HomeMy WebLinkAboutCC Resolution 13916 (Ambulance Services Cost Recovery)RESOLUTION NO. 13916
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 2013-2014.
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, section 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 2013-2014.
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, 2013 through July 1, 2014.
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 4`h day of May, 2015, by the following vote, to wit:
AYES: COUNCILMEMBERS: Bushey, Colin, Gamblin, McCullough & Mayor Phillips
NOES: COUNCILMEMBERS: None
ABSENT: COUNCILMEMBERS: None
14-9—Mc l�- ez- • A x -4-t
ESTHER C. BEIRNE, City Clerk
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HEALTH PLAN -PROVIDER AGREEMENT
Partnership HealthPlan of California and the City of San Rafael
AMENDMENT 1
2ey1 s
This Amendment is made this 04- day of tW {month/year), by and between
Partnership HealthPlan of California, a County Organized Health System hereinafter referred to
as "PLAN", and the City of San Rafael via the San Rafael Fire Department, 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, PROVIDER is a department of the City of San Rafael that provides
emergency response and transport to the City of San Rafael and to Marinwood and other
unincorporated areas of Marin County. PROVIDER's four ambulances provide Advanced Life
Support and Basic Life Support transport and treatment services. PROVIDER responds to 9-1-1
dispatches and serves all patients regardless of insurance or ability to pay including Medi -Cal
and Medicare beneficiaries; and
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 the 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 Cavitation Rate Range Increases to PLAN
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OR!
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A. Pavment
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, 2013 through June 30, 2014 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, 2014. 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 Receiving Local Medi -Cal Managed Care Rate Range 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;
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Template Version -1/20/12 The San Rafael Fire Department /Partnership FINAL 6/17/15
(2) maintain its current emergency response services for PLAN Medi -Cal
beneficiaries.
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 Intergoverrunental 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 Timing 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 saine 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.
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(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
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 terns 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 IT 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.
t. 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
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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.
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.
2. Term
The tenn of this Amendment shall commence on July 1, 2013 and shall terminate
on September 30, 2016.
All other terns 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 terns of this Amendment and the
Agreement, then the terns of this Amendment shall govern.
HEALTH PLAN:
dL�VDate:
By: Jack Horn CEO Partnership HealthPlan of California
PROVIDER:
W4W6q'Yj2�Ue"Date: i ;
By: Nancy Mackle`, Cit Manager, Cit of San Rafael
Y g, Y
Approved s to f®
Template Version -1/20/12 The San Rafael Fire Department /Partnership FINAL 6/17/15)
PAR'T'NERSHIP
�'
of CALIFORNIA
May 20, 2015
Hello IGT County Partner,
4665 Business Center Drive
Fairfield, California 94534
Included in this correspondence are two hard copies of the I lealth Plan Provider
Agreement for your signature. This document is based on the final Plan Provider
Agreement that DHCS approved and emailed to you with redline corrections. We
accepted the redline edits and changed the footer to indicate this is the final document.
This agreement is signed only by PI -IC and you, the Health Care Provider. DIICS wants a
photocopy or scanned copy of the executed agreement for their records by June 17tH,
2015. You can include a photocopy of the signed document in the packet of documents
you mail to DHCS or you can scan the signed Agreement and send it via email to Sandra
Dixon Sandra.dixonRD11CS.CA.v-ov.
Please keep one hard copy for your records and return the other to PIIC. Please mail the
hard copy signed agreements to:
Dawn James
4665 Business Center Drive
Fairfield, CA 94534
Please contact Elli Hall at 503-292-3240 if you have any questions about this process.
Thank you,
Amy Turnipseed
Director of Policy and Program Development
HEALTH CARE SERVICES AGREEMENT
Between
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
and
HEALTH CARE SERVICES PROVIDER
This Health Care Services Agreement is entered into this day of ,
20,, , by Partnership Health Plan of California, a public entity (PARTNERSHIP) and between
Cit roof San Rafael (please print) herein referred to as PROVIDER, a medical and/or
health care services, supplies, or equipment provider Iicensed in the State of California, as
applicable, and is eligible to participate in and meets the Standards of Participation of the Medi -
Cal Program to provide services under the California Medi -Cal (Medicaid) Program and meets
applicable requirements under Title 22 CCR Section 51000 et. seq., Titles XVII and XIX of the
Social Services Act.
IN WITNESS WHEREOF, the subsequent Agreement between PARTNERSHIP and Health
Care Services Provider is entered into by and between the undersigned parties.
CONTRACTOR
Citv of San Raf el A
(List Health Cm•e Seg +i s Prov el. Above)
Signature:
Printed Name: Christo her R. Gr
Title: Fire Chief
Date: June 12, 2014
Address for Notices:
City of San Rafael
San Rafael Fire Department (DBA)
1039 C Street, San Rafael, CA 94901
Attn: Christopher R. Gray
Aadllary Arra! Comma MNrth Care An) 01-01 1,f Page i
PLAN
Partnership HealthPlan of California
Signature:
Printed Na4� ( Yn
Title:—C V O
Date: �jjwv' /a j J -o I -
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
HEALTH CARE SERVICES AGREEMENT
TABLE OF CONTENTS
RECITALS................................................................................................................................3
SECTIONI DEFINITIONS...................................................................................................3
SECTION 2 - QUALIFICATIONS, OBLIGATIONS AND COVENANTS ..........................8
SECTION 3 - SCOPE OF SERVICES...................................................................................13
SECTION 4 EXCLUSIONS FROM AND LIMITATIONS OF COVERED SERVICES ..16
SECTION 5 - PAYMENTS AND CLAIMS PROCESSING.................................................17
SECTION 6 - RECORDS, ACCOUNTS, REPORTING AND RECOVERIES .................... 21
SECTION 7 - INSURANCE AND INDEMNIFICATION....................................................25
SECTION 8 - TERM, TERMINATION, AND AMENDMENT...........................................26
SECTION 9 GENERAL PROVISIONS..............................................................................29
SECTION 10 - GRIEVANCES AND APPEALS..................................................................32
SECTION I I - RELATIONSHIP OF PARTIES....................................................................34
ATTACHMENT A NON DISCRIMINATION CLAUSE...................................................35
ATTACHMENT B OFFICERS, OWNERS, AND STOCKHOLDERS..............................36
ATTACHMENT C - FACILITY LOCATIONS....................................................................37
A"i7torpMcatContract (NeatthCare, Sws)01-01-14 Page 2
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
HEALTH CARE SERVICES AGREEMENT
RECITALS
A. WHEREAS, PARTNERSHIP has entered into and will maintain contracts with (the
Medi -Cal Agreements) the State of California, Department of Health Care Services in
accordance with the requirements of the Knox -Keene Care Services Plan Act of 1975
Health and Safety Code, Section 1340 et. seq.; Title 10, CCR, Section 1300 et. seq.; W&I
Code, Section 14200 et. seq.; Title 22, CCR, Section 53250; and applicable federal and
State laws and under which Medi -Cal Beneficiaries assigned to PARTNERSHIP as
Member(s) receive all medical services hereinafter defined as "Covered Services"
through the PARTNERSHIP.
B. WHEREAS, PARTNERSHIP will arrange for Covered Services of its Medi -Cal
Members under the case management of designated Primary Care Physicians chosen by
or assigned to Medi -Cal Members, and all healthcare services (with the exception of
emergency services) with be delivered only with authorization from the PARTNERSHIP.
C. WHEREAS, PROVIDER will participate in providing Covered Services to Medi -Cal
Members and will receive payment from PARTNERSHIP for the rendering of those
Covered Services.
D. WHEREAS, PROVIDER desires to provide medical care for such Medi -Cal Members.
IN CONSIDERATION of the foregoing recitals and the mutual covenants and promises
contained herein, receipt and sufficiency of which are hereby acknowledged, the parties set forth
in this agreement agree and covenant as follows:
SECTION 1
DEFINITIONS
As used in this Agreement, the following terms will have the meaning set forth herein below,
except where, from the context, it is clear that another meaning is intended. Many words and
terms are capitalized throughout this Agreement to indicate that they are defined as set forth in
this Section.
1.1 Ajzreement — This agreement and all of the Exhibits attached hereto and incorporated
herein by reference.
1.2 Attendine Phvsician — (a) any physician who is acting in the provision of Emergency
Services to meet the medical needs of the Medi -Cal Member or (b) any physician who is,
through referral from the Medi -Cal Member's Primary Care Physician, actively engaged
in the treatment or evaluation of a Member's condition or (c) any physician designated by
the Medical Director to provide services for Special Case Managed Members.
Ancillary Aleal Contract (Health Care Svrs) 01-01-14 Page 3
1.3 California Children's Services (CCS) — A public health program that assures the delivery
of specialized diagnostic, treatment, and therapy services to financially and medically
eligible children under the age of 21 years who have CCS eligible conditions, as defined
in Title 22, California Code of Regulations (CCR), Section 41800
1.4 Cavitation Pavment — The prepaid monthly amount that PARTNERSHIP pays to
PROVIDER as compensation for capitated services.
1.5 Case Managed Members — Medi -Cal Members who have been assigned or who chose a
Primary Care Physician for their medical care.
1.6 Child Health and Disabilitv Prevention Services (CHDP) Those health care preventive
services for beneficiaries under 21 years of age provided in accordance with the
provisions of Health and Safety Code Section 124025, et. seq., and Title 17, CCR,
Sections 6842 through 6852.
1.7 Contract Year — Twelve (12) month period following the effective date of this Agreement
between PROVIDER and PARTNERSHIP and each subsequent 12 month period
following the anniversary of the agreement. If the date of commencement of operations
is later than the effective date, the PARTNERSHIP operational date will apply.
1.8 Countv Organized Health Svstem (CORS) — A plan serving either a single or multiple
county area.
1.9 Covered Services — Medical Management and those services set forth in Title 22, CCR,
Division 3, Subdivision 1, Chapter 3, beginning with Sections 51301, and Title 17, CCR,
Chapter 4, Subchapter 13, Article 4, beginning with Section 6842, except for excluded
and limited services outlined in Section 3.4 of this Agreement.
1.10 DHCS _ The State of California Department of Health Care Services.
1.11 Eligible Beneficiary — Any Medi -Cal Beneficiary who receives Medi -Cal benefits under
the terms of one of the specific aid codes set forth in the Medi -Cal Agreement between
PARTNERSHIP AND DHCS, and who is certified as eligible for Medi -Cal by the State
of California.
1.12 Emeraencv Medical Condition A medical condition which is manifested by acute
symptoms of sufficient severity, including severe pain, such that a prudent lay person
who possesses an average knowledge of health and medicine could reasonably expect the
absence of immediate medical attention to result in: i) placing the health of the individual
(or, in the case of a pregnant woman, the health of the woman or her unborn child) in
serious jeopardy; ii) serious impairment to bodily functions; or iii) serious dysfunction of
any bodily organ or part.
Ancillary Ateal Contract (Health Care Svcs) 01 01-14 Page 4
1.13 Emergencv Services. Those health services needed to evaluate or stabilize a Medical
Condition.
1.14 Encounter Form. The CMS -1500 or UB -04 claim form used by PROVIDER to report to
PARTNERSHIP regarding the provision of covered services to Medi -Cal Members.
1.15 Enrollment. The process by which an Eligible Beneficiary selects or is assigned to the
PARTNERSHIP.
1.16 Excluded Services. Those services for which the PARTNERSHIP is not responsible and
for which it does not receive a capitation payment as outlined in Section 4 of this
Agreement.
1.17 Fee -For -Service Pavment (FFS). (1) The maximum Fee -For -Service rate determined by
DHCS for the service provided under the Medi -Cal Program or (2) the rate agreed to by
contractor and the provider. All Covered Services that are Non -Capitated Services, or
authorized by the PARTNERSHIP per the PARTNERSHIP Operations Manual, and
compensated by PARTNERSHIP pursuant to this Agreement will be compensated by
PARTNERSHIP at the lowest allowable Fee -For -Service rate unless otherwise identified
in Section 5 and of this Agreement.
