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Home My WebLink About2023-188A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK Public Emergency Medical Transportation Letter of Agreement THIS LETTER OF AGREEMENT (LOA) is made and entered into in duplicate on the day of 2023, by and between Indian River County Emergency Services Distirct on behalf of Indian River County ALS, and the State of Florida, Agency for Health Care Administration (the "Agency"), for good and valuable consideration, the receipt and sufficiency of which is acknowledged. DEFINITIONS "Intergovernmental Transfers (IGTs)" means transfers of funds from a non -Medicaid governmental entity (e.g., counties, hospital taxing districts, providers operated by state or local government) to the Medicaid agency. IGTs must be compliant with 42 CFR Part 433 Subpart B. "Medicaid" means the medical assistance program authorized by Title XIX of the Social Security Act, 42 US.C. §§ 1396 et seq., and regulations thereunder, as administered in Florida by the Agency. "Public Emergency Medical Transportation (PEMT)," pursuant to the General Appropriation Act, Laws of Florida 2023-156 is the program that provides supplemental payments for eligible Public Emergency Medical Transportation (PEMT) entities that meet specified requirements and provide emergency medical transportation services to Medicaid beneficiaries. A. GENERAL PROVISIONS Per Senate Bill 2500, the General Appropriations Act of State Fiscal Year 2023-2024, passed by the 2023 Florida Legislature, the Indian River County Emergency Services Distirct and the Agency agree that the Indian River County Emergency Services Distirct will remit IGT funds to the Agency in an amount not to exceed the total of $363,337.25. The Indian River County Emergency Services Distirct and the Agency have agreed that these IGT funds will only be used for the PEMT program. 2. The Indian River County Emergency Services Distirct will return the signed LOA to the Agency. 3. The Indian River County Emergency Services Distirct will pay IGT funds to the Agency in an amount not to exceed the total of $363,337.25. The Indian River County Emergency Services Distirct will transfer payments to the Agency in the following manner: a. Per Florida Statute 409.908, annual payments for the months of July 2023 through June 2024 are due to the Agency no later than October 31, 2023, unless an alternative plan is specifically approved by the agency. b. The Agency will bill the Indian River County Emergency Services Distirct when payment is due. 4. The Indian River County Emergency Services Distirct and the Agency agree that the Agency will maintain necessary records and supporting documentation applicable to Indian River County Emergency Services Distirct Indian River County ALS—PEMT LOA_SFY 2023-24 A TRUE COPY ,ERTIFICATION ON LAST PAGE ".UTLER, CLERK health services covered by this LOA in accordance with public records laws and established retention schedules. a. AUDITS AND RECORDS i. Indian River County Emergency Services Distirct agrees to maintain books, records, and documents (including electronic storage media) pertinent to performance under this LOA in accordance with generally accepted accounting procedures and practices, which sufficiently and properly reflect all revenues and expenditures of funds provided. ii. Indian River County Emergency Services Distirct agrees to assure that these records shall be subject at all reasonable times to inspection, review, or audit by state personnel and other personnel duly authorized by the Agency, as well as by federal personnel. iii. Indian River County Emergency Services Distirct agrees to comply with public record laws as outlined in section 119.0701, Florida Statutes. b. RETENTION OF RECORDS The Indian River County Emergency Services Distirct agrees to retain all financial records, supporting documents, statistical records, and any other documents (including electronic storage media) pertinent to performance under this LOA for a period of six (6) years after termination of this LOA, or if an audit has been initiated and audit findings have not been resolved at the end of six (6) years, the records shall be retained until resolution of the audit findings. ii. Persons duly authorized by the Agency and federal auditors shall have full access to and the right to examine any of said records and documents. iii. The rights of access in this section must not be limited to the required retention period but shall last as long as the records are retained. c. MONITORING i. Indian River County Emergency Services Distirct agrees to permit persons duly authorized by the Agency to inspect any records, papers, and documents of the Indian River County Emergency Services Distirct which are relevant to this LOA. d. ASSIGNMENT AND SUBCONTRACTS The Indian River County Emergency Services Distirct agrees to neither assign the responsibility of this LOA to another party nor subcontract for any of the work contemplated under this LOA without prior written approval of the Agency. No such approval by the Agency of any assignment or subcontract shall be deemed in any event or in any manner to provide for the incurrence of any obligation of the Agency in addition to the total dollar amount agreed upon in this LOA. All such assignments or subcontracts shall be subject to the conditions of this LOA and to any conditions of approval that the Agency shall deem necessary. 5. This LOA may only be amended upon written agreement signed by both parties. Indian River County Emergency Services Distirct_ Indian River County ALS_PEMT LOA_SFY 2023-24 A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK The Indian River County Emergency Services Distirct and the Agency agree that any modifications to this LOA shall be in the same form, namely the exchange of signed copies of a revised LOA. 6. Indian River County Emergency Services Distirct confirms that there are no pre- arranged agreements (contractual or otherwise) between the respective counties, taxing districts, and/or the providers to re -direct any portion of these aforementioned supplemental payments in order to satisfy non -Medicaid, non -uninsured, and non - underinsured activities. 7. Indian River County Emergency Services Distirct agrees the following provision shall be included in any agreements between Indian River County Emergency Services Distirct and local providers where IGT funding is provided pursuant to this LOA. Funding provided in this agreement shall be prioritized so that designated IGT funding shall first be used to fund the Medicaid program and used secondarily for other purposes. 8. This LOA covers the period of July 1, 2023, through June 30, 2024, and shall be terminated September 30, 2024, which includes the states certified forward period. 9. This LOA may be executed in multiple counterparts, each of which shall constitute an original, and each of which shall be fully binding on any party signing at least one counterpart. PEMT Local Intergovernmental Transfers Program / Amount State Fiscal Year 2023-2024 Estimated IGTs $363,337.25 Total Funding Not to Exceed $363,337.25 IN WITNESS WHEREOF, the parties have caused this page Letter of Agreement to be executed by their undersigned officials as duly authorized. Indian River County Emergency Services Distirct SIGNED BY: NAME: Jo /0 41. %�'ifa�riG�� ✓� TITLE: qq /fin Lo•v.�t -r•..•f�/� �sr DATE: �i�24�ZOLJ* STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION SIGNED BY: NAME: Thomas Wallace TITLE: Deputy Secretary, Division of Medicaid DATE: Indian River County Emergency Services Distirct_ Indian River County ALS_PEMT LOA_SFY 2023-24 ` yI" CARE 10 C ST�iIf OF FLOR�� A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK Intergovernmental Transfers Questionnaire IGT Provider Name: Indian River Count Health Care Provider Name: IGT Amount: $363,337.25 State Fiscal Year Ending: 6/30/2024 1. What type of governmental entity is your organization considered? (county, city, hospital taxing district, or other) Count It other, please explain The Emergency Services District is a Dependent Special District of Indian River County 2. Does your organization have a relationship with the provider for which you contribute IGTs as named in the preamble of the enclosed Letter of Agreement (LOA)? Yes If yes, please describe your relationship, including services provided to/by the provider to/by the organization and any other financial transactions between the provider and the organization. The District is both the provider of and the agency that will be making the required IGT. 3. Please describe the source of the IGT funding for your organization, including whether the source is from a tax, a provider donation, or other funds. Provide the amount of funding from each source. Source Amount Ad Valorem Tax Revenue FY 23/24 Budget $ 363,337 $ - $ - If other, please explain a. Verify whether the funds are public funds as defined by 42 CFR § 433.51, and exclude any federal funds. Yes If no, please explain 4. Does your organization have taxing authority? Yes A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK 5. If the source of IGT funding is from taxes, please answer the following questions: a. Is the tax a state, county, city, or hospital district tax? County I f other, please explain b. What entities are taxed? c. WI- CnTiTh 'roperty it is the tax structure (i.e. property tax, percentage of revenue, assessment, etc.)? 'roperty Tax it is the amount or percent or the tax ?.3531 mills e. Does at least 85% of the burden of the tax revenue fall on health care providers as defined in 42 CFR §433.55? (Provide the total tax revenue and the health care provider tax burden) If so, please answer the following questions: Amount Total Tax Burden $ - Healthcare Provider Tax Burden $ - 0.00% i) Is the tax broad based? A broad based tax can be defined as a tax that is imposed on at least all health care items or services in the class or providers of such items or services furnished by all non -Federal, non-public providers in the State, and is imposed uniformly, pursuant to 42 CFR § 433.68. F no, please explain TRUE COPY "IFICATION ON LAST PAGE L. SUTLER, CLERK ii) Is the tax uniform across all entities being taxed? Based on 42 CFR § 433.68, a health care - related tax will be considered to be imposed uniformly even if it excludes Medicaid or Medicare payments (in whole or in part), or both; or in the case of health care -related tax based on revenue or receipts with respect to a class of items or services, if it excludes either Medicaid or Medicare revenue with respect to a class of items or services, or both. The exclusion of Medicaid revenue must be applied uniformly to all providers being taxed. IT no, please explain iii) Is the tax generally redistributive and a waiver of the broad-based or uniform tax requirement was granted in accordance with 42 CFR §433.68(e)? If no, please explain iv) Does the tax program comply with the hold harmless provisions included in 42 CFR § 433.68(f)? If no, please explain v) Does every tax paying. entity receive a supplemental payment equal to or exceeding its tax cost? If yes, please explain 6. Please answer the following regarding provider funds received from the healthcare entity and/or other health care entities. a. Are provider voluntary payments or in-kind services received by the organization as defined in 42 CFR § 433.52? No b. How much of the organization's revenue is received from provider -related donations (Provide the total revenue and the provider -related donation amounts)? Amount Total Revenue $ - Provider Related Donations $ - c. Do individual provider donations exceed $5,000 per year or $50,000 per year for a health care organizational entity? No If yes, please list the provider and payment amount. F'roviaer Name runaing oource HmounL d. Does any portion of the provider donation constitute as a "bona fide donation" pursuant to 42 CFR § 433.54? 42 CFR § 433.54 requires donations will not be returned to the individual provider, the provider class, or related entity under a hold harmless provision. e. Is there an agreement between the IGT provider and the health care entity? If so, please specify whether the agreement is written and provide the details. 7. Were funds utilized for the IGT specifically appropriated by the organization's board? If yes, provide the board minutes and date of the appropriation. I certify that the statements and information contained in this submittal are true, accurate, and complete. STATE OF FLORIDA INDIAN RIVER COUNTY THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF THE ORIGINAL ON FILE IN THIS OFFICE. kyr RYMI L DALER aERK B y P; C K DATE I[� ignature bf Officer or Admrinistrator Title Date