997413, MS 4413 Sacramonto, CA 95899-7413 Phone (916) 322-5831 Fax (916) 650-6860 www.dhcs.ca.gov Chris Gray Page 2 The 20 -percent Assessment Fee relating to the 2015-16 dollar amount in the Intergovernmental Agreement Regarding the Transfer of Public Funds #16-93679 was collected in September 2017. If you have any questions regarding this request, please contact Sandra Dixon at (916) 552-9460. Sincerely, Jeifer Lopez Acting Division Chief Capitated Rates Development Division Enclosure cc: Jim Schutz City Manager City of San Rafael 1400 511 Ave 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 # 16-93679 INTERGOVERNMENTAL AGREEMENT REGARDING TRANSFER OF PUBLIC FUNDS This Agreement is entered into between the CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES ("DHCS") and the City of San Rafael (GOVERNMENTAL FUNDING ENTITY) with respect to the matters set forth below. RECITALS A. This Agreement is made pursuant to the authority of Welfare & Institutions Code, sections 14164 and 14301.4. B. The Partnership HealthPlan of California (HEALTH PLAN) is a County Organized Health System formed pursuant to Welfare and Institutions Code section 14087.54 and County Code Chapter 7.58, County Code Chapter 2.45, County Code Chapter 2, Title 2, and County Code Chapter 34. HEAL TH PLAN is a party to a Medi-Cal managed care contract with DHCS, entered into pursuant to Welfare and Institutions Code section 14087.3, under which HEALTH PLAN arranges and pays for the provision of covered Medi-Cal health care services to eligible Medi-Cal members residing in the County. THEREFORE, the parties agree as follows: AGREEMENT 1. Transfer of Public Funds 1.1 The GOVERNMENT FUNDING ENTITY shall transfer funds to DHCS pursuant to sections 14164 and 14301.4 of the Welfare and Institutions Code, up to a maximum total amount of Two Hundred Thirty Six Thousand, Nine Hundred Seventy Five Dollars ($236,975) for the period of July 1,2015 through June 30,2016, and a maximum total amount of Two Hundred Fifty One Thousand, Nine Hundred Seventy Two Dollars ($251,972) for the period of July 1,2016 through June 30, 2017, to be used solely as a portion of the nonfederal share of actuarially sound Medi-Cal managed care capitation rate increases for HEALTH PLAN for the periods of July 1,2015 through June 30, 2016, and July 1,2016 1 1 1 " CONTRACT # 16-93679 through June 30, 2017 as described in section 2.2 below. The funds shall be transferred in accordance with a mutually agreed upon schedule between the GOVERNMENTAL FUNDING ENTITY and DHCS, in the amounts specified therein. 1.2 The GOVERNMENTAL FUNDING ENTITY shall certify that the funds transferred qualify for federal financial participation pursuant to 42 C.F.R. part 433 subpart B, and are not derived from impermissible sources such as recycled Medicaid payments, federal money excluded from use ' as State match, impermissible taxes, and non-bona fide provider-related donations. For transferring units of government that are also direct service providers, impermissible sources do not include patient care or other revenue received from programs such as Medicare or Medicaid to the extent that the program revenue is not obligated to the State as the source of funding. 2. Acceptance and Use of Transferred Funds by DHCS 2.1 DHCS shall exercise its authority under section 14164 of the Welfare and Institutions Code to accept funds transferred by the GOVERNMENTAL FUNDING ENTITY pursuant to this Agreement as intergovernmental transfers ("IGTs"), to use for the purpose set forth in section 2.2 below. 2.2 The funds transferred by the GOVERNMENTAL FUNDING ENTITY pursuant to this Agreement shall be used to fund a portion of the nonfederal share of increases in Medi-Cal managed care actuarially sound capitation rates described in paragraph (4) of subdivision (b) of section 14301.4 of the Welfare and Institutions Code and shall be paid, together with the related federal financial participation, by DHCS to HEALTH PLAN as part of HEAL TH PLAN'S capitation rates for the periods of July 1,2015 through June 30, 2016 and July 1,2016 through June 30, 2017. The rate increases paid under section 2.2 shall be used for payments related to Medi-Cal services rendered to Medi-Cal 2 CONTRACT # 16-93679 beneficiaries. The rate increases paid under this section 2.2 shall be in addition to, and shall not replace or supplant, all other amounts paid or payable by DHCS or other State agencies to HEALTH PLAN. 2.3 DHCS shall seek federal financial participation for the rate increases specified in section 2.2 to the full extent permitted by federal law. 2.4 The parties acknowledge the State DHCS will obtain any necessary approvals from the Centers for Medicare and Medicaid Services prior to the payment of any rate increase pursuant to section 2.2. 2.5 The parties agree that none of these funds, either GOVERNMENTAL FUNDING ENTITY or federal matching funds will be recycled back to the GOVERMENTAL FUNDING ENTITY'S general fund, the State, or any other intermediary organization. Payments made by the HEALTH PLAN to providers under the terms of this Agreement and their provider agreement constitute patient care revenues. 2.6 Within One Hundred Twenty (120) calendar days of the execution of this Agreement, DHCS shall advise the GOVERNMENTAL FUNDING ENTITY and HEALTH PLAN of the amount of the Medi-Cal managed care capitation rate increases that DHCS paid to HEALTH PLAN during the applicable rate year involving any funding under the terms of this Agreement. 