1.18 Fiscal Year of Partnership HealthPlan of California. The 12 month period starting July 1.
1.19 Governmental Agencies. The Department of Managed Health Care ("DMHC"),
Department of Health Care Services "DHCS", United States Department of Health and
Human Services ("DHHS"), United States Department of Justice ("DOJ"), and California
Attorney General and any other agency which has jurisdiction over PARTNERSHIP or
Medi -Cal (Medicaid).
1.20 Hosvital — Any acute general care or psychiatric hospital licensed by the DHCS.
1.21 Identification Card. The card that is prepared by the PARTNERSHIP which bears the
name and symbol of PARTNERSHIP and contains: a) Member name and identification
number, b) Member's Primary Care Physician, and other identifying data. The
Identification Card is not proof of Member eligibility with PARTNERSHIP or proof of
Medi -Cal eligibility.
1.22 Medical Director. The Medical Director of PARTNERSHIP or his/her designee, a
physician licensed to practice medicine in the State of California, employed by
PARTNERSHIP to monitor the quality assurance and implement Quality Improvement
Activities of PARTNERSHIP.
1.23 Medically Necessarv. Reasonable and necessary services to protect life, to prevent
significant illness or significant disability, or to alleviate severe pain through the
diagnosis or treatment of disease, illness, or injury. These services will be in accordance
Ancillary Mcal Contract (Health CareSts) 01 01 14 Page 5
with accepted standards of medical practice and not primarily for the convenience of the
Member or the participating PROVIDER.
1.24 Medi -Cal Managed Care Program. The program that PARTNERSHIP operates under its
Medi -Cal Agreement with the DHCS .
1.25 Medi -Cal Provider Manual. The Allied Health or Vision Care Services Provider Manuals
of the DHCS, issued by the DHCS Fiscal Intermediary.
1.26 Medical Transportation.. The transportation of the sick, injured, invalid, convalescent,
infirm or otherwise incapacitated persons by ambulances, litter vans or wheelchair vans
licensed, operated, and equipped in accordance with applicable state or local statutes,
ordinances or regulations. Medical transportation services do not include transportation
of beneficiaries by passenger car, taxicabs or other forms of public or private
conveyances.
1.27 Member. An Eligible Medi -Cal Beneficiary who is enrolled in the PARTNERSHIP.
1.28 Member Handbook. The PARTNERSHIP Medi -Cal Combined Evidence of Coverage
and Disclosure Fonn that sets forth the benefits to which a Medi -Cal Member is entitled
under the Medi -Cal Managed Care Program, the limitations and exclusions to which the
Medi -Cal Member is subject and terms of the relationship and agreement between
PARTNERSHIP and the Medi -Gal Membcr.
1.29 Non -Medical Transportation. Transportation services required to access medical
appointments and to obtain other Medically Necessary Covered Services by Member who
do not have a medical condition necessitating the use of medical transportation as defined
in Title 22, CCR, Section 51323.
1.30 Non-Phvsician Medical Practitioner., A physician assistant, nurse practitioner, or
certified midwife authorized to provide primary care under physician supervision.
1.31 Operations Manual. (also referred to as Provider Manual) The Manual of Operations
Policies and Procedures for the PARTNERSHIP Medi -Cal Managed Care Program.
1.32 Other Services. Vision Care and other Covered Services, including but not limited to
chiropractic; acupuncture; occupational therapy; speech pathology; audiology; podiatry;
physical therapy; durable medical equipment, and medical supplies.
1.33 PARTNERSHIP. The Medi -Cal Managed Care Program governed by the Partnership
Health Plan of California.
1.34 Partnershin HealthPlan of California lPHCI. The locally administered, prepaid Medi -Cal
Managed Care program.
AndUary Mcal Contract (Heahh Care Svcs) 01-01-14 Page 6
1.35 Phvsician. Either an Attending Physician or a Primary Care Physician, who has entered
into an Agreement with PARTNERSHIP and who is licensed to provide medical care by
the Medical Board of California and is enrolled in the State Medi -Cal Program.
1.36 Phvsicians' Advisory Group. The committee of physicians chosen each year from among
contracting physicians by the PARTNERSHIP for the purpose of advising the
PARTNERSHIP. The physicians must be Board Certified.
1.37 Phvsician Patient Load Limitation. The maximum number of Beneficiary Members for
whom the Primary Care Physician has contracted to serve, which has been accepted by
the PARTNERSHIP. The PARTNERSHIP agrees that additional Members will not be
permitted to select or be assigned to that Primary Care Physician. Such limit may be
changed by mutual agreement of the parties.
1.38 Primary Care Case Manaaement. The responsibility for primary and preventive care, and
for the referral, consultation, ordering of therapy, admission to hospitals, provision of
Medi -Cal covered health education and preventive services, follow-up care, coordinated
hospital discharge planning that includes necessary post -discharge care, and maintenance
of a medical record with documentation of referred and follow-up services.
1.39 Primary Care Phvsician. A physician or physicians who has/have executed an Agreement
with PARTNERSHIP to provide Primary Care Services. The Physician must be duly
licensed by the Medical Board of California and enrolled in the State Medi -Cal Program.
The Primary Care Physician is responsible for supervising, coordinating, and providing
initial and Primary Care to Members; initiating referrals; and for maintaining the
continuity of care for the Members who select or are assigned to the Primary Care
Physician. Primary care physicians include general and family practitioners, internists,
Obstetrician -Gynecologists and pediatricians. A resident or intern will not be a Primary
Care Physician.
1.40 Primary Care Services. Those services defined in the DHCS contract with
PARTNERSHIP to be provided to Beneficiaries Members by a Primary Care Physician.
These services constitute a basic level of healthcare usually rendered in ambulatory
settings and focus on general health needs.
1.41 Primary Hospital. Any hospital affiliated with Primary Care Physician that has entered
into an Agreement with the PARTNERSHIP.
1.42 Participatine Referral Provider. Any health professional or institution contracted with
PARTNERSHIP that meets the Standards for Participation in the State Medi -Cal
Program to render Covered Services to Medi -Cal Members.
1.43 Qualitv Improvement Plan (OIP). Systematic activities to monitor and evaluate the
clinical and non -clinical services provided to Members according to the standards set
forth in statute, regulations, and PARTNERSHIP Agreement with the DHCS. The QIP
Dy War) .ilea( Contract (Health Care &rs) 01 01 14 Page 7
consists of processes, which measure the effectiveness of care, identifies problems, and
implements improvement on a continuing basis towards an identified, target outcome
measurement.
1.44 Referral Authorization Form or RAF. The form or number evidencing authorization
referral by PCP or Medical Director, or designee, to render specific non -emergency
Covered Services to Medi -Cal Members.
1.45 Referral Phvsician. Any qualified physician, duly licensed in California that meets the
Standards of Participation and has been enrolled in the State Medi -Cal Program in
accordance with Article 3 Title 22 CCR Section 51000 et.seq. The physician has
executed an Agreement with PARTNERSHIP, to whom a Primary Care Physician may
refer any Member for consultation or treatment. Also called Participating Referral
Physician.
1.46 Referral Services. Covered services, which are not Primary Care Sei vices, and which are
provided by physicians or healthcare service providers after authorization by the
PARTNERSHIP as a non -capitated service
1.47 Special Case Manaeed Members. Medi -Cal Members enrolled with PARTNERSHIP
who have not been assigned to a Primary Care Physician for administrative or medical
reasons, e.g. CCS, ESRD, LTC, out -of -area Members, organ transplant cases, or Mcdi-
Cal Members that the Medical Director has determined can remain unassigned to a
Primary Care Physician because of a long term physician/patient relationship.
1.48 Treatment Authorization Reauest or TAR. "TAR" means the Treatment Authorization
Request form approved by Plan for the provision of Non -Emergency Services. Those
Non -Emergency Services that require a Treatment Authorization Request form approved
by Plan are set forth in the Provider Manual.
1.49 Ureent Care Services. Medical services required to prevent serious deterioration of
health following the onset of an unforeseen condition or injury (e.g., sore throat, fever,
minor lacerations, and some broken bones).
1.50 Utilization Mananement ProRram. The program(s) approved by PARTNERSHIP, which
are designed to review and to monitor the utilization of Covered Services. Such
program(s) are set forth in the PARTNERSHIP Operations Manual.
1.51 Vision Care. Routine basic eye examinations, lenses and frames provided benefit
provided every 24 months for eligible members defined by the State of California
Medical -Cal Program.
AncillatyAlcal Contract (Health CareStrs) 01-01-14 Page g
SECTION 2
QUALIFICATIONS, OBLIGATIONS AND COVENANTS
2.1 PROVIDER of Healthcare (Covered) Services is responsible for:
2.1.1 Standards of Care- Provide Covered Services for those complaints and disorders
of Mcdi-Cal Members that are within the PROVIDER's professional competence
and licensure, as applicable, with the same standards of care, skill, diligence and
in the same economic and efficient manner as are generally accepted practices and
standards prevailing in the professional community.
2.1.2 Licensure — Warrant that PROVIDER has, and will continue to have as long as
this Agreement remains in effect, a currently valid unrestricted license,
certification or registration in the State of California, as applicable to the Covered
Services rendered. Warrant that PROVIDER has the personal capacity to perform
pursuant to the terms of this Agreement; and will satisfy any continuing
professional education requirements prescribed by state licensure and/or
certification regulations or by PARTNERSHIP. Warrant that the PROVIDER
has, and will continue to have as long as this Agreement remains in effect,
eligibility to participate in the Medi -Cal Program in accordance with the program
Standards of Participation contained in Article 3, Chapter 3, Subdivision 1,
Division 3, of Title 22 of the California Code of Regulations.
2.1.3 Covered Services — Provide the Medically Necessary Covered Services for those
medical complaints and disorders that are within his/her professional competence
and in accordance with Section 2.1.5 of this Agreement.
2.1.4 Accessibilitv and Hours of Service* Providing Covered Services to Medi -Cal
Members on a readily available and accessible basis in accordance with
PARTNERSHIP policies and procedures as set forth in the PARTNERSHIP
Operations Manual during normal business hours at PROVIDERS usual place of
business
2.1.5 Referrals — Unless otherwise agreed to by PARTNERSHIP except for Emergency
Services and Urgent Care Services, provide Covered Services to Medi -Cal
Members, only upon receipt of an appropriate referral to provide such services
from Medi -Cal Member's Primary Care Physician, PARTNERSHIP, or such
other treatment authorization as described in the PARTNERSHIP Operations
Manual.
2.1.6 Case Management — Cooperate with Medi -Cal Member's Referring Physician and
PARTNERSHIP in the monitoring, coordination, and case management of the
Medi -Cal Member's healthcare services. PROVIDER will promptly famish a
complete written report of the services rendered to a Medi -Cal Member to the
Medi -Cal Member's Referring Physician and, upon receipt of an appropriate
Ancillaty Aical Contract (Health Cam Acs) 01 01-14 Pap 9
consent, to PARTNERSHIP, on such form as may be prescribed in the
PARTNERSHIP Operations Manual.
a. PROVIDER agrees to abide by the Case Management Protocols which are
included in the PARTNERSHIP Operations Manual.
b. PROVIDER agrees to abide by the PARTNERSHIP Operations Manual
policies and procedures, which may be amended from time to time with
thirty (30) days, notice to PROVIDER.
C. PROVIDER and any Attending Physician or Referral Physician to whom
the Primary Care Physician has delegated the authority to proceed with
treatment or the use of resources, will be responsible for coordinating
medical services performed or prescribed through them for the Member.
d. PROVIDER acknowledges that PARTNERSHIP's Medical Director will
assist in the management of Catastrophic Cases. PROVIDER will fully
cooperate with PARTNERSHIP's Medical Director by providing
information that may be required in the care of Catastrophic Cases,
including but not limited to, prompt notification of known or suspected
Catastrophic Cases.
