HomeMy WebLinkAboutIowa Dept of Human Svcs - Intergovernmental Transfer of Public Funds Agmnt 9.8.2020 INTERGOVERNMENTAL TRANSFER OF PUBLIC
FUNDS AGREEMENT BETWEEN
THE IOWA DEPARTMENT OF HUMAN SERVICES AND
City of Waterloo , Iowa
Ground Emergency Medical Transportation Provider (GEMT Provider)
This Intergovernmental Transfer Agreement (Agreement) is entered into between the Iowa
Department of Hunan Services (IDHS) and the ground emergency medical transportation
(GEMT) Provider. It provides for an intergovernmental transfer of fiords to the IDHS from the
GEMT Provider in order to provide the non-federal share of the reconciled cost reimbursement
amount for the uncompensated Medicaid cost associated with GEMT services .
The GEMT Provider is authorized by House File (HF) 2285 of the 2018 Iowa legislative
session to enter into and carry out an Intergovernmental Transfer (IGT) Agreement to transfer
fiords through IGTs to the IDHS for use as the non-federal share of Medicaid expenditures.
AGREEMENT
1 . GEMT Program Compliance. Attached hereto as Exhibit A is State Plan Amendment
IA- 19-002 (SPA), which address the GEMT Program. The GEMT Provider shall at all
times comply with all requirements of the SPA.
2 . Compliance with Provider Agreement and GEMT Program Eligibility. The GEMT
Provider' s Iowa Medicaid Provider Agreement is incorporated herein by reference . The
parties stipulate to the inclusion of any future amendments or replacement of any such
provider agreements by this reference. The GEMT Provider hereby represents, warrants
and covenants that is and at all relevant times will be an Eligible GEMT Provider as that
term is defined in the SPA. If at any time the GEMT Provider' s status changes such that
it is no longer an Eligible GEMT Provider, the GEMT Provider shall immediately notify
the IDHS .
3 . Fund Transfer. The GEMT Provider agrees to transfer finds to IDHS at the times and
in the amounts determined in accordance with the following paragraphs of this
Agreement. The transfer shall be made prior to the payment by IDHS for the
uncompensated Medicaid cost associated with GEMT services . The GEMT Provider
will transfer funds to IDHS equivalent to the non-federal share of the payments to be
made upon notification by IDHS .
4 . Funds Certification. The GEMT Provider shall certify that the funds transferred
qualify for federal financial participation (FFP) pursuant to 42 CFR 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. Impermissible sources do not include 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.
Updated July 30, 2020
5 . Record Retention and Access. The parties agree that each shall maintain necessary
records and supporting documentation applicable to the uncompensated Medicaid cost
associated with GEMT services payments to assure that claims for total fiords and
federal funds are in accordance with applicable federal requirements, including but not
limited to those record retention requirements set forth in the SPA. The parties agree to
make those records available to the parties and to any and all state or federal oversight
authorities immediately upon request.
6 . Notices : Any written notice required by this Agreement shall be sent to :
For : City of Waterloo , Iowa
GEMT Provider
Printed Name : Jason Hernandez
Title: Mayor
Address : 425 E 3rd Street
Waterloo , IA 50703
E-mail address Jason . Hernandez@Waterloo- IA . org
For IDHS :
Printed Name : Iowa Medicaid Enterprise
Title: Provider Cost Audit and Rate Setting Unit
Address : 611 5th Avenue
Des Moines, IA 50309
E-mail address : costaudit@dhs.state.ia .us
7 . Repayment Obligation : In the event that any State and/or federal funds are deferred
and/or disallowed as a result of any audits or expended in violation of the laws applicable
to the expenditure of such funds, the GEMT Provider shall be liable to the Agency for the
full amount of any claim disallowed and for all related penalties incurred. The
requirements of this paragraph shalt apply to the GEMT Provider as well as any
subcontractors of the GEMT Provider. To the extent that the GEMT Provider receives
Updated July 30, 2020
payments that exceed the permissible amount allowed pursuant to the SPA, the parties
hereby deem the excess funds received by the GEMT Provider to be an "overpayment"
subject to return to the IDHS within 60 days pursuant to Section 2.5 of the Provider
Agreement.