2.7 If any portion of the funds transferred by the GOVERNMENTAL FUNDING ENTITY pursuant to this Agreement is not expended for the specified rate increases under Section 2.2, DHCS shall return the unexpended funds to the GOVERNMENTAL FUNDING ENTITY. 3. Amendments 3.1 No amendment or modification to this Agreement shall be binding on either party unless made in writing and executed by both parties. 3 CONTRACT # 16-93679 3.2 The parties shall negotiate in good faith to amend this Agreement as necessary and appropriate to implement the requirements set forth in section 2 of this Agreement. 4. Notices. Any and all notices required, permitted or desired to be given hereunder by one party to the other shall be in writing and shall be delivered to the other party personally or by United States first class, certified or registered mail with postage prepaid, addressed to the other party at the address set forth below: To the GOVERNMENTAL FUNDING ENTITY: Chris Gray Fire Chief The City of San Rafael Fire Department 1600 Los Gamos Drive Suite #345 San Rafael, Ca 94903 chris.gray@cityofsanrafael.org With copies to: ToDHCS: Jim Schutz City Manager City of San Rafael 1400 5th Ave San Rafael, Ca 94901 jim. schutz@cityofsanrafael.org Carolyn Stewart Senior Director of Financial Analysis Partnership HealthPlan of California 4665 Business Center Drive Fairfield, CA 94534 cstewart@partnership.org Sandra Dixon California Department of Health Care Services 4 CONTRACT # 16-93679 Capitated Rates Development Division 1501 Capitol Ave ., Suite 71-4002 MS 4413 Sacramento, CA 95814 Sandra.Dixon@dhcs.ca.gov 5. Other Provisions 5.1 This Agreement contains the entire Agreement between the parties with respect to the Medi-Cal rate increases for HEALTH PLAN described in section 2.2 that are funded by the GOVERNMENTAL FUNDING ENTITY and supersedes any previous or contemporaneous oral or written proposals, statements, discussions, negotiations or other agreements between the GOVERNMENTAL FUNDING ENTITY and 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 already 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. 5.2 The nonenforcement or other waiver of any provision of this Agreement shall not be construed as a continuing waiver or as a waiver of any other provision of this Agreement. 5.3 Section 2 of this Agreement shall survive the expiration or termination of this Agreement. 5.4 Nothing in this Agreement is intended to confer any rights or remedies on any third party, including, without limitation, any provider(s) or groups of providers, or any right to medical services for any individual(s) or groups of individuals; accordingly, there shall be no third party beneficiary of this Agreement. 5.5 Time is of the essence in this Agreement. 5 "1 '.' '. CONTRACT # 16-93679 5.6 Each party hereby represents that the person(s) executing this Agreement on its behalf is duly authorized to do so. 6. State Authority. Except as expressly provided herein, nothing in this Agreement shall be construed to limit, restrict, or modify the DHCS' powers, authorities, and duties under federal and state law and regulations. 7. Approval. This Agreement is of no force and effect until signed by the parties. 8. Term. This Agreement shall be effective as of July 1,2015 and shall expire as of June 30, 2019 unless terminated earlier by mutual agreement of the parties. SIGNATURES IN WITNESS WHEREOF, the parties hereto have executed this Agreement, on the date of the last signature below. THE CITY OF SAN RAFAEL By: Date: ~ //b r' (7 Approved As To Form: La 9Y,1b. fJf(P~ City Attorney :citi0fal1R~ THE STATE OF CALIFORNIA, DEPARTMENT OF HEALTH CARE SERVICES: By: Jennifer Lopez, Acting Division Chief, Capitated Rates Development Division Date: 6 CONTRACT ROUTING FORM INSTRUCTIONS: Use this cover sheet to circulate all contracts for review and approval in the order shown below. TO BE COMPLETED BY INITIATING DEPARTMENT PROJECT MANAGER: Contracting Department: Fire Project Manager: Danielle Ferrigno Extension: 3138 Project: Intergovernmental Transfer Agreements Contractor Name: State of California DHCS Contractor's Contact: Sandra Dixon Contact's Email: maiitoO FPPC: Check if Contractor/Consultant must file Form 700 Step RESPONSIBLE DESCRIPTION COMPLETED REVIEWER DEPARTMENT DATE Check/Initial 1 Project Manager a. Email PINS Introductory Notice to Contractor Not Needed 0 5/1/2017 b. Email contract (in Word) & attachments to City Atty c/o Laraine.Gittens@cityofsanrafael,org 1ZI 2 City Attorney a. Review, revise, and comment on draft agreement 5/8/2017 1ZI LAG and return to Project Manager 5/8/2017 1ZI LAG b. Confirm insurance requirements, create Job on N/A PINS, send PINS insurance notice to contractor 3 Project Manager Forward three (3) originals of final agreement to We need to 1ZI contractor for their signature sign first and we need five signed originals 4 Project Manager When necessary, * contractor-signed agreement 0 N/A agendized for Council approval 1ZI ·PSA > $20,000; or Purchase> $35 ,000 ; or Or Publ ic Works Contract> $125 ,000 Date of Council approval 5/15/2017 PRINT CONTINUE ROUTING PROCESS WITH HARD COpy 5 Project Manager Forward signed original agreements to City 5/8/2017 DF Attorney with printed copy of this routing form 6 City Attorney Review and approve hard copy of signed sj/~/J7 RS-agreement 7 City Attorney Review and approve insurance in PINS , and bonds sjJft,/r7 ;V~~ (for Public Works Contracts) 8 City Manager / Mayor Agreement executed by Council authorized official ,-lh -17 ~ 9 City Clerk Attest signatures, retains original agreement and -~. forwards copies to Project Manager tt;.)b ./7