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FD Intergovernmental Transfer 2017 DHCSCONTRACT #17-94812 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,FIRE DEPARTMENT (GOVERNMENTAL FUNDING ENTITY) with respect to the matters set forth below. The parties agree as follows: AGREEMENT Transfer of Public Funds 1.1 The GOVERNMENTAL FUNDING ENTITY agrees to make a transfer of funds to DHCS pursuant to sections 14164 and 14301.4 of the Welfare and Institutions Code. The amount transferred shall be based on the sum of the following rate category per member per month (PMPM) contribution'increments multiplied by member months: Funding entity: Health Pian: Ratino Region: City of San Rafael Fire Department_ Partnership Marin w w Rate Category Contribution PMPM Estimated Member Months Estimated Contribution (Non - Federal Share) Child - non MCHIP $ 0.30 120,452 $36,1_36 ..$_- _._ 4,365 Child - MCHIP $ 0.07 82,220 Adult -non MCHIP $ 0.72 51,994 $ 37,436 Adult - MCHIP $ 0.17 3,040 $ 517 SPD $ 2.41 26,471 $ 63,795 SPD Full Dual $ 0.36 51,105 $ 18,398 BCCTP $ 5.05 688 $ 3,472 LTC $ 12.78 117 $ 1,495 LTC Full Duals $ 7.49 4,302 $ 32,218 Optional Expansion 7/2017-1212017 $ 0.09 77,160 $ 6,946 Optional Expansion 112018 - 6/2018 $ 0.11 77,044 $ 8,475 Estimated Total 4.74,611 213,243 Template Version- 3/2018 y-3--1 Lb CONTRACT #17-94812 The GOVERNMENTAL FUNDING ENTITY agrees to initially transfer amounts that are calculated using the Estimated Member Months in the chart above, which will be reconciled to actual enrollment for the service period of July 1, 2017 through June 30, 2018 in accordance with Sub -Section 1.3 of this Agreement. The funds transferred shall be used as described in Sub - Section 2.2 of this Agreement. The fiends shall be transferred in accordance with the terms and conditions, including schedule and amount, established by DHCS. 1.2 The GOVERNMEN fAL 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 fiom impermissible sources such as recycled Medicaid payments, Federal money excluded from use as State match, impermissible taxes, and non -bona fide provider - related donations. 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. 1.3 DHCS shall reconcile the "Estimated Member Months," in Sub -Section 1.1 of this Agreement, to actual enrollment in HEALTH PLAN(S) for the service period of July 1, 2017 through June 30, 2018 using actual enrollment figures taken from DHCS records. Enrollment reconciliation will occur on an ongoing basis as updated enrollment figures become available. Actual enrollment figures will be considered final two years after June 30, 2018. If this reconciliation results in an increase to the total amount necessary to fund the nonfederal share of the payments described in Sub -Section 2.2, the GOVERNMENTAL FUNDING ENTITY agrees to transfer any additional funds necessary to cover the difference. If this reconciliation results in a decrease to the total amount necessary to fund the nonfederal share of 2 Template Version- 3/2018 CONTRACT #17-94812 the payments described in Sub -Section 2.2, DHCS agrees to return the unexpended funds to the GOVERNMENTAL FUNDING ENTITY. If DHCS and the GOVERNMENTAL FUNDING ENTITY mutually agree, amounts due to or owed by the GOVERNMENTAL FUNDING ENTITY may be offset against future transfers. 2. Acceptance and Use of Transferred Funds 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 IGTs, to use for the purpose set forth in Sub -Section 2.2. 2.2 The funds transferred by the GOVERNMENTAL FUNDING ENTITY pursuant to Section 1 of this Agreement shall be used to fund the non-federal share of Medi -Cal Managed Care actuarially sound capitation rates described in section 14301.4(b)(4) of the Welfare and Institutions Code as reflected in the contribution PMPM and rate categories reflected in the chart set forth in Sub -Section 1.1. The funds transferred shall be paid, together with the related Federal Financial Participation, by DHCS to HEALTH PLAN(S) as part of HEALTH PLAN(S)' capitation rates for the service period of July 1, 2017 through June 30, 2018, in accordance with section 14301.4 of the Welfare and Institutions Code. 2.3 DHCS shall seek Federal Financial Participation for the capitation rates specified in Sub -Section 2.2 to the full extent permitted by federal law. 2.4 The parties acknowledge that DHCS will obtain any necessary approvals from the Centers for Medicare and Medicaid Services. 2.5 DHCS shall not direct HLAL'1'H PLAN(S)' expenditure of the payments received pursuant to Sub -Section 2.2, 3. Assessment Fee Template Version- 3/2018 CONTRACT #17-94812 3.1 DHCS shall exercise its authority under section 14301.4 of the Welfare and Institutions Code to assess a 20 percent fee related to the amounts transferred pursuant to Section 1 of this Agreement, except as provided in Sub -Section 3.2. GOVERNMENTAL FUNDING ENTITY agrees to pay the full amount of that assessment in addition to the funds transferred pursuant to Section 1 of this Agreement. 