2.1.7 Officers. Owners and Stockholders — Providing information regarding officers,
owners and stockholders as set forth in Attachment B, attached to and
incorporated herein.
2.1.8 Credentialing — Provide PARTNERSHIP with accreditation, licensure and/or
certification documents, as applicable, and will use best efforts to notify
PARTNERSHIP in advance of any change in such information. PROVIDER will
successfully complete a facility site review, if deemed necessary by
PARTNERSHIP in accordance with DHCS Medi -Cal Agreement.
2.1.9 Actions Against PROVIDER PROVIDER will adhere to the requirements as set
forth in the PAR"T"NERSHIP Operations Manual and notify PARTNERSHIP by
certified mail within five (5) days of PROVIDER's learning of any action taken
which results in restrictions for a medical disciplinary cause or reason as defined
in Division 3 Chapter 3 Article 3 Title 22, CCR, commencing with Sections
51000 et.seq. regardless of the duration of the restriction or excluded from
participating in the Medi -Cal Program.
2.1.10 Financial and Accounting Records — Maintain, in accordance with standard and
accepted accounting practices, financial and accounting records relating to
services provided or paid for hereunder as will be necessary and appropriate for
the proper administration of this Agreement, the services to be rendered, and
payments to be made hereunder or in connection herewith. Submit reports as
required by PARTNERSHIP or DHCS.
AncilloryMcal Comma (Health Care Svcs) 01-01-14 Page 10
2.1.11 Compliance with Member Handbook — PROVIDER acknowledges that
PROVIDER is not authorized to make nor will PROVIDER make any variances,
alterations, or exceptions to the terms and conditions of the Member Handbook.
2.1.12 Promotional Materials - PROVIDER will consent to be identified as a
PROVIDER in written materials published by PARTNERSHIP, including without
limitation, marketing materials prepared and distributed by PARTNERSHIP and,
display promotional materials provided by PARTNERSHIP within his/her office.
2.1.13 Facilities. Eauipment and Personnel — Provide and maintain sufficient facilities,
equipment, personnel, and administrative services to perform the duties and
responsibilities as set forth in this Agreement. PROVIDER agrees to provide at
least 60 days notice to PARTNERSHIP prior to the opening of any new location
and 90 days prior to the closing of any location.
2.1.14 PROVIDER shall provide, as applicable, the ownership disclosure statement(s),
the business transactions disclosure statement(s), the convicted offenses
disclosure statement(s), and the exclusion from state or federal health programs
disclosure statement(s), prior to the Effective Date, on an annual basis, upon any
change in information, and upon request, if required by law or by the Medi -Cal
Agreements. Legal requirements include, but are not limited to, Title 22 CCR
Section 51000.35, 42 USC Sections 1320 a-3 (3) and 1320 a-5 et seq., and 42
CFR Sections 455.104, 455.105 and 455.106. PROVIDER shall also provide, as
applicable, the "Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transactions" and shall comply with
its instructions, if required by law or by the Medi -Cal Agreements. Such
Debarment Certification and its instructions are set forth in the Provider Manual.
2.1.15 Compliance with PARTNERSHIP Policies and Procedures. PROVIDER agrees
to comply with all policies and procedures set forth in the PARTNERSHIP
Provider Manual. The Provider Manual is available through the PARTNERSHIP
website at www.Partnershintimore. PARTNERSHIP may modify Provider
Manual from time to time. In the event the provisions of the Provider Manual are
inconsistent with the terms of this Agreement; the terms of this Agreement shall
prevail.
2.1.16 Cultural and Linguistic Services. PROVIDER shall provide Services to Members
in a culturally, ethnically and linguistically appropriate manner. PROVIDER
shall recognize and integrate Members' practices and beliefs about disease
causation and prevention into the provision of Covered Services. PROVIDER
shall comply with Plan's language assistance program standards developed under
California Health and Safety Code Section 1367.04 and Title 28 CCR Section
1300.67.04 and shall cooperate with plan by providing any information necessary
to assess compliance. Plan shall retain ongoing administrative and financial
responsibility for implementing and operating the language assistance program.
Ancillary dtcal Cantraet (Health Cara, Sirs) 01 01 14 Page I I
PROVIDER has 24 (twenty-four) hours, 7 (seven) days a week access to
telephonic interpretive services outlined in policies and procedures as set forth in
PARTNERSHIP Provider Manual.
2.1.17 PROVIDER will verify Medi -Cal Member eligibility with PARTNERSHIP prior
to rendering medical services. Referral from a Primary Care Physician is not a
guarantee of Medi -Cal Member eligibility with PARTNERSHIP or eligibility in
the State Medi -Cal Program.
a. Member eligibility is available via telephone or electronic media.
PARTNERSHIP makes best efforts to update Medi -Cal eligibility daily
from DHCS eligibility tapes.
b. PARTNERSHIP will maintain (or arrange to have maintained) records
and establish and adhere to procedures as will reasonably be required to
accurately ascertain the number and identity of Medi -Cal Members.
2.2 PARTNERSHIP is responsible for:
2.2.1 Member Assigmnent — Assigning Medi -Cal Members in the Medi -Cal Managed
Care Program to a Primary Care Physician and Primary Hospital.
a. The Medi -Cal Member can select from the Primary Care Physicians
contracting with PARTNERSHIP.
b. The Medi -Cal Member will seek all medical services, except those
outlined in Section 4.2 from their assigned Primary Care Physician or
Referring Physician.
C. If the Medi -Cal Member does not select a Primary Care Physician,
PARTNERSHIP will assign Members to a Primary Care Physician in a
systematic manner as the Partnership deems appropriate and/or in
accordance with Medi -Cal protocols.
d. The Medi -Cal Member will be assigned to a Primary Hospital for inpatient
and outpatient hospital services and at which the Attending Physician has
medical staff privileges.
2.2.2 Listing — PARTNERSHIP will enter the name of each contracted PROVIDER
onto a list from which Medi -Cal Members may choose to receive healthcare
services. Such a list will contain the following information concerning the
PROVIDER.
a. Name
b. Address(es)
Ancillary Meal Contract (Health Care Svcs) (11-01-14 Page 12
c. Office hours
d. Scope of services (specialty or provider type)
2.2.3 Pavment for Authorized Service Only — The PARTNERSHIP will reimburse
PROVIDER for Covered Services that are authorized by the PARTNERSHIP
Medical Director (or his/her Designee) or for covered services provided to a
special case managed member. Payment will be made based on required
authorization and claim billing requirements as identified in the PARTNERSHIP
Operations Manual.
SECTION 3
SCOPE OF SERVICES
3.1 Prior Authorization(s) — With the exception of Excluded Services described in Section 4
of this Agreement, a Referral Authorization Form (RAF) from a Referring Physician and
prior authorization(s) from the PARTNERSHIP's Medical Director or his/her designee is
required before rendering goods and/or Covered and Limited Services in accordance with
PARTNERSHIP's policies and procedures and Operations Manual to the extent
permitted by the statewide Medi -Cal Program including:
3.1.1 Ambulance (Medical Transportation) Services when medically necessary and in
accordance with Title 22, CCR, Section 51323 and PARTNERSHIP Operations
Manual policies and procedures. Medical transportation services do not include
transportation of beneficiaries by passenger car, taxicabs or other forms of
public or private conveyances.
3.1.2 Other necessary durable medical equipment rental, and medical supplies
determined by Referring Physician to be medically necessary for the purpose of
diagnosis, management or treatment of diagnosed health impairment, or
rehabilitation of the Medi -Cal Member.
3.1.3 A Treatment Authorization Request (TAR) approved by PARTNERSHIP's
Medical Director shall be obtained for covered services per PARTNERSHIP's
policies and procedures as outlined in the PARTNERSHIP Provider Manual.
All services and goods required or provided hereunder will be consistent with
sound professional principles, community standards of care, and medical
necessity.
3.1.4 Interpreter Services Arrange interpreter services as necessary for Members at
all facilities.
3.1.5 Nothing expressed or implied herein shall require the PROVIDER to provide to
or order on behalf of the Medi -Cal Member, Covered Services which, in the
professional opinion of the Primary Care Physician or PROVIDER, are not
Ancillary Alta/ Contract (Health Care Svcs) 01 01 14 Page 13
medically necessary for the treatment of the Medi -Cal Member's disease or
disability.
3.2 Prescription Drues — Comply with the PARTNERSHIP drug formulary as approved by
PARTNERSHIP policies and subject to the restrictions on the PARTNERSHIP's Drug
Fonmulary regarding the prescription of generic or lowest cost alternative brand name
pharmaceuticals, in conformance with generally accepted medical and surgical practices
and standards prevailing in the professional community.
3.2.1 If for medical reasons, the PROVIDER believes a generic equivalent should not
be dispensed, the PROVIDER agrees to obtain prior authorization from the
PARTNERSHIP Pharmacy Director.
3.2.2 PROVIDER acknowledges the authority of PARTNERSHIP's participating
pharmacists to substitute generics for trade name drugs, as specified in Section
4073 of the California Business & Professions Code, and Title 22 CCR Section
51313 unless otherwise indicated.
3.2.3 The PARTNERSHIP Pharmacy and Therapeutic Committee is a professional
advisory board of participating providers that meets quarterly and makes
recommendations for changes to the drug formulary.
3.3 Non -Discrimination
3.3.1 Medi -Cal Members — PROVIDER will provide services to Medi -Cal Members in
the same manner as such services are provided to other patients of PROVIDER,
except as limited or required by other provisions of this Agreement or by other
limitations inherent in the operational considerations of the Mcdi-Cal Managed
Care Program. Subject to the foregoing, PROVIDER will not subject Medi -Cal
Members to discrimination on the basis of race, color, creed, religion, language,
ancestry, marital status, sexual orientation, sexual preference, national origin, age
(over 40), sex, gender, political affiliation, health status, or physical or mental
disability, medical condition (including cancer), pregnancy, childbirth or related
medical conditions, veteran's status, income, source of payment, status as a
Member of PARTNERSHIP, or filing a complaint as a Member of
PARTNERSHIP, in accordance with Title VI of the Civil Rights Act of 1964, 42
United States Code (USC), Section 2000(d), rules and regulations promulgated
pursuant thereto, or as otherwise provided by law or regulations. Discrimination
will include but is not limited to: denying any Medi -Cal Member any Covered
Service or availability of a Facility; providing to a Medi -Cal Member any
Covered Service which is different, or is provided in a different manner or at a
different time from that provided to other Medi -Cal Members under this Contract
except where medically indicated; subjecting a Medi -Cal Member to segregation
or separate treatment in any manner related to the receipt of any Covered Service;
restricting a Medi -Cal Member in any way in the enjoyment of any advantage or
Ancillaryhfcal Contract (Health Care Svcs) 01-01-14 Page 14
privilege enjoyed by others receiving many Covered Services, treating a Medi -Cal
Member differently from others in determining whether he or she satisfied any
admission, enrollment, quota, eligibility, membership, or other requirement or
condition which individuals must meet in order to be provided any Covered
Services; the assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin, ancestry, marital
status, sexual orientation, or the physical or mental handicap of the participants to
be served.
3.3.2 For the purpose of this Section, physical handicap includes the carrying of a gene,
which may, under some circumstances, be associated with disability in that
person's offspring, but which causes no adverse affects on the carrier. Such genes
include, but are not limited to, Tay -Sack trait, sickle-cell trait, Thallassemia trait,
and X-linked hemophilia.
3.3.3 General Compliance. Pursuant to the requirements of this Section of the Medi -
Cal Agreement, the PROVIDER will not unlawfully discriminate, harass, or allow
harassment against any employee or applicant for employment because of race,
color, creed, religion, language, ancestry, marital status, sexual orientation, sexual
preference, national origin, age (over 40), sex, gender, political affiliation, health
status, or physical or mental disability, medical condition (including cancer),
pregnancy, childbirth or related medical conditions, veteran's status, income,
source of payment, status as a Member of PARTNERSHIP, or filing a complaint
as a Member of PARTNERSHIP, and denial of family care leave. PROVIDER
will ensure the evaluation and treatment of PROVIDER's employees and
applicants for employment are free from discrimination and harassment.
PROVIDER will comply with the provisions of the Fair Employment and
Housing Act (Government Code, Section 12900 et.seq.). The applicable
regulations of the Fair Employment and Housing Commission implementing
Government Code, Section 12990 (a -f), set forth in CCR, Title 2, Division 4,
Chapter 5 are incorporated into this Agreement by reference and made a part
hereof as set forth in full. PROVIDER will give notice of his obligations under
this Section to labor organizations with which he has a collective bargaining or
other agreement.
3.4 Oualitv Improvement and Utilization Management Programs — PROVIDER agrees to
cooperate and to participate with PARTNERSHIP in Quality Improvement and
Utilization Management Programs including credentialing and recredentialing, peer
review and any other activities required by PARTNERSHIP, the Government Agencies
and any other regulatory and accrediting agencies, and will comply with the policies and
procedures associated with these Programs. In addition, the PROVIDER will participate
in the development of corrective action plans for any areas that fall below PHC standards
ensuring medical records are readily available to the PHC staff as requested.
PROVIDER agrees to provide performance data for review for purposes as it relates to
quality improvement activities.
Ancillary dfcal Contract (Health Care Socf) 01 01-14 Page 15
a. PROVIDER recognizes the possibility that PARTNERSHIP, through the
utilization management and quality assurance process, may be required to take
action requiring consultation with its Medical Director or with other physicians
prior to authorization of services or supplies or to terminate this agreement.
b. In the interest of program integrity or the welfare of Medi -Cal Members,
PARTNERSHIP may introduce additional utilization controls as may be
necessary.
c. In the event of such change, a thirty (30) day notice will be given to the
PROVIDER. PROVIDER will be entitled to appeal such action to the Provider
Grievance Review Committee, the Physician Advisory Group and then to the
PARTNERSHIP Board of Commissions.
SECTION 4
EXCLUSIONS FROM AND LIMITATIONS OF COVERED SERVICES
4.1 Exclusions. Members in need of services, which are not Covered Services, as described
in Division 3, Subdivision 1, Chapter 3, Article 4, Title 22, California Code of
Regulations, will not be reimbursed by the PARTNERSHIP. The PROVIDER will not
bill and expect reimbursement by the PARTNERSHIP for the following excluded
services provided to Medi -Cal Members:
4.2 Services Neither Covered nor Compensated. Provider understands that Provider will not
be obligated to provide Medi -Cal Members with, and the PARTNERSHIP will not be
obligated to reimburse Specialist for, the following Excluded Services pursuant to this
Agreement (services for which PARTNERSHIP does not receive capitation payment
from the DHCS.)
(a) Dental Services, unless deemed as medical services and are considered Covered
Benefits for Members.
(b) Long term in home waiver services and Multi -Senior Services.
(c) California Children's Services ("CCS") are not covered in Sonoma, Mendocino
Del Norte, Modoc, Lassen, Humboldt, Shasta, Siskiyou, Trinity and Lake
counties as set forth in the State Medi -Cal Contract. Covered services in Napa,
Marin, Solano, and Yolo counties.
(d) Specialty Mental Health and Drug Medi -Cal Substance Use Disorder Services are
excluded in all counties.
(e) Services rendered in a State or Federal governmental hospital;
Ancillary Alta! Contract (Health Care Svcs) 01 01 14 Page 16
(f) Laboratory services provided under the State serum alphafeto protein testing
program administered by the Genetic Disease Branch of the Department of Hcalth
Care Services;
(g) Fabrication of optical lenses;
(h) Targeted Case Management Services as specified in Title 22 CCR Sections 51185
and 51351;
(i) Direct Observed Therapy for tuberculosis;
0) Personal Care Services defined in Title 22 CCR Sections 51183 and 51350;
(k) Childhood lead poising case management services provided by the Local Health
Department;
(1) Certain Human Immunodeficiency Virus (HIV), Acquired linimme Deficiency
(AIDS), and psychotherapeutic drugs as set forth in the State Medi -Cal Contract;
and
(in) Drug benefits for full -benefit dual eligible Medi -Cal Members who are eligible
for drug benefits under Part D of Title XVIII of the Social Security Act (42
United States Code ("USC") Section 1395w-101 et seq.), except as set forth in the
State Medi -Cal Contract.
4.3 Restricted Services/Special Reimbursement..
4.3.1 PROVIDER will ensure that services provided to Medi -Cal members will be in
conformance with the limitations and procedures listed in the PARTNERSHIP Provider
Manual unless PROVIDER is notified of the modification to that policy by DHCS or
PARTNERSHIP.
a. Prior authorization for restricted and/or limited service will be provided
only through the Medical Director of PARTNERSHIP or his/hcr designee.
b. The Medi -Cal Provider Manual specifies certain restrictions and
limitations with respect to abortion and sterilization and is subject to the
limitations specified therein.
4.3.2 Primary Care Physician Referral or prior authorization from PARTNERSHIP is
not required for reimbursement by PARTNERSHIP to providers of the following
services.
a. The provision and reimbursement of Limited Services will be in
conformance with the policies and procedures of the Medi -Cal Fee -For -
Service Program.
b. Family Planning Services are excluded from Primary Care Physician
capitated services and may be obtained by patient self -referral in
AncillatyAlcal Contract (Health CareSii jr, W 01 14 P4gc � 7
accordance with 42 Code of Federal Regulations Section 441.20. Family
Planning services include: birth control supplies, pregnancy testing and
counseling, HIV testing and counseling, STD treatment and counseling,
follow-up care for complications related to contraceptive methods,
sterilization, and termination of pregnancy.
4.3.3 Primary care physician referral is not required for beneficiaries designated as
Special Case Managed Members.
4.3.4 California Children's Services (CCS) must be authorized by the respective County
CCS Program.
4.3.5 Genetically handicapped Persons Program (GHPP) services must be authorized
by the GHPP program.
SECTION 5
PAYMENTS AND CLAIMS PROCESSING
5.1 Pavment — PARTNERSHIP will reimburse PROVIDER for Covered Services provided
which have been authorized by the PARTNERSHIP in accordance with PARTNERSHIP
policies and procedures and upon submission of a complete CMS -1500 or UB -04 claim
form along with evidence of prior authorization, if required, submission of complete data
through electronic transfer, as described in Section 5.3 herein. Reimbursement will be
made within thirty (30) days of receipt by PARTNERSHIP of a "clean claim". The
following conditions must be met in addition to the above requirements for
reimbursement of services:
5.1.1 The Medi -Cal Member is eligible for Program benefits with PARTNERSHIP at
the time the Covered Service is rendered by PROVIDER on the first day of the
month for which PARTNERSHIP receives capitation based on the most current
enrollment information from DHCS, and
5.l .2 The service is a Covered Service under the State Medi -Cal Program according to
DHCS contract with PARTNERSHIP, PARTNERSHIP Operations Manual and
policies and procedures, and State and federal regulations in effect at that time.
5.1.3 All CMS -1500 or UB -04 claim forms and/or encounter data must be submitted to
the PARTNERSHIP within six (6) months of the date the service was provided
5.1.4 A summary report will accompany each check identifying Medi -Cal Members
who are eligible to receive Covered Services from PROVIDER and the
appropriate amount of reimbursement dispersed per Medi -Cal Member.
Andllary.Ncal Contract (Health Care Stns) 01-01-14 Page 18
5.2 Entire Payment — PROVIDER will accept from PARTNERSHIP compensation as
payment in full and discharge of PARTNERSHIP's financial liability. Covered Services
provided to Medi -Cal Members by PROVIDER will be reimbursed as set forth in this
agreement and in accordance with PARTNERSHIP's Operations Manual and policies
and procedures. PROVIDER will look only to PARTNERSHIP for such compensation.
PARTNERSHIP has the sole authority to determine reimbursement policies and
methodology of reimbursement under this Agreement, which includes reduction of
reimbursement rates if rates from the State to PARTNERSHIP are reduced by DHCS.
5.2.1 Fee -For -Service (FFS) — The PARTNERSHIP will reimburse the PROVIDER at
the current State of California Medi -Cal Fee -for Service Rates for all properly
documented Medi -Cal Covered Services provided to:
a. PARTNERSHIP enrolled Medi -Cal Members that present with prior
authorized Covered Services, which have been properly authorized in
accordance with PARTNERSHIP Operations Manual,
5.3 Claim Submission — The PROVIDER will obtain, complete, and submit CMS -1500, UB -
04 or universal claim forms through electronic transfer, or hard copy on as an exception
for all services rendered to Medi -Cal Members including capitated services as described
in the PARTNERSHIP Operations Manual.
5.3.1 All claims for reimbursement and encounter data, if applicable as described in
Section 5.3 of this Agreement, of Covered Services must be submitted to the
PARTNERSHIP within six (6) months from the end of the month that service was
provided as described in the PARTNERSHIP Operations Manual.
5.3.2 Upon submission of a complete and uncontested clean claim, payment will be
reimbursed within thirty (30) days after receipt by PARTNERSHIP. An
uncontested clean claim will include all information needed to process the claim.
5.3.3 CMS -1500 or UB -04 forms or electronic transfer are to be used for the
submission to the PARTNERSHIP of encounter data as documentation of
Capitated Covered Services provided to Medi -Cal Members by the PROVIDER.
The CMS -1500 forms or the submission by electronic transfer will be made by
PROVIDER the 15th day of the month following the month of service during the
term of this Agreement. As an exception PROVIDER can submit encounter data
via hard copy. All forms submitted should contain the data elements as Outlined
in the PARTNERSHIP Operations Manual.
5.4 Medi -Cal Member Billing — PROVIDER will not submit claims to or demand or
otherwise collect reimbursement from a Medi -Cal Member, unless share of cost, or from
other persons on behalf of the Medi -Cal Member, for any service included in the Medi -
Cal program's Covered Services in addition to a claim submitted to the PARTNERSHIP
for that service.
,4ncillary Alcal Contract (Health Cam Sirs) 01-01 14 Page 19
5.5 Third Partv Liabilitv — In the event that PROVIDER renders services to Medi -Cal
Members for injuries or other conditions resulting from the acts of third parties, the State
of California will have the right to recover from any settlement, award or recovery from
any responsible third party the value of all Covered Services which have been rendered
by PROVIDER pursuant to the terms of this Agreement.
5.5.1 PROVIDER will cooperate with the DHCS and PARTNERSHIP in their efforts
to obtain information and collect sums due to the State of California as a result of
third party liability tort, including Workers' Compensation claims for Covered
Services.
5.5.2 PROVIDER will report to PARTNERSHIP the discovery of third party tort
action for a Medi -Cal Member within ten (10) business days of discovery.
5.6 Subcontracts.
5.6.1 All subcontracts between PROVIDER and PROVIDER's Subcontractors will be
in writing, and will be entered into in accordance with the requirements of the
Medi -Cal Agreement, Health and Safety Code Section 1340 et seq.; Title 10,
CCR, Section 1300 et seq.; W & I Code Section 14200 et seq.; Title 22, CCR,
Section 53000 et seq.; and applicable federal and State laws and regulations.
5.6.2 All subcontracts and their amendments will become effective only upon written
approval by PARTNERSHIP and DHCS and will fully disclose the method and
amount of compensation or other consideration to be received by the
Subcontractor from the PROVIDER. PROVIDER will notify DHCS and
PARTNERSHIP when any subcontract is amended or terminates. PROVIDER
will make available to PARTNERSHIP and Governmental Agencies, upon
request, copies of all agreements between PROVIDER and Subcontractor(s) for
the purpose of providing Covered Services.