S. Assignment: This Agreement is not assignable.
9. No Third Party Beneficiaries. There are no third party beneficiaries to this Agreement.
This Agreement is intended only to benefit the IDHS and the GEMT Provider.
10. Amendment, This Agreement may be modified at any time by the written agreement of
Moth parties.
11. Term & Termination: This Agreement covers the period beginning on or after July 1,
2021 and ending June 30, 2022. This Agreement may be canceled by either party after
giving thirty (30) days prior notice in writing to the other party. All obligations of the
parties incurred or existing under this Agreement as of the date of expiration or
termination survive the expiration or termination of the Agreement.
12. Execution: In consideration of the mutual covenants in this Agreement and for other
good and valuable consideration, the receipt, adequacy and legal sufficiency of which are
hereby acknowledged, the parties have entered into this Agreement and have caused their
duly authorized representatives to execute this Agreement.
City of Waterloo, Iowa
GEMT Provider
9/8/2020
Signature Date
i
Qa�entivl �GU"fi
Printed Name
Mayor
Title
IOWA DEPARTMENT OF HUMAN SERVICES
Director Date
Updated July 30, 2020
Attachment A — Approved State Plan Amendment IA49A02
Attachment 4. 19-B
Revised Submission 7 . 10 . 19 PAGE - 16d -
State/Territory : IOWA
Methods and Standards for Establishing Payment Rates for Other Tunes of Care
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
This program provides supplemental payments for eligible Ground Emergency Medical
Transportation (GEMT) providers that meet specified requirements and provide GEMT services
to Iowa Medicaid members .
Supplemental payments provided by this program are available only for the uncompensated and
allowable direct and indirect costs incurred by eligible GEMT providers while providing GEMT
services to Iowa Medicaid members. The supplemental payment covers the gap between the
eligible GEMT provider' s total allowable costs for providing GEMT services as reported on the
GEMT services cost report and the amount of the base payment, mileage, and all other sources of
reimbursement.
The supplemental payment amounts shall be calculated annually on a prospective basis after the
conclusion of each state fiscal year (SFY). Payments shall not be paid as individual increases to
current reimbursement rates as described in other parts of this state plan for GEMT services.
This supplemental payment applies only to Iowa Medicaid services rendered to Iowa Medicaid
members by eligible GEMT providers on or after July 1 , 2019 .
A. Definitions
1 . "Department" means the Iowa Department of Human Services.
2. "Direct Costs" means all costs that can be identified specifically with particular final
cost objectives in order to meet all medical transportation mandates .
3 . "Shared Direct Costs" are direct costs that can be allocated to two or more
departmental fimctions or cost objectives on the basis of shared benefits .
4. "Indirect Costs" means costs for a common or joint purpose benefitting more than
one cost objective that are allocated to each benefiting objective using an agency
approved indirect rate or an allocation methodology. Indirect costs rate or allocation
i methodology must comply with 2 C.F .R. Part 200 and CMS non-institutional
reimbursement policy ,
f
t
State Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN # NEW Approved July 12 2019
Attachment 4. 19-B
Revised Submission 7 . 10 . 19 PAGE - 16e-
State/Territory : IOWA
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
5 . "Eligible GEMT Provider" means a provider who is eligible to receive supplemental
reimbursement because it meets all of the following requirements continuously during
the claiming period:
a. Provides Ground Emergency Medical Transportation services to Iowa
Medicaid members .
b. It is a provider that is enrolled as an Iowa Medicaid provider for the period
being claimed.
c. Is owned or operated by an eligible governmental entity, to include the state, a
city, county, fire protection district, community services district, health care
district, federally recognized Indian tribe or any unit of government as defined
in 42 C .F.R. Sec. 433 . 50.
6 . "Dry Run" means a run that does not result in either a transport or a delivery on-site
of Medicaid covered services.
7 . "GEMT Transport' means GEMT services provided by eligible GEMT providers to
individuals and does not, include dry runs as defined in Paragraph, A. 6 .
8 . "GEMT Services" means both the act of transporting all individual from any point of
origin to the nearest medical facility capable of meeting the emergency medical needs
of the patient, as well as the advanced, limited-advance, and basic life support
services provided to an individual by GEMT providers before or during the act of
transportation .
a. "Advanced Life Support' means special services designed to provide
definitive prehospital emergency medical care, including but not limited to,
cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation,
advanced airway management, intravenous therapy, administration with drugs
and other medicinal preparations, and other specified techniques and
procedures .