3.2 The 20 -percent assessment fee shall not be applied to any portion of finds transferred pursuant to Section 1 that are exempt in accordance with sections 14301.4(d) or 14301.5(b)(4) of the Welfare and Institutions Code. DHCS shall have sole discretion to determine the amount of the funds transferred pursuant to Section 1 that will not be subject to a 20 percent fee. DHCS has determined that $0.00 of the transfer amounts, will not be assessed a 20 percent fee, subject to Sub -Section 3.3. 3.3 The 20 -percent assessment fee pursuant to this Agreement is non- refundable and shall be wired to DHCS separately from, and simultaneous to, the transfer amounts made under Section 1 of this Agreement. If, at the time of the reconciliation performed pursuant to Sub -Section 1.3 of this Agreement, there is a change in the amount transferred that is subject to the 20 -percent assessment in accordance with Sub -Section 3. 1, then a proportional adjustment to the assessment fee will be made. 4. Amendments 4.1 No amendment or modification to this Agreement shall be binding on either party unless made in writing and executed by both parties. 4.2 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 Template Version- 3/2018 CONTRACT #17-94812 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: Jim Schutz, City Manager City of San Rafael 1400 Fifth Avenue San Rafael, CA 94901 Jiiii.Schtitz@cityofs,vuaf,,iel.org With copies to: To DHCS: Chris Gray, Fire Chief San Rafael Fire Department 1600 Los Gamos Drive, Suite 345 San Rafael, CA 94903 Chris.Gray@cityofsanrafael.org And Carolyn Stewart Senior Director of Financial Analysis Partnership HealthPlan of California 4665 Business Center Drive Fairfield, CA, 94534 CStewart@partnerslniphp.org Sandra Dixon California Department of Health Care Services Capitated Rates Development Division 1501 Capitol Ave., Suite 71-4002 MS 4413 Sacramento, CA 95814 Sandra.Dixon@dhes.ca.gov Template Version- 3/2018 CONTRACT #17-94812 6. Other Provisions 6.1 This Agreement contains the entire Agreement between the parties with respect to the Medi -Cal payments described in Sub -Section 2.2 of this Agreement that are fimded by the GOVERN1ViENTAI, 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 relating to the subject matter of this Agreement. This Agreement is not, however, intended to be the sole agreement between the parties on matters relating to the fiinding and administration of the Medi - Cal program. This Agreement shall not modify the terms of any other agreement, existing or entered into in the future, between the parties. 6.2 The non -enforcement 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. 6.3 Sections 2 and 3 of this Agreement shall survive the expiration or termination of this Agreement. 6.4 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. 6.5 Time is of the essence in this Agreement. 6.6 Each party hereby represents that the person(s) executing this Agreement on its behalf is duly authorized to do so. 6 Template Version- 3/2018 CONTRACT #17-94812 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. Approval. This Agreement is of no force and effect until signed by the parties. 9. Term. This Agreement shall be effective as of July 1, 2017 and shall expire as of December 31, 2020 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�FIRE DEPARTMENT By: �,._ - ,�'� t/ Date: Juin Sehutz, City M\a er, City of San Rafael Tl LE STATE OF CALIFORNIA, DEPARTMENT OF HEALTH CARE SERVICES: Date: 0 klu L Jennifer Lopez, Acting Division Chief, Capitated Rates Development Division Template Version- 3:3018 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: Christopher Gray Extension: x3084 Contractor Name: California Department of Health Care Services (DHCS) Contractor's Contact: Sandra Dixon Contact's Email: Sandra.Dixon@dhcs.ca.gov D FPPC: Check if Contractor/Consultant must file Form 700 Step 1 2 3 4 RESPONSIBLE DEPARTMENT Project Manager City Attorney Project Manager Project Manager DESCRIPTION a. Email PINS Introductory Notice to Contractor b. Email contract (in Word) & attachments to City Atty c/o Laraine.Gittens@cityofsanrafael.org a. Review, revise, and comment on draft agreement and return to Project Manager b. Confirm insurance requirements, create Job on PINS, send PINS insurance notice to contractor Forward three (3) originals of final agreement to contractor for their signature When necessary, * contractor-signed agreement agendized for Council approval *P5A > $20,000; or Purchase> $35,000; or Public Works Contract> $125,000 COMPLETED DATE Click here to enter a date. Click here to enter a date. CI ick here to enter a date. Click here to enter a date. Click here to enter a date. D N/A Or r-----""" Date of Council approval ( 6/18/2018 ,) PRINT 5 Project Manager 6 City Attorney 7 City Attorney CONTINUE ROUTING PROCESS WITH HARD COPY Forward signed original agreements to City Attorney with printed copy of this routing form Review and approve hard copy of signed agreement Review and approve insurance in PIN,S I and bonds (for Public Works Contracts) )J J A- REVIEWER Check/Initial D D D D D 8 City Manager / Mayor Agreement executed by Council authorized official 6-U-//f tK 9 City Clerk Attest signatures, retains original agreement and forwards copies to Project Manager I