5.6.3 All agreements between PROVIDER and any Subcontractor will require
Subcontractor to comply with the following:
a. Records and Records Inspection — Make all applicable books and records
available at all reasonable times for inspection, examination or copying by
the Governmental Agencies; and, retain such books and records for a term
of at least seven (7) years from the close of DHCS' fiscal year in which
the Subcontract is in effect and submit to PROVIDER and
PARTNERSHIP all reports required by PROVIDER, PARTNERSHIP or
DHCS, and timely gather, preserve and provide to DHCS any records in
Subcontractor's possession, in accordance with the Provider Manual,
Records Related to Recovery for Litigation.
Ancillary,Meal Contmet (Health Care Svcs) 01 01,14 Page 20
b. Surcharges — Subcontractor will not collect a Surcharge for Covered
Services for a Medi -Cal Member or other person acting on their behalf. If
a Surcharge erroneously occurs, Subcontractor will refund the amount of
such Surcharge to the Medi -Cal Member within fifteen (15) days of the
occurrence and will notify PARTNERSHIP of the action taken. Upon
notice of any Surcharge, PARTNERSHIP will take appropriate action
consistent with the terms of this Agreement to eliminate such Surcharge,
including, without limitation, repaying the Medi -Cal Member and
deducting the amount of the Surcharge and the expense incurred by
PARTNERSHIP in correcting the payment from the next payment due to
PROVIDER.
Notification — Notify DHCS and PARTNERSHIP in the event the
agreement with Subcontractor is amended or terminated. Notice will be
given in the manner specified in Section 9.4 Notices.
d. Assignment - Agree that assignment or delegation of the subcontract will
be void unless prior written approval is obtained from DHCS and
PARTNERSHIP.
e. Additional Requirements .- Be bound by the provisions of Section 8.7,
Survival of Obligations after Termination, and Section 7.4, PROVIDER
Indemnification and Hold Harmless.
f. Domestic Partners Any subcontracting of subcontracting health facility,
licensed in accordance with California Health & Safety Code Section 1250
will ensure that Medi -Cal Member's are pennitted to be visited by the
Medi -Cal Member's domestic partner, the children of the Medi -Cal
Member's domestic partner, and the domestic partner of the Medi -Cal
Member's parent or child.
SECTION 6
RECORDS, ACCOUNTS, REPORTING AND RECOVERIES
6.1 Medical Record — Ensure that a medical record will be established_ and maintained for
each Medi -Cal Member who has received Covered Services. Each Mcdi-Cal Member's
medical record will be established upon the first visit to PROVIDER. The record will
contain infonnation normally included in accordance with generally accepted practices
and standards prevailing in the professional community.
6.1.1 PROVIDER will facilitate the sharing of medical information with other
providers in cases of referrals, subject to all applicable laws and professional
standards regarding the confidentiality of medical records.
Ancillary Alcal Contract (health Care Suer) 01 01 14 Pop 21
6.1.2 PROVIDER will ensure records are available to authorized PARTNERSHIP
personnel in order for PARTNERSHIP to conduct its Quality Improvement and
Utilization Management Programs
6.1.3 PROVIDER will ensure that medical records are legible.
6.1.4 PROVIDER will maintain such records for at least seven years from the close of
the State's fiscal year in which this Agreement was in effect.
6.2 Records and Records Inspection Riehts.
6.2.1 Access to Records PROVIDER will permit PARTNERSHIP's Medical
Director, or officers or their designees, any agency having jurisdiction over
PARTNERSHIP, including and without limitation the Governmental Agencies, to
inspect the premises, records and equipment of Health Care Services Provider and
review all operational phases of the medical services provided to Medi -Cal
Members.
a. PROVIDER or PARTNERSHIP will make all of PROVIDER's books and
records, and papers ("Records") relating to the provision of, pertaining to
the goods and services to Medi -Cal Members, to the cost of such goods
and services, and to payments received by PROVIDER from Medi -Cal
Members or from others on their behalf available for inspection,
examination and copying by PARTNERSHIP and all other state and
federal agencies with jurisdiction over PARTNERSHIP or this
Agreement, including without limitation, Governmental Agencies, at all
reasonable times at PROVIDER's place of business or at such other
mutually agreeable location in California.
b. PARTNERSHIP will pay for the cost of copying Records, not to exceed
$0.10 per page. The ownership of Records will be controlled by
applicable law and this Agreement furnished under the terms of this
Agreement, available for inspection, examination or copying.
C. PROVIDER shall permit PARTNERSHIP, Government Agencies and any
other regulatory and accrediting agencies, with or without notice, during
normal business hours, to interview employees, to inspect, audit, monitor,
evaluate and review PROVIDER's work performed or being performed
hereunder, PROVIDER's locations(s) (including security areas),
information systems, software and documentation and to inspect, evaluate,
audit and copy Records and any other books, accounts and materials
relevant to the provisions of services under this Agreement. PROVIDER
will provide all reasonable facilities, cooperation and assistance during
such inspection and reviews, including for the safety and convenience of
the authorized representatives in the performance of their duties.
4ncillay Slcal Con"er (Heahh Care Srrs) 01-01-14 Page 22
PROVIDER shall allow such inspections and reviews for the Records
retention time of seven years. The State reserves the right to conduct
unannounced validation reviews to verify compliance with State and
federal regulations and contract requirements.
6.2.2 Maintenance of Records - PROVIDER will maintain records in accordance with
the general standards applicable to such book and record keeping and in
accordance with applicable law, and the PARTNERSHIP.
a. Records will include all encounter data, working papers, reports submitted
to PARTNERSHIP, financial records, all medical records, medical charts
and prescription files, and other documentation pertaining to medical and
non-medical services rendered to Medi -Cal Members for a ten -n period of
at least seven (7) years.
b. PROVIDER will retain all Records for a period of at least seven (7) years
from the close of the State Department of Health Care Services' fiscal year
in which this Agreement was in effect.
C. PROVIDER's obligations set forth in this Section will survive the
termination of this Agreement, whether by rescission or otherwise.
d. The PROVIDER will not charge the Medi -Cal Member for the copying
and forwarding of their medical records to another provider.
6.3 Disclosure to Government Officials. PROVIDER shall comply with all provisions of
law regarding access to books, documents and records. Without limiting the foregoing,
PROVIDER shall maintain, provide access to, and provide copies of Records, this
Agreement and other information to the Director of DMHC, DHCS, External Quality
Review Organizations, the State Bureau of Medi -Cal Fraud, the State Managed Risk
Medical Insurance Board, the Bureau of State Audits, the State Auditor, the Joint
Legislative Audit Committee, the California Department of General Services, the
California Department of Industrial Relations, certified Health Plan Employer Data
Information Set ("HEDIS") auditors from the National Committee on Quality Assurance,
the California Cooperative Healthcare Reporting Initiative, the U.S. Department of
Justice, the Secretary of the U.S. Department of Health and Human Services, the U.S.
Comptroller General, the Centers for Medicare and Medicaid Services, Peer Review
Organizations, their designees, representatives, auditors, vendors, consultants and
specialists and such other officials entitled by law or under Membership Contracts
(collectively, "Government Officials") as may be necessary for compliance by
PARTNERSHIP with the provisions of all state and federal laws and contractual
requirements governing PARTNERSHIP, including, but not limited to, the Act and the
regulations promulgated thereunder and the requirements of Medicare and Medi -Cal
programs. Such information shall be available for inspection, examination and copying
at all reasonable times at PROVIDER's place of business or at some other mutually
Ancillary Alcal Contract {health Care SM) 01-01-14 Page 23
agreeable location in California. Copies of such information shall be provided to
Government Officials promptly upon request. The disclosure requirement includes, but
is not limited to, the provision of information upon request by DHCS, subject to any
lawful privileges, relating to threatened or pending litigation by or against DHCS.
PROVIDER shall use all reasonable efforts to immediately notify DHCS of
anysubpoenas, document production requests, or requests for records received by
PROVIDER related to this Agreement.
6.4 Patient Confidentialitv.
a. Notwithstanding any other provision of the Agreement, names of persons
receiving public social services are confidential information and are to be
protected from unauthorized disclosure in accordance with Title 42 CFR, Section
431.300 et. seq. and Section 14100.2, Welfare and Institutions Code and
regulations adopted thereunder.
b. For the purpose of this Agreement, all information, records, data and data
elements collected and maintained for the operation of the Agreement and
pertaining to Beneficiaries will be protected by the PROVIDER and his/her staff
from unauthorized disclosure.
C. PROVIDER may release Medical Records in accordance with applicable law
pertaining to the release of this type of infonnation.
d. With respect to any identifiable infonnation concerning a Medi -Cal Member
under this Agreement that is obtained by the PROVIDER, the PROVIDER (1)
will not use any such information for any purpose other than carrying out the
express terms of the Agreement, (2) will promptly transmit to the
PARTNERSHIP all requests for disclosure of such infonnation, (3) will not
disclose except as otherwise specifically permitted by the Agreement, any such
information to any party other than PARTNERSHIP, the federal government
including the Department of Health and Human Services and Comptroller General
of the United States, the Department of Justice Bureau of Medi -Cal Fraud, the
Department of Health Care Services or any other government entity which is
statutorily authorized to have oversight responsibilities of the COHS program and
contracts, without prior written authorization specifying that the information is
releasable under Title 42, CFR, Section 431.300 et. seq., Section 14100.2,
Welfare and Institutions Code, and regulations adopted thereunder, (4) will, at the
expiration or termination of the Agreement, return all such information to the
PARTNERSHIP or maintain such information according to written procedures
sent to the PARTNERSHIP by the Department of Health Care Services for this
purpose.
6.5 Other Insurance Coverage. Medi -Cal is the payor of last resort recognizing Other
Health coverage as primary. PROVIDER must bill Other Health Coverage (primary)
carrier before billing PARTNERSHIP for reimbursement of covered services and, with
Ancillary Mcal Contract (Health Care Sties) 01-01-14 Page 24
the exception of authorized Medi -Cal share of cost payments, will at no time seek
compensation from Medi -Cal Members or the DHCS. The Specialist may look to the
Member for non -covered services.
6.5.1 Coordination of Benefits. PROVIDER has the right to collect all sums as a result
of Coordination of Benefits efforts for Covered Services provided to Medi -Cal
Member with Other Health Coverage.
The determination of liability will be in accordance with the usual
procedures employed by the appropriate Governmental Agencies and
applicable law, the Medi -Cal Provider Manual, and the PARTNERSHIP
Operations Manual.
b. The authority and responsibility for Coordination of Benefits will be
carried out in accordance with Title 22, CCR, Section 51005, and the
DHCS Agreement with PARTNERSHIP.
c. PROVIDER shall report to PARTNERSHIP the discovery of third party
insurance coverage for a Medi -Cal Member within 10 days of discovery.
d. Specialist will recover directly from Medicare for reimbursement of
medical services rendered. Medicare recoveries are retained by the
PROVIDER, but will be reported to the PARTNERSHIP on the encounter
form or encounter tape.
6.6 Third Partv Liabilitv Tort. In the event that PROVIDER provides services to Medi -Cal
Members for injuries or other conditions resulting from the acts of third parties, the State
of California will have the right to recover from any settlement, award or recovery from
any responsible third party the value of all Covered Services which have been rendered
by PROVIDER pursuant to the terns of this Agreement.
a. Primary Care Physician will cooperate with the DHCS and
PARTNERSHIP in their efforts to obtain information and collect sums
due to the State of California as result of third party liability tort, including
Workers' Compensation claims for Covered Services.
b. PROVIDER shall report to PARTNERSHIP the discovery of third party
insurance coverage for a Medi -Cal Member within 10 days of discovery.
SECTION 7
INSURANCE AND INDEMNIFICATION
7.1 Insurance — Throughout the term of this Agreement and any extension thereto,
PROVIDER will maintain appropriate insurance programs or policies as follows:
Ancillary Mcal Contract (Heatrh Care Sms) 01 01 14 Page 25
7.1.1 PROVIDER will carry, at its sole expense, liability insurance or other risk
protection programs, in the amounts of at least Five Hundred Thousand Dollars
($500,000) per person per occurrence in aggregate, including "tail coverage" in
the same amounts whenever claims made malpractice is involved. Notification of
PARTNERSHIP by PROVIDER of cancellation or material modification of the
insurance coverage or the risk protection program will be made to
PARTNERSHIP at least thirty (30) days prior to any cancellation. Documents
evidencing professional liability insurance or other risk protection required under
this Subsection will be provided to PARTNERSHIP upon execution of this
Agreement.
7.2 Othcr Insurance Coverase. In addition to Section 7. 1.1 above, PROVIDER will also
maintain, at its sole expense, a policy or program of general liability insurance (or other
risk protection) with minimum coverage including and no less than One Hundred
Thousand Dollars ($100,000) per person for the protection of the interest and property of
PROVIDER's property together with a Combined Singlc Limit Body Injury Liability and
Property Damage Insurance of not less than One Hundred Thousand Dollars ($100,000)
for its members and employees, PARTNERSHIP Members, PARTNERSHIP and third
parties, namely, personal injury on or about the premises of the PROVIDER, and general
liability.
73 Workers' Compensation. PROVIDER's employees will be covered by Workers'
Compensation Insurance in an amount and form meeting all requirements of applicable
provisions of the California Labor Code. Documents evidencing such coverage will be
provided to PARTNERSHIP upon request.
7.3 PARTNERSHIP Insurancc PARTNERSHIP, at its sole cost and expense, will procure
and maintain a professional liability policy to insure PARTNERSHIP and its agents and
employees, acting within the scope of their duties, in connection with the performance of
PARTNERSHIP`s responsibilities under this Agreement.
7.4 PROVIDER Indemnification The PROVIDER will indemnify, defend, and hold hannless
Medi -Cal Members. the State of California, the PARTNERSHIP and their respective
officers, agents, and employees from the following:
a. PROVIDER claims. Any and all claims and losses accruing or resulting to
PROVIDER or any of its Subcontractors or any person, firm, corporation or other
entity furnishing or supplying work, services, materials or supplies in connection
with the performance of this Agreement.
b. Third Party claims. Any and all claims and losses accruing or resulting to any
person, firm, corporation, or other entity injured or damaged by PROVIDER, its
agents, employees and Subcontractors, in the performance of this Agreement.
7.5 PARTNERSHIP Indemnification, — PARTNERSHIP will indemnify, defend, and hold
harmless PROVIDER, and its agents, and employees from any and all claims and losses
AncilIM Hcal Cantrurt (Health Care Nca) 01-01-14 Page 26
accruing or resulting to any person, firm, corporation, or other entity injured or damaged
by PARTNERSHIP, its officers, agents or employees, in the performance of this
Agreement.
SECTION 8
TERM, TERMINATION,
AND AMENDMENT
8.1 Initial Term and Renewal — This Agreement will be effective on the date indicated and
will automatically renew at the end of one year and annually thereafter unless terminated
sooner as set forth below.
8.2 Termination Without Cause Either party upon sixty (60) days prior written notice to the
other party may terminate this Agreement without cause.
8.3 hnmediate Tennination for Cause by PARTNERSHIP — The PARTNERSHIP may
terminate this Agreement immediately by written notice to PROVIDER upon the
occurrence of any of the following events:
8.3.1 The suspension or revocation of PROVIDER's license to practice medicine in the
State of California; the suspension or termination of PROVIDER's membership
on the active medical staff of any hospital; or the suspension, revocation or
reduction in PROVIDER's clinical privileges at any hospital; or suspension from
the State Medi -Cal Program; or loss of malpractice insurance; or failure to meet
PARTNERSHIP's recredentialing criteria.
8.3.2 PROVIDER's death or disability. As used in this Subsection, the term
"disability" means any condition which renders PROVIDER unable to carry out
his/her responsibilities under this Agreement for more than forty-five (45)
working days (whether or not consecutive) within any 12 -month period.
8.3.3 If PARTNERSHIP detennines, pursuant to procedures and standards adopted in
its Utilization Management or Quality Improvement Programs, that PROVIDER
has provided or arranged for the provision of services to Medi -Cal Members
which are not Medically Necessary or provided or failed to provide Covered
Services in a manner which violates the provisions of this Agreement or the
requirements of the PARTNERSHIP Operations Manual.
8.3.4 If PARTNERSHIP determines that the continuation hereof constitutes a threat to
the health, safety or welfare of any Medi -Cal Member.
8.3.5 If PARTNERSHIP determines that PROVIDER has filed a petition for
bankruptcy or reorganization, insolvency, as defined by law or PARTNERSHIP
determines that PROVIDER is unable to meet financial obligations as described
in this Agreement.
AncillaryMeal Conlract (Health Care Svcs) 01-01 14 Page 27
8.3.6 If PROVIDER breaches Article 9.10, Marketing Activity and Patient Solicitation.
An immediate termination for cause made by PARTNERSHIP pursuant to this
will not be subject to the cure provisions specified in Section 8.4 Termination for
Cause with Cure Period.
8.4 Termination for Cause With Cure Period In the event of a material breach by either
party other than those material breaches set forth in Section 8.3, Immediate Termination
for Cause by PARTNERSHIP above of this Agreement, the non -breaching party may
terminate this Agreement upon twenty (20) days written notice to the breaching party
setting forth the reasons for such termination; provided, however, that if the breaching
party cures such breach during the twenty (20) day period, then this Agreement will not
be terminated because of such breach unless the breach is not subject to cure.
8.5 Continuation of Services Following Termination — Should this Agreement be terminated,
PROVIDER will, at PARTNERSHIP's option, continue to provide Covered Services to
Medi -Cal Members who are under the care of PROVIDER at the time of termination
until the services being rendered to the Medi -Cal Members by PROVIDER are
completed, unless PARTNERSHIP has made appropriate provision for the assumption of
such services by another physician and/or provider. PROVIDER will ensure an orderly
transition of care for Medi -Cal Members, including but not limited to the transfer of
Medi -Cal Member medical records. Payment by PARTNERSHIP for the continuation of
services by PROVIDER after the effective date of tennination will be subject to the terms
and conditions set forth in this Agreement including, without limitation, the
compensation provisions herein. The costs to the physician of photocopying such records
will be reimbursed by the PARTNERSHIP at a cost not to exceed $.10 per page.
8.6 Medi -Cal Member Notification Upon Termination — Notwithstanding Section 8.3,
hnmediate Termination for Cause by PARTNERSHIP, upon the receipt of notice of
termination by either PARTNERSHIP or PROVIDER, and in order to ensure the
continuity and appropriateness of medical care to Medi -Cal Members, PARTNERSHIP
at its option, may immediately inform Medi -Cal Members of such termination notice.
Such Medi -Cal Members will be required to select another PROVIDER prior to the
effective date of termination of this Agreement.
8.7 Survival of Obligations After Termination Termination of this Agreement will not
affect any right or obligations hereunder which will have been previously accrued, or will
thereafter arise with respect to any occurrence prior to termination. Such rights and
obligations will continue to be governed by the terms of this Agreement. The following
obligations of PROVIDER will survive the termination of this Agreement regardless of
the cause giving rise to termination and will be construed for the benefit of the Medi -Cal
Member: 1) Section 8.5, Continuation of Services Following Termination; 2) Section
6.2, Records and Records Inspection; and, 3) Section 7.3, Hold Harmless. Such
obligations and the provisions of this Section will supersede any oral or written
agreement to the contrary now existing or hereafter entered into between PROVIDER
Ancillary Mcal Comma (fleahh Care Sirs) 01-01-14 Page 28
and any Medi -Cal Member or any persons acting on their behalf. Any modification,
addition, or deletion to the provisions referenced above or to this Section will become
effective on a date no earlier than thirty (30) days after the DHCS has received written
notice of such proposed changes. PROVIDER will assist PARTNERSHIP in the orderly
transfer of Medi -Cal Members to the provider they choose or to whom they are referred.
Furthermore, PROVIDER shall assist PARTNERSHIP in the transfer of care as set forth
in the Provider Manual, in accordance with the Phaseout Requirements set forth in the
Medi -Cal Contract.
8.8 Access to Medical Records Uuon Termination, — Upon termination of this Agreement and
request by PARTNERSHIP, PROVIDER will allow the copying and transfer of medical
records of each Medi -Cal Member to the physician and/or provider assuming the Medi-
cal Member's care at termination. Such copying of records will be at PARTNERSHIP's
expense if termination was not for cause. PARTNERSHIP will continue to have access
to records in accordance with the terms hereof.
8.9 Termination or Expiration of PARTNERSHIP's Medi -Cal Agreement — In the event the
Medi -Cal Agreement terminates or expires, prior to such termination or expiration,
PROVIDER will allow DHCS and PARTNERSHIP to copy medical records of all Medi -
Cal Members, at DHCS' expense, in order to facilitate the transition of such Medi -Cal
Members to another health care system. Prior to the termination or expiration of the
Medi -Cal Agreement, upon request by DHCS, PROVIDER will assist DHCS in the
orderly transfer of Medi -Cal Member's medical care by making available to DHCS
copies of medical records, patient files, and any other pertinent information, including
information maintained by any of the PROVIDER's Subcontractors, necessary for
efficient case management of Medi -Cal Members, as determined by DHCS. Costs of
reproduction of all such medical records will be borne by DHCS. Under no
circumstances will a Medi -Cal Member be billed for this service. Termination will
require sixty (60) days advance written notice of intent to terminate, transmitted by
PARTNERSHIP to PROVIDER by Certified U S Mail, Return Receipt Requested,
addressed to the office of PROVIDER, as provided in Section 9.4.of this Agreement.
SECTION 9
GENERAL PROVISIONS
9.1 Assismment This Agreement and the rights, interests and benefits hereunder will not be
assigned, transferred, pledged, or hypothecated in any way by PROVIDER and will not
be subject to execution, attachment or similar process, nor will the duties imposed on
PROVIDER be set, contracted or delegated without the prior written approval of
PARTNERSHIP and DHCS. Subcontractor's agreements must state that assignment or
delegation of the Subcontract will be void unless prior written approval is obtained from
DHCS. PARTNERSHIP will not assign this Agreement without the approval of
PROVIDER.
9.2 Amendment — This Agreement may be amended at any time upon written agreement of
both parties subject to review and approval by the DHCS and shall become effective only
Ancillary Meal Contract (Health Care Svcs) 01 01 14 page 29
as set forth in subparagraph C Department Approval — Non Federally Qualified HMOS of
the Medi -Cal Agreement. This Agreement may be amended by the PARTNERSHIP
upon thirty (30) days written notice to the PROVIDER.
9.2.1 If PROVIDER does not give written notice of termination within sixty (60) days,
as authorized by Section 8, PROVIDER agrees that any such amendment by
PARTNERSHIP will be a part of the Agreement.
9.2.2 Unless PROVIDER or DHCS notifies PARTNERSHIP that it does not accept
such amendment, the amendment will become effective sixty (60) days after the
date of PARTNERSHIP's notice of proposed amendment.
9.2.3 Proposed amendments to the compensation, services or term provisions of this
Agreement, will become effective sixty (60) days after the date DHCS has
acknowledged receipt of the notice.
9.2.4 In the event a change in law, regulation or the Medi -Cal Agreement requires an
amendment to this Agreement, PROVIDER's refusal to accept such amendment
will constitute reasonable cause for PARTNERSHIP to tenninate this Agreement
pursuant to the termination provisions hereof.
