Okaloosa County BOCC — May 6, 2014 — Medicaid amend 6 — reading text

STATE OF FLORIDA COMMISSION FOR THE TRANSPORTATION DISADVANTAGED MEDICAID NON-EMERGENCY TRANSPORTATION (NET) PROGRAM SUBCONTRACTED TRANSPORTATION PROVIDER AGREEMENT AMENDMENT NO.: 6 AGREEMENT #: BDN10 FINANCIAL PROJECT ID#: 41604318201 F.E.I.D. # 59-6000765-049 THIS amendment, entered into on 2014 by and between the State of Florida, Commission for the Transportation Disadvantaged, hereinafter called “Commission” and Okaloosa County Board of County Commissioners, 1804 Lewis Turner Blvd., Ste 206, Fort Walton Beach, Florida_32547, hereinafter called “Subcontracted Transportation Provider” for Okaloosa County(ies). WHEREAS, this amendment and extension is necessitated by the implementation of Florida’s Managed Medical Assistance Program administered by the Agency for Health Care Administration and is beyond the control of the STP. WHEREAS, this amendment is for the mutual benefit of both parties; and NOW, THEREFORE, the aforesaid Agreement is hereby amended in the following respects only: 1. 2. Page 1 of 3 Services and Performance: The services and performance of the agreement is not changed. Term of Agreement: The term of this agreement is extended and will remain in effect until August 31 2014. Compensation and Payment: This agreement is increased by $21,097.00 for the month of July only. Effective August 1, 2014, Section I. is deleted in its entirety to remove the contract ceiling and replaced with the following: For the satisfactory performance of the services and the submittal of Encounter Data as outlined in Exhibit A, Scope of Services, the STP shall be paid a monthly rate for each recipient enrolled in categories identified in Exhibit B, Method of Compensation. The Commission may also reimburse the STP for costs associated with transporting Medicaid recipients to specialized Medicaid compensable services, including services received out of state. The STP must receive approval from the Commission before incurring costs for these specialized services. Such reimbursements will be based on costs of transportation and lodging, supported by receipts, and may include meals and/or per diem not to exceed the State of Florida reimbursement rates per Chapter 112.061, Florida Statutes. The STP shall request payment through submission of a properly completed invoice to the Commission in accordance with Exhibit B, Method of Compensation. Miscellaneous: Effective August 1, 2014, Section P. is amended to include Attachment 9, Commission for the Transportation Disadvantaged Medicaid Recipient Travel Form. Exhibit A, Scope Of Services - XI Method Of Payment: Effective August 1, 2014, Section A., Paragraph 1 is deleted in its entirety and replaced with the following: The Commission shall pay the STP, upon satisfactory completion of all terms and conditions specified in the Agreement, a per-member per-month (PMPM) rate for each category listed below. The PMPM rates shall be a part of this agreement as specified in Exhibit B, Method of Compensation. The number of Medicaid recipient months for each category shall be provided to the STP monthly. The written Notification should be provided with the invoice when it is submitted for processing for audit verification. The total monthly amount to be paid to the STP will be calculated using the number of Medicaid recipient months in each category multiplied by the PMPM rate, then totaling the funds of all categories. Monthly Payment amounts will vary due to the changing numbers of Medicaid recipients per category. The Commission may also reimburse the STP for costs associated with transporting Medicaid recipients to specialized Medicaid compensable services, including services received out of state. The STP must receive approval from the Commission before incurring costs for these specialized services. Such reimbursements will be based on costs of transportation and lodging, supported by receipts, and may include meals and/or per diem not to exceed the State of Florida reimbursement rates per Chapter 112.061, Florida Statutes. Medicaid Recipients Enrollment Categories: Excluded Population ° Children receiving services in a prescribed pediatric extended care center (PPEC) ° Presumptively Eligible Pregnant Women (PEPW) ° Women who are eligible only for breast and cervical cancer services Voluntary Population ° Recipients who have other creditable health care coverage, excluding Medicare. . Recipients enrolled in the home and community based services waiver pursuant to Chapter 393 needing transportation to a non-waiver Medicaid compensable service, and recipients waiting for waiver services (Persons with Developmental Disabilities). Mandatory Population ° Medicaid eligible persons not enrolled in a plan. Exhibit A, Scope of Services - XI Method Of Payment: Effective August 1, 2014, Section C. is deleted in its entirety. Exhibit B, Method of Compensation, of said Agreement is replaced by Amendment Number 6 Exhibit B and is attached hereto and made a part hereof. EXCEPT as hereby modified, amended, or changed, all other terms of the Agreement dated 1/1/2009 and amendments 1, 2, 3, 4 and 5, shall remain in full force and effect. This amendment cannot be executed unless all previous amendments to this Agreement have been fully executed. In witness whereof, the authorized representatives of the parties hereto have executed this AMENDMENT, effective June 30, 2014. STATE OF FLORIDA OKALOOSA BOARD OF COUNTY COMMISSIONERS COMMISSION FOR THE TRANSPORTATION DISADVANTAGED SIGNATURE SIGNATURE Executive Director Chairman TITLE TITLE Steven Holmes Charles K. Windes, Jr. PRINTED NAME Page 2 of 3 PRINTED NAME AGREEMENT NO.: BDN10 COUNTY NAME: Okaloosa AMENDMENT NO._6 EXHIBIT B METHOD OF COMPENSATION PURPOSE: This Exhibit defines the method of compensation to be made to the contractor for the services set forth in Exhibit “A” and the method by which payments shall be made. COMPENSATION AND PAYMENTS: For the month of July, the Commission shall pay the STP, upon satisfactory completion of all terms and conditions specified in the Agreement $21,097.00. Effective August 1, 2014, the Commission shall pay the STP, upon satisfactory completion of all terms and conditions specified in the Agreement, a per-member per-month (PMPM) rate for each category as listed below. The number of Medicaid recipient months for each category shall be provided to the STP monthly. The total monthly amount to be paid to the STP will be calculated using the number of Medicaid recipient months in each category multiplied by the PMPM rate, then totaling the funds of all categories. Monthly payment amounts will vary due to the changing numbers of Medicaid recipients per category. The Commission may also reimburse the STP for costs associated with transporting Medicaid recipients to specialized Medicaid compensable services, including services received out of state. The STP must receive approval from the Commission before incurring costs for these specialized services. Such reimbursements will be based on costs of transportation and lodging, supported by receipts, and may include meals and/or per diem not to exceed the State of Florida reimbursement rates per Chapter 112.061, Florida Statutes. Payment requests including meals and/or per diem shall include the Commission for the Transportation Disadvantaged Medicaid Recipient Travel Form. Medicaid Recipients Per Member Per Month Rate Enrollment Categories Excluded Population — PPEC $1,333.54 Excluded Population — Other $ 21 Voluntary Population $3.43 Mandatory Population $ 34 Costs associated with transporting | Reimbursements will be based on Medicaid recipients to specialized | costs of transportation and lodging, Medicaid compensable services, supported by receipts, and may including services received out of | include meals and/or per diem not to state. The STP must receive exceed the State of Florida rates per approval from the Commission Chapter 112.061, Florida Statutes. before incurring costs for these Payment requests including meals specialized services. and/or per diem shall include the Commission for the Transportation Disadvantaged Medicaid Recipient Travel Form. Page 3 of 3 ATTACHMENT 9 STATE OF FLORIDA COMMISSION FOR THE TRANSPORTATION DISADVANTAGED MEDICAID NON-EMERGENCY TRANSPORTATION PROGRAM MEDICAID RECIPIENT TRAVEL FORM Subcontracted Transportation Provider: Contract #: Invoice #: Medicaid Recipient Name: Medicaid Recipient County of Residence: Name of Other Persons Traveling with Recipient: Date | Travel Performed from Point of Origin to Purpose or Reason for Travel Hour of Class Per Diem or Map Incidental Expenses Destination Departure A&B Actual Lodging Mileage (Receipts must be included) and Return Meal (Receipts must Allowance be included) Amount Type Column Column Total Total Miles Column SUMMARY Total Total TOTAL | hereby certify or affirm that the above expenses were actually incurred for the provision of transportation services X @0.445 for the recipient as noted above to access Medicaid compensable services and that the claim is true and correct and conforms to every respect with the terms of the contract, Section 112.061, Florida Statutes, Chapter 691-42 F.A.C., $ $ $ $ Department of Financial Services Reference Guide, and the Disbursement Handbook for Employees and Managers. Subcontracted Transportation Provider Manager Date Pursuant to the terms of the Contract and Section 112.061(3)(a), Florida Statutes, | hereby certify or affirm that to the best of my knowledge the above travel expenses were incurred by the Subcontract Transportation Provider for the provision of transportation services for the recipient as noted above. Commission for the Transportation Disadvantaged Project Manager Date Commission for the Transportation Disadvantaged Review: | Receipts Attached | Agency for Health Care Administration Approval Letter Attached (if applicable) i Commission for the Transportation Disadvantaged Approval Document Attached Instructions for Completing the Commission for the Transportation Disadvantaged Medicaid Non-Emergency Transportation Program Medicaid Recipient Travel Form Travel Form should be completed by the Subcontracted Transportation Provider for costs associated with transporting Medicaid recipients to specialized Medicaid compensable services, including services received out of state. The Subcontracted Transportation Provider must receive approval from the Commission for the Transportation Disadvantaged before incurring costs for these specialized services. Reimbursements will be based on costs of transportation and lodging, supported by receipts, and may include meals and/or per diem not to exceed the State of Florida reimbursement rates, per Chapter 112.061, F.S. Subcontracted Transportation Provider: Name of the Subcontracted Transportation Provider agency. Contract #: Number of the contract on which work was performed. Invoice#: Invoice number that the travel form is being submitted with. Medicaid Recipient Name: The full legal name of the Medicaid Recipient that travel was provided for. Medicaid Recipient County of Residence: Name of the county the Medicaid Recipient resides in. Name of Other Persons traveling with Recipient: List the names of other persons who were authorized to travel with the Recipient (parent, guardian, etc). Date: (MM/DD/YYYY) Date of actual travel. Travel Performed for Point of Origin to Destination: Departing location to the city or town of where Medicaid services will be provided. List each location. NO ABBREVIATIONS. Purpose or Reason for Travel: The purpose of the trip should be only to receive Specialized Medicaid compensable medical care. Hour of Departure and Return: Actual time of departure and return. Must state A.M. or P.M. Meal Allowance: Itemize daily using the appropriate meal allowance: $6 for breakfast, $11 for lunch, and $19 for dinner per F.S. 112.061. Per Diem/Actual