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Home My WebLink About312010 05/31/17 CITY OF CARMEL, INDIANA VENDOR: 370756 ONE CIVIC SQUARE TREASURER STATE OF INDIANA CHECK AMOUNT: $****45,120.81* CARMEL, INDIANA 46032 INDIANA FSSA CHECK NUMBER: 312010 �y 13992 COLLECTIONS CENTER DR CHECK DATE: 05/31/17 CHICAGO IL 60693 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 101 5023990 MEDICAID 45,120.81 OTHER EXPENSES Walthall, Dianne S. From: Harrington, Michelle Sent: Tuesday, May 30, 2017 12:33 PM To: Daniel@malconindiana.com; Charles@malconindiana.com;Walthall, Dianne S. Cc: Haboush, David G; Pauley, Christine Subject: 2014 Governmental Ambulance Payment Adjustment for Managed Care Service Attachments: 2014MANAGEDCARE.pdf Importance: High Dianne, City of Carmel needs to send a $45,120.81 check made payable to Treasurer of the State of Indiana Indiana Family and Social Services Administration 13992 Collections Center Drive Chicago, IL 60693 We only have 15 days from 05/24/2017 Please call me-once check is ready to be mailed and I will pick up the check and send it- Federal Express. As you know, the Office of Medicaid Policy and Planning (DMPP) prc qualified in-state government-owned ambulance providers. The Payr r eim'sburse in-state government-owned ambulance providers the actu; ambulance services to eligible Indiana Medicaid beneficiaries. Thank you for all your continued support! Michelle Harrington- CPC EMS Administrator-HIPAA Privacy Officer City of Carmel Fire Department Office 317-571-2604 Fax 317-571-2660 1 I C I r1I 1�I (, t �� SOW v- - Eric Holcomb, Governor �C 4,S�,j & $oc"I State of Indiana J' Indiana Health Coverage Programs . � www.indianamedicaid.com r c� MYERS AND STAUFFER LC r pj� 9265 COUNSELORS ROW,SUITE 100 INDIANAPOLIS, IN 46240 �� jNISTR800.877.6927(317.846.9521 www.mslc.com/Indiana May 23, 2017 David G. Haboush Fire Chief City of Carmel Fire Department-Ambulance Service 2 Civic Square Carmel, IN 46032 RE: 2014 Governmental Ambulance Payment Adjustment for Managed Care Services UPS Tracking Number—1Z 9V1 W32 03 9419 9535 Dear Provider, As you know, the Office of Medicaid Policy and Planning (OMPP) provides a payment adjustment to qualified in-state government-owned ambulance providers. The payment adjustment is intended to reimburse in-state government-owned ambulance providers the actual incurred costs of providing ambulance services to eligible Indiana Medicaid beneficiaries. This letter communicates the managed care payment for calendar year 2014. A provider-specific cost-to- charge ratio was developed based upon a review of your fiscal year ended 2014 Indiana Medicaid Freestanding Governmental Ambulance Provider cost report. This cost-to-charge ratio was utilized to calculate the ambulance payment adjustment for Medicaid managed care ambulance services for calendar year 2014. These payments will be made by the state's contracted managed care entities during calendar year 2017. Similar to other Medicaid payments, the ambulance payment adjustment is funded in part by the federal government(federal share)and in part through state or local funds(non-federal share). The OMPP has determined that the non-federal share of the Medicaid managed care ambulance payment adjustment will be made through the use of an intergovernmental transfer(IGT)funding mechanism. An IGT is the transfer of funds from one unit of government to another. For the Medicaid managed care ambulance payment adjustment,the non-federal share must be supplied by the ambulance provider. The payment is structured as follows: 1) The provider will issue a payment to the OMPP for the state(non-federal) share of the ambulance payment adjustment. 