9.3 Severabilitv — If any term, provision, covenant, or condition of this Agreement is held by
a court of competent jurisdiction to be invalid, void, or unenforceable, the remainder of
the provisions hereof will remain in full force and effect and will in no way be affected,
impaired, or invalidated as a result of such decision.
9.4 Notices Any notice required or permitted to be given pursuant to this Agreement will
be in writing addressed to each party at its respective last known address. Either party
will have the right to change the place to which notice is to be sent by giving forty eight
(48) hours written notice to the other of any change of address.
9.4.1 PARTNERSHIP will notify DHCS in the event this Agreement is amended or
terminated. Notice is considered given when properly addressed and deposited in
the United States Postal Service as first class registered mail, postage attached. A
copy of the written notice will also be mailed as first-class registered snail to:
California State Department of Health Care Services,
Medi -Cal Managed Care Division
1501 Capitol Avenue, Suite 71.4001
MS 4407, P.O. Box 997413
Sacramento, CA 95899-7413
9.4.2 PROVIDER will notify PARTNERSHIP in the event this Agreement is amended
or terminated. Notice is considered given when properly addressed and deposited
AnallaryMcal Contract (Health Care Sirs) 01-01-14 Page 30
in the United States Postal Service as first class registered mail, postage attached.
A copy of the written notice will also be mailed as first-class registered mail to:
Partnership HealthPlan of California
4665 Business Center Drive
Fairfield, CA 94534
9.4.3 PARTNERSHIP will notify PROVIDER in the event this Agreement is amended
or terminated. Notice is considered given when properly addressed and deposited
in the United States Postal Service as first class registered mail, postage attached.
A copy of the written notice will also be mailed as first-class registered mail to
the address indicated on the signature page of this Agreement.
9.5 Entire Aereement — This Agreement, together with the Exhibits and the PARTNERSHIP
Operations Manual and policies and procedures, contains the entire agreement between
PARTNERSHIP and PROVIDER relating to the rights granted and the obligations
assumed by this Agreement. Any prior agreement, promises, negotiations or
representations, either oral or written, relating to the subject matter of this Agreement not
expressly set forth in this Agreement are of no force or effect.
9.6 Headings — The headings of articles and paragraphs contained in this Agreement are for
reference purposes only and will not affect in any way the meaning or interpretation of
this Agreement.
9.7 Governing Law — The validity, construction, interpretation and enforcement of this
Agreement will be governed by the laws of the State of California, the United States of
America, and the contractual obligations of PARTNERSHIP. Further, this Agreement is
subject to the requirements of the Act and the regulations promulgated thereunder. Any
provision required in this Agreement by law, regulation, or the Medi -Cal Agreement will
bind PARTNERSHIP and PROVIDER whether or not provided in this Agreement.
9.8 Affirmative Statement. Treatment Alternatives,. Practitioners may freely communicate
with patients regarding appropriate treatment options available to them, including
medication treatment options, regardless of benefit coverage limitations.
9.9 Reporting Fraud and Abuse — PROVIDER is responsible for reporting all cases of
suspected fraud and abuse, as defined in 42 CFR Section 455.2 where there is reason to
believe that an incident of fraud and/or abuse has occurred by Medi -Cal Members or by
PARTNERSHIP contracted physicians or providers, within 10 days to PARTNERSHIP
for investigation.
9.10 Marketine Activitv and Patient Solicitation -- PROVIDER will not engage in any
activities involving the direct marketing of Eligible Beneficiaries without the prior
approval of PARTNERSHIP and DHCS.
Ancillary Mcal Cantraet (Health Care Swi) 01-01-14 Page 31
9.10.1 PROVIDER will not engage in direct solicitation of Eligible Beneficiaries for
enrollment, including but not limited to door-to-door marketing activities, mailers
and telephone contacts.
9.10.2 During the period of this Agreement and for a one year period after termination of
this Agreement, PROVIDER and PROVIDER's employees, agents or
Subcontractors will not solicit or attempt to persuade any Medi -Cal Member not
to participate in the Medi -Cal Managed Care Program or any other benefit
program for which PROVIDERS render contracted services to PARTNERSHIP
Members.
9.10.3 In the event of breach of this Section 9. 10, in addition to any other legal rights to
which it may be entitled, PARTNERSHIP may at its sole discretion, immediately
terminate this Agreement. This tennination will not be subject to Section 8.4,
Termination for Cause with Cure Period.
9.11 Nondisclosure and Confidentialitv PROVIDER will not disclose the payment
provisions of this Agreement except as may be required by law.
9.12 Proprietary Information With respect to any identifiable information concerning a
Medi -Cal Member that is obtained, PROVIDER and its Subcontractors will not use any
such information for any purpose other than carrying out the express terms of this
Agreement; will promptly transmit to PARTNERSHIP all requests for disclosure of such
information, except requests for medical records in accordance with applicable law; will
not disclose any such information to any party other than DHCS without
PARTNERSHIP's prior written authorization, except as specifically permitted by this
Agreement or the PARTNERSHIP Medi -Cal Agreement with DHCS, specifying that the
information is releasable by law as set forth in the Medi -Cal Agreement; and, will, at
expiration or termination of this Agreement, return all such information to
PARTNERSHIP or maintain such information according to written procedures provided
by PARTNERSHIP for this purpose.
9.13 Non -Exclusive Aereement — To the extent compatible with the provision of Covered
Services to Medi -Cal Members for which PROVIDER accepts responsibility hereunder,
PROVIDER reserves the right to provide professional services to persons who are not
Medi -Cal Members including Eligible Beneficiaries. Nothing contained herein will
prevent PROVIDER from participating in any other prepaid health care program.
9.14 Counterparts — This Agreement may be executed in two (2) or more counterparts, each
one (1) of, which will be deemed an original, but all of which will constitute one (1) and
the same instrument.
9.15 HIPAA. Health Insurance Portability and Accountability Act. Section 1171 (5)(e). The
PARTNERSHIP is required to comply with HIPAA standards. PROVIDER is required
to be in compliance with HIPAA standards.
Ancillary Mcal Cantmet (Health Care Sirs) 01-01-14 Page 32
9.16 Provisions for Protected Health Information - The agreement between the PROVIDER
and PHC includes the use of protected health information (PHI). PHI may be used for
purposes of payment, treatment, and operations. The PROVIDER must protect PHI
internally and within any organization with which the PROVIDER contracts for clinical
or administrative services. Upon request, the PROVIDER must provide individuals with
access to their PHI. If the PROVIDER identifies any inappropriate uses of or breach of
PHI, the PROVIDER must notify PHC's Privacy Officer immediately. If the
PROVIDER agreement ends or is terminated, the PROVIDER agrees to continue to
protect PHI.
9.17 Compliance with Laws. PROVIDER shall comply with all laws and regulations
applicable to its operations and to the provision of services hereunder.
SECTION 10
GRIEVANCES AND APPEALS
10.1 Appeals and Grievances.
10.1.1 PROVIDER complaints, concerns, or differences, which may arise as a health
care provider under contract with PARTNERSHIP will be resolved as outlined in
the following paragraphs and as set forth in the PARTNERSHIP Operations
Manual. PROVIDER and PARTNERSHIP agree to and will be bound by the
decisions of PARTNERSHIP's grievance and appeal mechanisms.
10.1.2 PROVIDER will cooperate with PARTNERSHIP in identifying, processing and
resolving all Medi -Cal Member complaints and grievances in accordance with the
Medi -Cal Member grievance procedure set forth in the PARTNERSHIP
Operations Manual.
10.2 Responsibility It is the responsibility of the PARTNERSHIP's Executive Director for
maintenance, review, formulation of policy changes, and procedural improvements of the
grievance systern. The Executive Director will be assisted in this process by the Directors
of Provider Relations and Health Services.
10.3 Arbitration — If the parties cannot settle grievances or disputes between them in an
informal and expeditious fashion, the dispute will be submitted, upon the motion of either
party, to arbitration under the appropriate rules of the American Arbitration Association
(AAA). All such arbitration proceedings will be administered by the AAA; however, the
arbitrator will be bound by applicable state and federal law, and will issue a written
opinion setting forth findings of fact and conclusions of law. The parties agree that all
arbitration proceeding will take place in Fairfield, California, that the appointed arbitrator
will be encouraged to initiate hearing proceedings within thirty (30) days of the date of
his/her appointment, and that the decision of the arbitrator will be final and binding as to
each of them. The party against whom the award is rendered will pay any monetary
Ancillary Mcal Contract (Health Care Sms) 01-0114 Page 33
award and/or comply with any other order of the arbitrator within sixty (60) days of the
entry of judgment on the award, or take an appeal pursuant to the provisions of the
California Civil Code.
10.3.1 Administration and Arbitration Fees. In all cases submitted to AAA, the parties
agree to share equally the AAA administrative fee as well as the arbitrator's fee, if
any, unless otherwise assessed by the arbitrator. The administrative fees will be
advanced by the initiating party subject to final apportionment by the arbitrator in
the award.
10.3.2 Enforcement of Award. The parties agree that the arbitrator's award may be
enforced in any court having jurisdiction thereof by the filing of a petition to
enforce said award. Costs of filing may be recovered by the party, which initiates
such action to have an award enforced.
10.3.3 Impartial Dispute Settlement. Should the parties, prior to submitting a dispute to
arbitration, desire to utilize other impartial dispute settlement techniques such as
mediation or fact-finding, joint request for such services may be made to the
AAA, or the parties may initiate such other procedures as they may mutually
agree upon at such time.
10.3.4 Initiation of Procedure. Nothing contained herein is intended to create, nor will it
be construed to create, any right of any Medi -Cal Member to independently
initiate the arbitration procedure established in this Article. Further, nothing
contained herein is intended to require arbitration of disputes regarding
professional negligence between the Case Managed Member and the PROVIDER.
10.3.5 Administrative Disputes. Notwithstanding anything to the contrary in this
Agreement, any and all administrative disputes which are directly or indirectly
related to an allegation of Primary Care Physician malpractice may be excluded
from the requirements of this Article.
10.4 Peer Review and Fair Hearine Process — Providers determined hereto to constitute a
threat to the health, safety or welfare of Medi -Cal Members will be referred to the
PARTNERSHIP Peer Review Committee. The Provider will be afforded an opportunity
to address the Committee. The Provider will be notified in writing of the Peer Review
Committee's recommendation and of their rights to the Fair Hearing process. The Peer
Review Committee can reconunend to suspend, restrict, or terminate the provider
affiliation, to institute a monitoring procedure, or to implement continuing educational
requirements.
10.5 Credentialiniz The PHC Credentialing Committee will review all provider files to
determine whether a provider meets the PARTNERSHIP credentialing or recredentialing
requirements or, as applicable, provider licensure and compliance with the State Medi -
Cal Program Standards of Participation. If the committee deems otherwise, the Provider
Ancillary Afcal Contract (Health Care Svcs) 01-01-14 Page 34
will be afforded an opportunity to address this committee. The Provider will be advised
in writing of the Credentialing Committee's recommendation and notified of their rights
to the Fair Hearing process. The Credentialing Committee can recommend denial of a
provider's initial application or can deny the recredentialing of a current provider.
SECTION 11
RELATIONSHIP OF PARTIES
11.1 Overview — None of the provisions of this Agreement are intended, nor will they be
construed to create, any relationship between the parties other than that of independent
entities contracting with each other solely for the purpose of effecting the provisions of
this Agreement; neither is this Agreement intended, except as may otherwise be
specifically set forth herein, to create a relationship of agency, representation, joint
venture or employment between the parties. Unless mutually agreed, nothing contained
herein will prevent PROVIDED from independently participating as a provider of
services in any other health maintenance organization or system of prepaid health care
delivery. In such event, PROVIDER will provide written assurance to PARTNERSHIP
that any contract providing commitments to any other prepaid program will not prevent
PROVIDER from fulfilling its obligations to Medi -Cal Members under this Agreement,
including the timely provision of services required hereunder and the maximum capacity
allowed under the Medi -Cal Agreement.
