HomeMy WebLinkAboutAgreement - Indiana Family & Social Services Administration - Medicaid Managed Care Ambulance Services for SBFDI
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AGREEMENT BETWEEN SOUTH BEND FIRE DEPARTMENT/EMS AND THE STATE OF
INDIANA FOR ITS 2014 GOVERNMENTAL AMBULANCE PAYMENT ADJUSTMENT FOR
MANAGED CARE SERVICES
This Agreement is entered into by South Bend Fire Department/EMS of St. Joseph County,
Indiana ("Provider"), a governmental ambulance provider, and the State of Indiana, through the Family
and Social Services Administration, Office of Medicaid Policy and Planning ("OMPP" or "the State").
This Agreement is an amendment to the Indiana Health Coverage Programs (IHCP) Provider Agreement
for South Bend Fire Department/EMS.
WHEREAS, in .Tune 2017 the Provider will make a permissible intergovernmental transfer
(IGT) of funds in order to fund the Fiscal Year 2014 Governmental Ambulance Payment Adjustment
for managed care services (the "Payments"). The Payments will be paid to Provider in 2017 by the
state's contracted managed care entities; and
WHEREAS, the Provider and the State recognize that the Centers for Medicare & Medicaid
Services ("CMS") has the authority to determine whether the Payments are Medicaid expenditures of
funds which are eligible for federal financial participation ("FFP");
NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein,
it is hereby agreed as follows:
1. The Provider will make an IGT of funds via check in the amount of Four Hundred
Seventy -One Thousand Eighty -Eight Dollars and Thirty -One Cents ($471,088.31),
which are not federal funds, or are federal funds authorized by federal law to match
other federal funds.
2. The State's Payment to the Provider will be made by the state's contracted managed
care entities in the amount of One Million Four Hundred Eleven Thousand Nine
Hundred Thirty -One Dollars and Forty -Seven Cents ($1,411,931.47), the total amount.
3. The Provider will retain one hundred percent (100%) of the Payment described in
Paragraph 2, above.
4. In the event that the State is notified by CMS that FFP will not be recognized, CMS
defers the State's claim for FFP, or CMS issues a notice of disallowance, the Provider
shall do the following:
(a) If CMS defers the State's claim for FFP for any reason, the Provider shall
provide to the State any and all information requested by CMS to support the
claim and resolve the deferral. The parties agree that the State has no
responsibility, other than to submit information to CMS that is provided by
the Provider, to attempt to resolve the deferral in favor of the Provider.
(b) If CMS issues a notice of disallowance, the Provider shall, within fifteen (15)
calendar days after notification by the State that CMS has declined to approve
the Payments for purposes of FFP eligibility: deliver to the State funds in the
amount of One Million Four Hundred Eleven Thousand Nine Hundred Thirty -
One Dollars and Forty -Seven Cents ($1,411,931.47). Such payment shall be
the amount of the Provider's ambulance payment adjustment described in
Paragraph 2, above.
& soo
May 23, 2017
Stephen Cox
Fire Chief
South Bend Fire Department/EMS
1222 S. Michigan Street
South Bend, IN 46601
Eric Holcomb, Governor
State of Indiana
Indiana Health Coverage Programs
www.indianamedicaid.com
MYERS AND STAUFFER LC
9265 COUNSELORS ROW, SUITE 100
INDIANAPOLIS, IN 46240
800.877.6927 1 317, 846, 9521
www.msfc.com/Indiana
RE: 201.4 Governmental Ambulance Payment Adjustment for Managed Care Services
UPS Tracking Number— I 9V1 W32 03 9301 3094
Provider Name: South Bend Fire Department/EMS
Provider Number: 100286930A
NOTICE OF PROGRAM REIMBURSEMENT
This letter is the Office of Medicaid Policy and Planning's Notice of Program Reimbursement (NPR) of
your facility's Indiana Medicaid Governmental Ambulance Payment Adjustment for Medicaid managed
care ambulance services for calendar year 2014.
This payment adjustment was calculated based on your facility's submitted cost report for fiscal year
ended December 31, 2014 and Medicaid managed care claims for services incurred during calendar year
2014.
FINAL ORDER
The Indiana Medicaid Governmental Ambulance Payment Adjustment for Medicaid managed care
ambulance services for calendar year 2014 is $1,411,931.47.
The intergovernmental transfer (IGT) amount is $471,088.31.
If you are in agreement with this payment, upon receipt of this letter, please submit the following
information to the address below no later than fifteen (15) days of your receipt of this letter: a cover letter,
a copy of this payment letter, the signed Payment Agreement (enclosed with this letter), and the
Intergovernmental transfer check in the amount of $471,088.31 made payable to the Treasurer of the
State of Indiana. We recommend submitting these documents in a manner through which delivery can
be confirmed, such as hand delivery, courier, United States Post Service certified mail, United Parcel
Service, or Federal Express.
Indiana Family and Social Services Administration
13992 Collections Center Drive
Chicago, 1L 60693
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Children's Health Insurance Program Healthy Indiana Plan Hoosier Care Connect " F
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South Bend Fire Department/EMS
May 23, 2017
Page 2 of 2
The cover letter must include your facility's name and address and your federal tax identification number.
You will receive your Indiana Medicaid Governmental Ambulance Payment Adjustment for managed care
services for calendar year 2014 after this information has been received.
APPEAL SECTION
This notification constitutes an appealable order. If you disagree with this determination, you have the
right to appeal under 405 IAC 1-1.5. In order to assert your appeal rights, you must file an appeal request
within fifteen (15) days of your receipt of this letter. The appeal request must state that you are the party
to whom the order is specifically directed; that you are adversely affected by the determination; and that
you are entitled to review under the law. Please refer to the rule for further information on your appeal
rights.
Appeals should be sent to the following address:
Jennifer Walthall, M.D, MPH, Secretary
MS07-Office of Medicaid Policy and Planning
ATTN: Mr. Chris Fletcher
402 West Washington Room W382
Indianapolis, IN 46204
A copy of this notice must accompany your appeal request. A copy of the appeal should also be sent to
Myers and Stauffer LC at the address listed below. Failure to file an appeal request within fifteen (15)
days from receipt of this letter will result in the waiver of any right to appeal this determination.
if you elect to appeal this determination, you must; also file a statement of issues within forty-five (45)
days after you receive notice of this determination. The statement of issues should be sent to the same
address as the appeal request. The statement of issues should conform to 405 IAC 1-1.5-2 (e). The
statement of issues and the appeal request may be filed together. Please also forward a copy of the
statement of issues to Myers and Stauffer LC at the following address:
Myers and Stauffer LC
Attn: Berry Bingaman
9265 Counselors Row, Suite 100
Indianapolis, IN 46240
If you elect to waive your right to an appeal, please fax or mail such notification to Berry Bingaman, in
care of Myers and Stauffer LC. The fax telephone number is (317) 571-8481.
Sincerely,
Berry Bingaman, CPA
Myers and Stauffer LC
cc: Jennifer White, OMPP
Enclosure