2) Following receipt of the non-federal share, payment will be made to the provider for the total amount(federal and non-federal share)of the ambulance payment adjustment. Payments will be paid to the provider by the state's contracted managed care entities. Children's Health Insurance Program • Healthy Indiana Plan • Hoosier Care Connect Hoosier Healthwise • M.E.D.Works • Traditional Medicaid f & Soc�l Eric Holcomb,Governor State of Indiana ''T Indiana Health Coverage Programs `C www.indianamedicaid.com r • MYERS AND STAUFFER LC Gj 9265 COUNSELORS ROW,SUITE 100 INDIANAPOLIS, IN 46240 �� ly1STR,,'C�°� 800.877.6927 1 317.846.9521 www.msic.com/Indiana May 23, 2017 David G. Haboush Fire Chief City of Carmel Fire Department-Ambulance Service 2 Civic Square Carmel, IN 46032 RE: 2014 Governmental Ambulance Payment Adjustment for Managed Care Services UPS Tracking Number— 1Z 9V1 W32 03 9419 9535 Provider Name: City of Carmel Fire Department-Ambulance Service Provider Number: 200124160A 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 Govemmental Ambulance Payment Adjustment for Medicaid managed care ambulance services for calendar year 2014 is$135,234.72. The intergovernmental transfer(IGT)amount is$45,120.81. 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$45,120.81 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, IL 60693 Children's Health Insurance Program • Healthy Indiana Plan • Hoosier Care Connect i Hoosier Healthwise • M.E.D.Works • Traditional Medicaid 4�� , City of Carmel Fire Department-Ambulance Service May 23,2017 Page 2 of 2 Enclosed is a Payment Agreement and Notice of Program Reimbursement(NPR)for the ambulance payment adjustment for Medicaid managed care ambulance services for calendar year 2014. At your earliest convenience, please sign the enclosed Payment Agreement and return it to OMPP with a check for the non-federal share of the payment. Instructions for submitting the check for the IGT are contained in the enclosed NPR. We appreciate and value your participation in the Medicaid program and the care you render its recipients. Should you have any questions, please do not hesitate to contact Myers and Stauffer by telephone at 800-877-6927 or 317-846-9521. Sincerely, Myers and Stauffer LC Enclosures City of Carmel Fire Department-Ambulance Service 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 AGREEMENT BETWEEN THE CITY OF CARMEL FIRE DEPARTMENT-AMBULANCE SERVICE AND THE STATE OF INDIANA FOR ITS 2014 GOVERNMENTAL AMBULANCE PAYMENT ADJUSTMENT FOR MANAGED CARE SERVICES This Agreement is entered into by The City of Carmel Fire Department-Ambulance Service of Hamilton 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 The City of Carmel Fire Department-Ambulance Service. WHEREAS, in June 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 Forty-Five Thousand One Hundred Twenty Dollars and Eighty-One Cents ($45,120.81), 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 Hundred Thirty-Five Thousand Two Hundred Thirty-Four Dollars and Seventy-Two Cents($135,234.72),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 Hundred Thirty-Five Thousand Two Hundred Thirty-Four Dollars and Seventy-Two Cents ($135,234.72). Such payment shall be the amount of the Provider's ambulance payment adjustment described in Paragraph 2,above. (c) The Provider shall waive any appeal based on the CMS determination to disallow FFP for the Provider's Payments. Such waiver shall include any demands of payment or offset against claims by the State. 5. In the event the State is notified by CMS that FFP will not be recognized for the Payment,the State shall, within fifteen(15)calendar days after notification that CMS has declined to approve the Payment as eligible for FFP,deliver to the Provider funds in the amount of Forty-Five Thousand One Hundred Twenty Dollars and Eighty-One Cents($45,120.81). Such payment represents the Provider's IGT made in the form of a check as described in Paragraph 1, above. In the event that the State fails to make this payment in full during the fifteen(15)day period specified, the Provider shall be entitled to immediately pursue any and all recoupment efforts against DMPP. 6. This Agreement cannot be amended,modified,or supplemented in any respect except by subsequent written agreement signed by the parties. 7. This Agreement shall be governed by the laws of the State of Indiana. 8. This Agreement shall be binding upon the parties hereto, and their personal representatives,heirs,assigns,and successors in interest. IN WITNESS WHEREOF,the Provider and the State,by their duly authorized officers or agents,have executed this Agreement. THE ITY OF CARMEL FIRE DEPARTMENT-AMBULANCE SERVICE: Davi G.Haboush ` L Fire Chief 2� Date:" THE STATE OF INDIANA: Allison Taylor Interim Medicaid Director, Family and Social Services Administration Date: