AGR-7309 - CALOPTIMA - HEALTH PLAN-PROVIDER AGREEMENT INTERGOVERNMENTAL TRANSFER RATE RANGE PROGRAM AGREEMENTr R-73 0
HEALTH PLAN-PROVIDER AGREEMENT
INTERGOVERNMENTAL TRANSFER RATE RANGE PROGRAM AGREEMENT
This Agreement is made this 1 st day of November, 2021,by and between CALOPTIMA,
a California public agency hereinafter referred to as "PLAN", and the City of Orange, a California
municipal corporation operating through its Fire Department,hereinafter referred to as "PROVIDER".
RECITALS:
WHEREAS, PLAN is a public agency formed pursuant to California Welfare and
Institutions Code Section 14087.54 and Orange County Ordinance No. 3896 as amended by Ordinance
Nos. 00-8, OS-008, 06-012, 09-001, 11-013, 14-002 and 16-001, and is party to a Medi-Cal managed care
contract with DHCS, entered into pursuant to Welfare and Institutions Code Section 14087.3, under
which PLAN arranges and pays for the provision of covered Medi-Cal health care services to eligible
Medi-Cal members residing in Orange County;
WHEREAS, the City of Orange is an emergency transport provider who provides
transportation on a non-contract basis,including to CalOptima Medi-Cal Members;
WHEREAS, PLAN and PROVIDER desire to enter into this Agreement to provide for
Medi-Cal managed care capitation rate increases to PLAN as a result of intergovernmental transfers
IGTs") from the City of Orange (GOVERNMENTAL FiJNDING ENTITY) 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:
IGT MEDI-CAL MANAGED CARE CAPITATION RATE RANGE INCREASES
1. IGT Capitation Rate Ran e Increases to PLAN
A. Pavment
Should PLAN receive any Medi-Cal managed care capitation rate increases from State
DHCS where the nonfederal share is funded by the GOVERNMENTAL FUNDING ENTITY specifically
pursuant to the provisions of the Intergovernmental Agreement Regarding Transfer of Public Funds,#21-
10183, ("Intergovernmental Agreement") effective for the period of and January 1, 2021 through
December 31, 2021 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 1.E 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) a. PLAN shall retain 31.71 percent from the Medi-Cal managed care rate
increases paid to PLAN by DHCS as described in this agreement prior to disbursing LMMCRR IGT
Payments to PROVIDER. The retained funds will be expended by PLAN for Covered Services under
PLAN's contract with DHCS for Medi-Cal, in either the State fiscal year received, or in subsequent State
fiscal years,as appropriated by the CalOptima Board of Directors.
Each provider's share of the retained funds shall be calculated based on the provider's proportionate share
ofthe LMMCRR IGT payment made by PLAN in Orange County.
b. The amounts referenced in this agreement are estimates. The parties
understand and agree that the total amount of the Medi-Cal managed care capitation rate increases paid by
DHCS to PLAN may fluctuate as a result of enrollment. The parties further understand and agree that
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any such fluctuations will likewise affect the amount to be retained by the PLAN and the amount payable
to PROVIDER by the same percentage as the variance in the capitation rate increases,if any.
2)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) continue to provide emergency transport services to PLAN Members promptly
and in a manner which ensures access to care consistent with PROVIDER's regular business practices for
providing such services; and
2)not discriminate against PLAN Members or in any way impose limitations on
the acceptance of PLAN Members for care or treatment that are not imposed on other patients of
PROVIDER.
D. Schedule and Notice of Transfer of Non-Federal Funds
1. PROVIDER shall provide PLAN with a copy of the schedule regarding the
transfer of funds to State DHCS referred to in the Intergovermnental Transfer Agreement within fifteen
15) calendar days of establishing such schedule with 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 to the amounts specified therein.
2. PROVIDER shall provide PLAN with written notice of the amount and date of
the transfer within seven(7) calendar days after funds have been transferred to State DHCS for use as the
nonfederal share of any IGT MMCRRIs.
E. Form and Timin of Payments
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
same 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 froin 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
emergency ainbulance services rendered to Medi-Cal PLAN members by PROVIDER between January 1,
2021, and December 31, 2021, and shall be used by PROVIDER solely to fund the costs that exceed the
fee-for-service rates paid by Medi-Cal PLAN for covered services provided to Medi-Cal PLAN Members
during that period.
b) To the extent that total payments received by PROVIDER for any State
fiscal year under this Agreement exceed the cost of Covered Services provided to Medi-Cal PLAN
members by PROVIDER during that fiscal year, any remaining LMMCRR IGT Payment amounts shall
constitute an overpayment, and shall by returned to Medi-Cal PLAN pursuant to the provisions of Section
1.K.,below
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2) Both parties agree that none of these funds, either from the
GOVERNMENTAL FUNDING ENTITY or federal matching funds will be recycled back to the
GOVERNMENTAL FUNDING ENTITY'S general fund, the State, or any other intermediary
organization. Payxnents made by the health plan to providers under the terms of this Agreement
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 1.F 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 Orange County.
I.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 Payxnents 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 resolution process set forth in Section 1.H. The reconciliation
processes established under this paragraph are distinct from the indemnification provisions set forth in
Paragraph 1.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 agrees to and acknowledges the following: (1) PLAN has no obligation to
make any payments hereunder until PLAN has received IGT MMCRRIs from State DHCS; (2) that
PLAN is not responsible for State DHCS payments to PLAN, including any mathematical calculations
made by DHCS, and (3) PLAN is not responsible for the timing of the payments from DHCS to PLAN
including the conditions precedent to the timing of such payxnents which includes the timing of DHCS
submission to CMS andlor CMS review and approval). In addition, PLAN and PROVIDER agree and
acknowledge that nothing herein is intended to create an obligation on the part of PLAN to agree to
delays in capitation payment(s)from DHCS in order to accommodate this IGT.
K. Overpayments and CalOptima Right to Recover
PROVIDER has an obligation to report any overpayment identified by PROVIDER, and
to repay such overpayment to CalOptima within sixty(60) days of such identification by PROVIDER, or
of receipt of notice of an overpayment identified by CalOptima. PROVIDER acknowledges and agrees
that,in the event that CalOptima determines that an amount has been overpaid or paid in duplicate,or that
funds were paid which were not due under this Contract to PROVIDER, CalOptima shall have the right to
recover such amounts from PROVIDER by recoupment or offset from current or future amounts due from
CalOptima to PROVIDER, after giving notice and an opportunity to return/pay such amounts. This right
to recoupment or offset shall extend to any amounts due from PROVIDER to CalOptima, including, but
not limited to,amounts due because of overpayments as described in the provisions of this agreement.
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2. Term
The term of this agreement shall commence on January 1,2021 and shall terminate on
June 30,2024.
SIGNATURES
HEALTH PLAN: CalOptima
I Date: j a-a 3 1
By:
PROVIDER:
le
City of O nge
Date:
By: Mark A.Murphy,Mayor
T:
Date: I t'36'd.1
Pamela Coleman,City Clerk
APPROVED AS TO FORM:
Date: It- 30-911
Mary• . Binning, st City Attorney IT
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