Stats Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN # NEW Approved July 12, 2019
Attachment 4 . 19-13
Revised Submission 7 . 10 . 19 PAGE - 16f-
State/Territory : IOWA
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
b . "Limited-Advanced Life Support' means special services to provide
prehospital emergency medical care limited to techniques and procedures that
exceed basic life support but are less than advanced life support services .
C6 "Basic Life Support' means emergency fust aid and cardiopulmonary
resuscitation procedures to maintain life without invasive techniques .
9 . "Service Period" means the period from July 1 through June 30 of each SFY.
10 . "Shift' means a standard period of time assigned for a complete cycle of work, as set
by each eligible GEMT provider. The number of hours in a shift may vary by GEMT
provider, but will be consistent to each GEMT provider.
B . Supplemental Reimbursement Methodology — General Provisions
1 . Computation of allowable costs and their allocation methodology must be determined
in accordance with Medicaid cost principles at 2 C.F.R. Part 200, which establish
principles and standards for determining allowable costs and the methodology for
allocating and apportioning those expenses to the Iowa Medicaid program, except as
expressly modified below .
2 . Iowa Medicaid base payments to the GEMT providers for providing GEMT services
are derived from the Ambulance provider fee schedule established for
reimbursements payable by the Iowa Medicaid program by procedure code. The base
payments for these eligible GEMT providers are fee-for-service (FFS) payments . The
primary source of paid claims data and other Iowa Medicaid reimbursements is the
Iowa Medicaid Management Information System (IA-MMIS) . The number of paid
Iowa Medicaid FFS GEMT transports is derived from and supported by the IA-MMIS
reports for services during the applicable service period.
i
State Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN 4 NEW Approved July 12 2019
Attachment 4. 19-B
Revised Submission 7 . 10 . 19 PAGE - 16g-
State/Territory: IOWA
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
3 . The total uncompensated care costs of each eligible GEMT provider available to be
reimbursed under this supplemental payment program will equal the shortfall
resulting from the allowable costs determined using the Cost Detennination Protocols
(Section C . ) for each eligible GEMT provider rendering GEMT services to Iowa
Medicaid members net of the amounts received and payable from the Iowa Medicaid
program and all other sources of reimbursement for GEMT services provided to Iowa
Medicaid members . If the eligible GEMT providers do not have any uncompensated
care costs, then the provider will not receive supplemental reimbursement under this
supplemental payment program.
4. The Iowa Medicaid supplemental payment under this segment are the uncompensated
care costs for GEMT services provided by eligible GEMT providers to Iowa
Medicaid members as determined by the Prospective Supplemental Payment Amount
(Section D .).
C. Cost Determination Protocols
I . An eligible GEMT provider' s specific allowable cost per-GEMT transport rate will
be calculated based on the provider' s audited financial data reported on the GEMT
services cost report. The per-GEMT transport cost rate will be the sum of actual
allowable direct, shared direct, and indirect costs of providing GEMT services
(excluding cost associated with dry runs as defined in Paragraph A.6 and runs
where a Medicaid covered service was delivered but no transport occurred)
divided by the actual number of GEMT transports (including dry runs as defined in
Paragraph A. 6 and runs where a Medicaid covered service was delivered but no
transport occurred) provided for the applicable service period.
a. Direct costs for providing GEMT services include only the unallocated payroll
costs for the shifts in which personnel dedicate 100 percent of their time to
providing GEMT services, medical equipment and supplies, and other costs
directly related to the delivery of covered services, such as first-line
supervision, materials and supplies, professional and contracted services,
capital outlay, travel, and training. These costs must be in compliance with
Medicaid non-institutional reimbursement policies and are directly
attributable to the provision of the GEMT services .
State Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN # NEW Approved July 12, 2019
Attachment 4 . 19-E
Revised Submission 7 . 10. 19 PAGE - 16h-
State/Territory: IOWA
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
b . Shared direct costs for GEMT services must be allocated for personnel, capital
outlay and other costs; such as medical supplies, professional and contracted
services, training and travel . The personnel costs will be allocated based on a
percentage of total hours logged performing GEMT services activities versus
other service activities . The capital and other shared direct costs will be
allocated based on the percentage of total call volume.
c. Indirect costs are determined by applying the cognizant agency specific
approved indirect cost rate to its total direct costs (Paragraph C. La) or derived
from provider's approved cost allocation plan. Eligible GEMT providers that
do not have a cognizant agency approved indirect cost rate or approved cost
allocation plan, the costs and related basis used to determine the allocated
indirect costs must be in compliance with Medicaid cost principles specified
at 2 C .F .R. Part 200.
d . The GEMT provider specific per-GEMT transport cost rate is calculated by
dividing the total net GEMT services allowable costs (Paragraph C. La, C. Lb,
and C. l .c) of the specific provider by the total number of GEMT transports
provided by the provider for the applicable service period.
D . Prospective Supplemental Payment Amount
1 . The Department will calculate annual prospective supplemental payment amounts for
eligible GEMT provider on a per-GEMT transport basis . The per-GEMT transport
prospective supplemental payment amount for each provider is based on the
provider' s completed annual cost report in the format prescribed by the Department
for the applicable cost reporting year. The Department will make adjustments to the
as-filed cost report based on the results of the most recently retrieved IA-MMIS
report.
r
2 . Each eligible GEMT provider must compute the annual cost in accordance with the
Cost Determination Protocols (Section C .) and must submit the completed annual as-
filed cost report, to the Department five (5) months after the close of the service
period .
II
State Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN # NEW Approved July 12, 2019
Attachment 4 . 19-13
Revised Submission 7 . 10 . 19 PAGE - 16i-
State/Territory : IOWA
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
3 . The prospective supplemental payment amount is calculated by subtracting from
Iowa Medicaid ' s portion of the total GEMT allowable costs (Paragraph C . 1 ) from the
as-filed cost report adjusted by the Department (Paragraph D . 1 ), the total Iowa
Medicaid base payments (Paragraph B .2) and other payments, such as Iowa Medicaid
co-payments, received by the providers for providing GEMT services to Iowa
Medicaid members . The result of this calculation is the uncompensated care costs for
GEMT services provided to Iowa Medicaid members .
4. The result in Paragraph D . 3 is divided by the Iowa Medicaid GEMT transports
(including dry runs as defined in Paragraph A.6) from the as-filed cost report adjusted
by the Department to calculate the per-GEMT services prospective supplemental
payment amount. This amount will be paid prospectively, in addition to the Iowa
Medicaid base payments (Paragraph B . 2) on a claim by claim basis .
5 . The prospective supplemental payment amount will be updated the following July 1 ,
and every year thereafter, following submission and review of the cost report.
Specifically, the prior year' s uncompensated care amount per Medicaid transport will
be paid as an adjustment to the following year' s base rate.
E. Eligible GEMT Provider Reporting Requirements
Eligible GEMT providers shall :
1 . Submit the GEMT services cost report no later than five (5) months after the close of
the CY, unless a provider has made a written request for an extension and such
request is granted by the Department.
2. Provide supporting documentation to serve as evidence supporting information on the
submitted cost report and the cost determination as specified by the Department.
3 . Keep, maintain, and have readily retrievable, such records as specified by the
Department to fully disclose reimbursement amounts to which the eligible
government entity is entitled, and any other records required by CMS .
State Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN # NEW Approved .hely 12, 2019
Attachment 4. 19-B
Revised Submission 7 . 10 . 19 PAGE - 1G -
State/Territory: IOWA
Supplemental payment for publicly owned or operated ground emergency medical
transportation providers
4. Comply with the allowable cost requirements provided in 2 C.F.R. Part 200, and
Medicaid non-institutional reimbursement policy.
F . Department Responsibilities
1 . The Department will submit to CMS claims for GEMT services that are allowable
and in compliance with federal laws and regulations and Medicaid non-institutional
reimbursement policy.
2 . The Department will, on an annual basis, submit any necessary materials to the
federal government to provide assurances that claims will include only those
expenditures that are allowable under federal law.
3 . The Department may conduct on-site audits as necessary and will complete the audit
within two years of the postmark date of the accepted cost report.
i
State Plan TN # IA- 19-002 Effective July 1 , 2019
Superseded TN 4 NEW Approved July 12, 2019