11.2 Oversight Functions — Nothing contained in this Agreement will limit the right of
PARTNERSHIP to perform its oversight and monitoring responsibilities as required by
applicable state and federal law, as amended.
11.3 PROVIDER -Patient Relationship — This Agreement is not intended to interfere with the
professional relationship between any Medi -Cal Member and his or her PROVIDER.
PROVIDERS will be responsible for maintaining the professional relationship with
Medi -Cal Members and are solely responsible to such Medi -Cal Members for all medical
services provided. PARTNERSHIP will not be liable for any claim or demand on account
of damages arising out of, or in any manner connected with, any injuries suffered by the
Medi -Cal Member resulting from the acts or omissions of PROVIDER. PROVIDERS
are allowed to freely communicate with patients regarding their health status, medical
care and treatment options, alternative treatment, and medication treatment regardless of
benefit coverage limitations. Patients must be informed of risks, benefits and
consequences of the treatment options, including the option of no treatment and make
decisions about ongoing and future medical treatments. PROVIDERS must provide
information regarding treatment options, including the option of no treatment in a
culturally competent manner. Health care professionals must ensure that patients with
disabilities have effective communication throughout the health system in making
decisions regarding treatment options.
ancillary .tfral Contract (Health Care Sirs) 01 01 14 Page 35
ATTACHMENT A
NONDISCRIMINATION CLAUSE
(OPC -- 1)
During the performance of this Agreement, PROVIDER and its subcontractors shall not
unlawfully discriminate against any employee or applicant for employment because of
race, religion, color, national origin, ancestry, physical disability, mental disability,
medical condition, marital status, age (over 40), or sex. PROVIDERS and
Subcontractors shall comply with the provisions of the Fair Employment and Housing
Act (Government Code, Section 12900, et seq.) and the applicable regulations
promulgated thereunder (California Code of Regulations, Title 2, Section 7285.0, et seq.).
The Applicable regulations of the Fair Employment and Housing Commission
implementing Government Code, Section 12990, set forth in Chapter 5 of Division 4 of
Title 2 of the California Code of Regulations and incorporated into this Agreement by
reference and made part hereof as set fourth in full. PROVIDER and its Subcontractors
shall give written notice of their obligations under this clause to labor organizations with
which they have collective bargaining or other agreement.
2. This PROVIDER shall include the nondiscrimination and compliance provisions of this
clause in all Subcontractors to perform work under this Agreement.
AncillaryMcal Contract (Health Care Svcs) 01-01-14 Page 36
ATTACHMENT B
INFORMATION REGARDING OFFICERS,
OWNERS, AND STOCKHOLDERS
List the names of the officers, owners, stockholders owning more than 5% of the stock issued by
the physician, and major creditors holding more than 5% of the debt of the organization
identified on the execution page of this Agreement. (This is a requirement of Title 22, CCR,
Section 53250).
AncillaryUcal Contract (Health Cam Svcs) 01 01 14 page 37
ATTACHMENT C
FACILITY LOCATIONS
List under each applicable county name, the physician name, location(s) and hours of operation,
mid-level practitioners supervised and languages spoken that shall apply to this Agreement.
Ancillary• Alcal Contract (Health Care Svcs) 0101 14 Page 39
DHCS State of California—Health and Human Services Agency
4kol Department of Health Care Services
JENNIFER KENT
DIRECTOR
SEP 0 3 2015
Nancy Mackie
City Manager
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
Dear Ms. Mackie:
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 #13-90521, 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 City of San Rafael transfer the fee in the amount of $52,202 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
#13-90546. 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 #13-90546
Once the governmental funding entity has transferred the fee to the specified account,
please email Sandra Dixon at Sandra. Dixon(cDdhcs.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) 322-5831 Fax (916) 650-6860
www.dhcs.ca aov
Nancy Mackie
Page 2
If you have any questions regarding this request, please contact Sandra Dixon at
(916) 552-9460.
Sincerely,
IY&
WWUIL--
Meredith
Wurden
Assistant Deputy Director
Health Care Financing
Enclosure
cc: Chris Gray, Fire Chief
San Rafael Fire Department
1039 C Street
San Rafael, CA 94901
Sandra Dixon
Capitated Rates Development Division
Department of Health Care Services
P.O. Box 997413, MS 4413
Sacramento, CA 95899-7413
CONTRACT #13-90546
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 DH CS 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 13-90521, 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, 2013 through June 30, 2014.
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. Intergovernmental Transfer Assessment Fee
1
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CONTRACT #13-90546
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, 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 1 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 DIICS 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.
2
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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 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.
3
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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:
Nancy Mackle, City Manager, City of San Rafael p Approved as to form
TI IE STATE OF CALIFORNIA, DEPARTMENT OF HEALTH CARE SERVICES:
-7
By: -Date:
Meredith Wurden, Assistant Deputy Director, Health Care Financing
4
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OHS State of California—Health and Human Services Agency
Department of Health Care Services , k
JENNIFER KENT EDMUND G. BROWN JR.
DIRECTOR GOVERNOR
SER Q 3 "
Nancy Mackie
City Manager
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
Dear Ms. Mackie:
Per the Intergovernmental Agreement Regarding Transfer of Public Funds, #13-90521
the Department of Health Care Services (DHCS) is requesting that City of San Rafael
transfer funds in the amount of $261,010 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, 2013 through June 30, 2014. The Intergovernmental
Agreement Regarding Transfer of Public Funds 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 #13-90521
Once the governmental funding entity has transferred funds to the specified account,
please email Sandra Dixon at Sandra. Dixon(cDdhcs.ca.gov with the completed
transaction information.
The funds transferred by the governmental funding entity will be paid, together with the
related federal financial participation, by DHCS to Partnership HealthPlan of California
as part of its capitation rates for the period of July 1, 2013 through June 30, 2014.
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 caoov
Nancy Mackle
Page 2
If you have any questions regarding the Intergovernmental Transfer Agreement, please
contact Sandra Dixon at (916) 552-9460.
Sincerely,
I_1AW 04-1
wa---
Meredith Wurden
Assistant Deputy Director
Health Care Financing
Enclosure
cc: Chris Gray, Fire Chief
San Rafael Fire Department
1039 C Street
San Rafael, CA 94901
Sandra Dixon
Capitated Rates Development Division
Department of Health Care Services
P.O. Box 997413, MS 4413
Sacramento, CA 95899-7413
CONTRACT #13-90521
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 with respect to the matters set forth below.
RECITALS
A. This Agreement is made pursuant to the authority of Welfare & Institutions Code, section
14164 and 14301.4.
B. The Partnership HealthPlan of California 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. Partnership HealthPlan of
California 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 Partnership HealthPlan of California 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 CITY OF SAN RAFAEL shall transfer funds to DHCS pursuant to section
14164 and 14301.4 of the Welfare and Institutions Code, up to a maximum total amount of two hundred
sixty-one thousand and ten dollars ($261,010), to be used solely as a portion of the nonfederal share of
actuarially sound Medi -Cal managed care capitation rate increases for Partnership HealthPlan of
California for the period July 1, 2013 through June 30, 2014 as described in section 2.2 below. The funds
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shall be transferred in accordance with a mutually agreed upon schedule between the CITY OF SAN
RAFAEL and DIICS, in the amounts specified therein.
1.2 The CITY OF SAN RAFAEL 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 DIICS
2.1 DHCS shall exercise its authority under section 14164 of the Welfare and
Institutions Code to accept funds transferred by the CITY OF SAN RAFAEL 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 CITY OF SAN RAFAEL 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
Partnership HealthPlan of California as part of Partnership HealthPlan of California's capitation rates for
the period July 1, 2013 through June 30, 2014. The rate increases paid under section 2.2 shall be used for
payments related to Medi -Cal services rendered to Medi -Cal 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 Partnership HealthPlan of California.
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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 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 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 CITY OF SAN RAFAEL and Partnership HealthPlan of California of
the amount of the Medi -Cal managed care capitation rate increases that DHCS paid to Partnership
HealthPlan of California 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 CITY OF SAN RAFAEL pursuant to
this Agreement is not expended for the specified rate increases under Section 2.2, DHCS shall return the
unexpended funds to the CITY OF SAN RAFAEL.
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.
3.2 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.
3
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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 CITY OF SAN RAFAEL:
Nancy Mackle, City Manager
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
With copies to:
To DHCS:
Chris Gray, Fire Chief
San Rafael Fire Department
1039 C Street
San Rafael, CA 94901
Sandra Dixon
California Department of l lealth Care Services
Capitated Rates Development Division
1501 Capitol Ave., Suite 71-4002
MS 4413
Sacramento, CA 95814
5. Other Provisions
5.1 This Agreement contains the entire Agreement between the parties with respect to
the Medi -Cal rate increases for Partnership HealthPlan of California described in section 2.2 that are
funded by the CITY OF SAN RAFAEL and supersedes any previous or contemporaneous oral or written
proposals, statements, discussions, negotiations or other agreements between the CITY OF SAN
RAFAEL and DHCS. This Agreement is not, however, intended to be the sole agreement between the
El
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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.
Agreement.
5.3 Section 2 of this Agreement shall survive the expiration or termination of this
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.
5.6 Each party hereby represents that the person(s) executing this Agreement on its
behalf is duly authorized to do so.
6. State Authoritv. 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, 2013 and shall expire as of June 30,
2016 unless terminated earlier by mutual agreement of the parties.
5
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SIGNATURES
IN WITNESS WHEREOF, the parties hereto have executed this Agreement, on the date of
the last signature below.
CITY OF SAN RAFAEL:
By:Date:
Nancy Mackle, City Manager, City of San Rafael Apllrovd g to toren
. 1
THE STATE OF CALIFORNIA, DEPARTMENT OF HEALTII CARE SERVICES:
By: h/v-� VI Date:
6 -
Meredith Wurden, Assistant Deputy Director, Health Care Financing
2
Template Version -5/17/2013 City of San Rafael Fire /Partnership Final 06/17/2015
CITY OF SAN RAFAEL
ROUTING SLIP / APPROVAL FORM
INSTRUCTIONS: USE THIS FORM WITH EACH SUBMITTAL OF A CONTRACT, AGREEMENT,
ORDINANCE OR RESOLUTION BEFORE APPROVAL BY COUNCIL / AGENCY.
SRSA / SRCC AGENDA ITEM NO..
DATE OF MEETING: May 4, 2015
FROM: Chris Gray
DEPARTMENT: Fire
DATE: April 27,2015
TITLE OF DOCUMENT: 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 2013-2014.
Department Head (signature)
*** *** *** *** *** *** *** *** *** *** *** *** *** *** *** ***
(LOWER HALF OF FORM FOR APPROVALS ONLY)
APPROVED AS COUNCIL / AGENCY APPROVED AS TO FORM:
AGENDA ITEM:
City Manager (signature) City Attorney (signature)
NOT APPROVED
REMARKS:
CITY OF SAN RAFAEL
ROUTING SLIP / APPROVAL FORM
INSTRUCTIONS: USE THIS FORM WITH EACH SUBMITTAL OF A CONTRACT, AGREEMENT,
ORDINANCE OR RESOLUTION BEFORE APPROVAL BY COUNCIL / AGENCY.
SRSA / SRCC AGENDA ITEM NO.
DATE OF MEETING: May 4, 2015
FROM: Chris Gray
DEPARTMENT: Fire
DATE: April 27,2015
TITLE OF DOCUMENT: 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 2013-2014.
Department Head (signature)
*** *** *** *** *** *** *** *** *** *** *** *** *** *** *** ***
(LOWER HALF OF FORM FOR APPROVALS ONLY)
APPROVED AS COUNCIL / AGENCY APPROVED AS TO FORM:
AGENDA ITEM:
City Manager (signature) City Attorney (signature)
NOT APPROVED
REMARKS: