HomeMy WebLinkAboutCONSENT PH Medicaid admin claims 615 Sheridan Street
Port Townsend, WA 98368
c9eehson www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Healt
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Josh D. Peters, County Administrator
FROM: Apple Martine, Public Health Director
DATE: eil44 I,g_br .2;.
SUBJECT: Agenda item — WA State Health Care Authority Interagency Agreement for
Medicaid Administrative Claiming; January 1, 2026 — December 31, 2029; Fee
for service
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH), Community Health Division, requests Board approval of the
interagency agreement with WA State Health Care Authority (HCA) for Medicaid Administrative Claiming
(MAC); January 1, 2026 — December 31, 2029
ANALYSIS/STRATEGIC GOALS/PROS and CONS:
This contract covers reimbursement for a portion of expenses incurred when performing Medicaid-related
outreach and linkage (i.e., connecting qualified clients to Medicaid covered services). Activities assist
residents who have no or inadequate medical coverage by: 1) identifying potential Medicaid clients,
2) providing information about Medicaid, 3) facilitating the enrollment of potential clients, and 4) referring
clients to medical providers for health services. The Agreement provides a process for partially reimbursing
Contractor for allowable expenses incurred by staff performing MAC activities.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
Reimbursements for services provided are based on terms established in RCW 39.34.130: 50% for MAP
services, exceptskilled Professional Medical Personnel (which is reimbursed at 75%). This revenue is
estimated and budgeted in the 2026 Jefferson County Public Health Budget to benefit Community Health and
JCPH Administration.
RECOMMENDATION:
JCPH management requests approval of the interagency agreement with HCA for Medicaid Administrative
Claiming; January 1, 2026 — December 31, 2029.
REVIEWED BY:
Olde,; ee5E44z) Ig-
mr
Jos . Peters, County Administrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 If) 360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
N-25-084
CONTRACT REVIEW FORM I Clear Form I
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: WA State Health Care Authority Contract No: N-25-084
Contract For: Medicaid Administrative Claiming Term: 1/1/2026 - 12/31/2029
COUNTY DEPARTMENT: Public Health
Contact Person: Apple Martine
Contact Phone: x 443
Contact email: amartine@co.jefferson.wa.us
AMOUNT: fee for service PROCESS: ✓ Exempt from Bid Process
Revenue: Cooperative Purchase
Expenditure: Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s) of Matching Funds Vendor List Bid
Fund# 127 RFP or RFQ
Munis Org/Obj 12720162 Other:
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIES COMPLIk W .55 80 AND CHAPTER 42.23 RCW.
CERTIFIED: t N/A: — I l Dec. 8, 2025
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT B DEBA BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: fl N/A: I ' 1 ZPot-
Dec. 8, 2025
Signature Date
STEP 3: RISK MANAGEMENT REVIEW (will be added electronically through Laserfiche):
Electronically approved by Risk Management on 12/11/2025.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 12/10/2025.
State contract - very difficult to change.
STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL
1
INTERAGENCY AGREEMENT HCA Contract Number: K8627
Washington State
Medicaid Administrative or
Contractor Contract Number:
Health Care uthority N-25-084
Claiming
THIS AGREEMENT is made by and between Washington State Health Care Authority (HCA) and Jefferson
County, (Contractor), pursuant to the authority granted by Chapter 39.34 RCW.
CONTRACTOR NAME CONTRACTOR DOING BUSINESS AS (DBA)
Jefferson County
CONTRACTOR ADDRESS I Street City State Zip Code
615 Sheridan St Port Townsend WA 98368
CONTRACTOR CONTRACT MANAGER CONTRACTOR TELEPHONE CONTRACTOR E-MAIL ADDRESS
Glenn Gilbert (360) 385-9400 ext. 421 ggilbert@co.jefferson.wa.us
HCA PROGRAM HCA DIVISION/SECTION
Medicaid Administrative Claiming _ Medicaid Programs Division/Community Services
HCA CONTRACT MANAGER NAME AND TITLE HCA CONTRACT MANAGER ADDRESS
Health Care Authority
Jon Brogger, Health Care Program Manager
626 8th Avenue SE
Olympia, WA 98504
HCA CONTRACT MANAGER TELEPHONE HCA CONTRACT MANAGER E-MAIL ADDRESS
(360) 725-1647 on brogger(a�hca wa goy
CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT
AMOUNT
January 1, 2026 December 31, 2029 No Maximum
PURPOSE OF CONTRACT:
The purpose of this Contract is to support Medicaid related outreach and linkage activities performed by Local Health
Jurisdictions (LHJ) to Washington State residents who live within its jurisdiction. These activities assist residents who
have no or inadequate medical coverage, and includes explaining the benefits of the Medicaid program, assisting them
in the Medicaid application and renewal processes, and linking them to Medicaid covered services. This Agreement
provides a process for partially reimbursing the Contractor for allowable and reasonable expenses associated with the
time its staff spend performing Medicaid Administrative Claiming (MAC) activities.
The parties signing below warrant that they have read and understand this Contract, and have authority to execute this
Contract. This Contract will only be binding upon signature by both parties. The parties may execute this contract in
multiple counterparts, each of which is deemed an original and all of which constitute only one agreement. E-mail
(electronic mail) transmission of a signed copy of this contract shall be the same as delivery of an original.
CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE
Heidi Eisenhour, Chair
Board of County Commissioners
Jefferson County Washingrton
HCA SIGNATURE PRINTFrp NAME AND TITLE DATE
DocuSiGned by. n rfa owerton
11/25/2025
-'4"" -..- Deputy Contracts Administrator
F` `T7 3 ec°°' APPROVrf')AS Tr. FORM ONLY:
v l"Ct'"`"tecember 10, 2025
Washington State Philip C. Hunsucker, Date HCA IAA K8627
Health Care Authority Chief Civil Deputy Prosecuting Attorney, Jefferson County WA Revised 07/2023
Page 1 of 35
Table of Contents
1. DEFINITIONS 3
2. STATEMENT OF WORK 9
3. PERIOD OF PERFORMANCE 9
4. PAYMENT 9
5. BILLING PROCEDURE 10
6. ACCESSIBILITY 11
7. AGREEMENT CHANGES, MODIFICATIONS AND AMENDMENTS 12
8. SUBCONTRACTING 12
9. ASSIGNMENT 12
10. CONTRACT MANAGEMENT 12
11. DISALLOWED COSTS 12
12. DISPUTES 12
13. GOVERNANCE 13
14. INDEPENDENT CAPACITY 13
15. RECORDS MAINTENANCE 13
16. RIGHTS IN DATA 14
17. CONFIDENTIALITY 14
18. SEVERABILITY 14
19. FUNDING AVAILABILITY 14
20. TERMINATION 14
21. TERMINATION FOR CAUSE 15
22. WAIVER 15
23. ALL WRITINGS CONTAINED HEREIN 15
24. SURVIVORSHIP 15
Attachment 1: Statement of Work 16
Washington State Page 2 of 35 HCA IAA K8627
Health Care Authority Revised 07/2023
1. DEFINITIONS
"A19-1A Invoice Voucher" or "A19" means the state of Washington Invoice Voucher used by
Contractors and vendors to submit claims for payment in return for goods and/or Services provided
to Health Care Authority (HCA) or its clients.
"Activity Code" or "Code" means the code assigned to the daily activities performed by Contractor
staff in order to identify the percentage of time spent on any given activity.
"Administrative Fee" means the dollar amount charged to a contractor by HCA based on a
percentage of each contractor's billing for Federal Financial Participation (FFP) claimed at the
federally approved match rate, to offset HCA's costs incurred in administering this Contract.
"Apple Health" or"Medicaid" means the Washington State Medicaid program funded by the
federal and state government, which pays for medical coverage for children and adults who meet
specific income criteria.
"Audit" means an investigation of a contractor's MAC program and financial information to ensure
compliance with state, federal, and local laws.
"Authorized Representative" means a person to whom signature authority has been delegated in
writing acting within the limits of the person's authority.
"Billing Quarter" means a calendar quarter consisting of three (3) consecutive calendar months
beginning with the first date of the calendar quarter during which this Agreement starts. The
Contractor shall use Billing Quarters as the time periods for which claims for FFP are made.
"Budget Unit" means the individual contractor eligible to submit a claim for reimbursement to HCA,
and includes all of its subunits.
"Budgeting, Accounting and Reporting System" or "BARS" or "BARS Manual" The BARS
Manual prescribes accounting and reporting for local governments in accordance with RCW
43.09.200 and found at this website https.//sao wa.gov/.
"Business Days" means Monday through Friday, 8:00 a.m. to 5:00 p.m., Pacific Time, except for
holidays observed by the state of Washington.
"Centers for Medicare and Medicaid Services" or "CMS" means the federal office under the
Secretary of the United States Department of Health and Human Services, responsible for the
Medicare and Medicaid programs.
"Certified Public Expenditure" or "CPE" means the sources of funds certified as actual
expenditures by a local or public governmental entity and used as the State share in order to receive
federal matching Medicaid funds, or Federal Financial Participation (FFP).
"Client" means an individual who is eligible for or receiving services through HCA program(s).
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"Code of Federal Regulations" or "C.F.R." means all references in this Contract to C.F.R.
chapters or sections include any successor, amended, or replacement Regulation. The C.F.R. may
be accessed at http://www.eC.F.R..qovicai-bin/EC.F R.7page=browse
"Cognizant Agency" means the federal agency responsible for reviewing, negotiating, and
approving Indirect Cost Rates.
"Confidential Information" means information that may be exempt from disclosure to the public or
other unauthorized persons under chapter 42.56 RCW or chapter 70.02 RCW or other state or
federal statutes or regulations. Confidential Information includes, but is not limited to, any information
identifiable to an individual that relates to a natural person's health, finances, education, business,
use or receipt of governmental services, names, addresses, telephone numbers, social security
numbers, driver license numbers, financial profiles, credit card numbers, financial identifiers and any
other identifying numbers, law enforcement records, HCA source code or object code, or HCA or
State security information.
"Contract" or "Agreement" means the entire written agreement between HCA and the contractor,
including any exhibits, documents, or materials incorporated by reference. MContract and
Agreement may be used interchangeably.
"Contracts Administrator" means the HCA individual designated to receive legal notices and to
administer, amend, or terminate this Contract.
"Contractor" means [Contractor Name], its employees and agents. Contractor includes any firm,
provider, organization, individual or other entity performing services under this Agreement. It also
includes any Subcontractor retained by Contractor as permitted under the terms of this Agreement.
"Corrective Action" or"Corrective Action Plan" means the written description of the plan the
Contractor will complete in order to correct any finding or deficiency as identified by HCA or
government entity.
"Cost Allocation Plan" or "CAP" means the official document which describes the procedures that
states use in identifying, measuring, and allocating state agency costs incurred in support of all
programs administered or supervised by the state agency. The Cost Allocation Plan makes explicit
reference to the methodologies, claiming mechanisms, interagency agreements, and other relevant
issues pertinent to the allocation of costs and submission of claims by MAC Contract acts. The Cost
Allocation Plan must be reviewed and approved by CMS.
"Covered Entity" has the same meaning as defined in 45 C.F.R. 160.103.
"CPE Local Match Certification" means HCA's form the Contractor must submit with each
quarterly invoice to report the source of funds certified as public expenditures and therefore eligible
to be used as match for the MAC program.
"Data" means information disclosed, exchanged or used by Contractor in meeting requirements
under this Agreement. Data may also include Confidential Information as defined in this Contract.
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•
"Data Breach" means the acquisition, access, use, or Disclosure of Data in a manner not permitted
under law or by this Contract, including but not limited to the HIPAA Privacy Rule which
compromises the security or privacy of the Protected Health Information, with the exclusions and
exceptions listed in 45 C.F.R. 164.402.
"Direct Charge Method" means the method of accounting for Direct Costs without a
stepdown allocation for single funding sources expenses wholly attributed to the MAC
program.
"Direct Cost" means an operating expenese that is wholly attributable to the MAC program and is
not already included in the Indirect Cost Rate.
"Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid Services
and Administrative Claiming" or"CMS Guide" means the document issued by CMS in 2023 and
any supplements, amendments, or successor; incorporated herein by reference which provides
guidance to States for developing and managing MAC programs.
"Designated Record Set" means a group of records maintained by or for a Covered Entity as
defined in 45 C.F.R. 160.103, that is: the medical and billing records about individuals maintained by
or for a covered health care provider; the enrollment, payment, claims adjudication, and case or
medical management record systems maintained by or for a health plan; or used in whole or part by
or for the Covered Entity to make decisions about individuals.
"Disclosure" means the release, transfer, provision of, access to, or divulging in any other manner
of information outside the entity holding the information.
"Effective Date" means the first date this Contract is in full force and effect. It may be a specific
date agreed to by the parties; or, if not so specified, the date of the last signature of a party to this
Contract.
"Electronic Protected Health Information" or "ePHI" means Protected Health Information that is
transmitted by electronic media or maintained in any medium described in the definition of electronic
media at 45 C.F.R. § 160.103.
"Eligible Participant" or "Participant" or "RMTS Participant" means an employee of the
Contractor that is in compliance with all federal, state, and HCA regulations including this Contract,
the CAP, the Manual, CMS guidance, and any other requirements for participation in the MAC
program and whose costs are eligible for claiming their staff time costs for conducting MAC activities.
"Federal Financial Participation" or "FFP" means the federal payment (or federal "match") that is
available at a rate of 50% for amounts expended by a state "as found necessary by the Secretary for
the proper and efficient administration on the state plan" per 42 CFR § 433.15(b)(7). An enhanced
FFP rate of seventy five percent (75%) is available for certain SPMP or interpretation administrative
costs. Only permissible, non-federal funding sources are allowed to be used as the state match for
FFP.
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"Fiscal Coordinator" means the Contractor's employee who is assigned to be the liaison between
HCA and the Contractor for the accounting purposes of this Agreement. The Contractor may assign
the fiscal and RMTS coordinator roles to the same staff if desired.
"HCA Contract Manager" means the individual identified on the cover page of this Contract who
will provide oversight of the Contractor's activities conducted under this Contract.
"Health Care Authority" or "HCA" means the Washington State Health Care Authority, any
division, section, office, unit or other entity of HCA, or any of the officers or other officials lawfully
representing HCA.
"Health Insurance Portability and Accountability Act of 1996" or "HIPAA" means, as codified at
42 USC 1320d-8, as amended, and its attendant Regulations as promulgated by the U.S.
Department of Health and Human Services (HHS), CMS, the HHS Office of the Inspector General,
and the HHS Office for Civil Rights. HIPAA inlcudes the Privacy, Security, Breach Notification, and
Enforcement Rules at 45 C.F.R. Part 160 and Part 164.
"Individual(s)" means the person(s) who is the subject of PHI and includes a person who qualifies
as a personal representative in accordance with 45 C.F.R. § 164.502(g).
"Indirect Cost" means an operating expense that is allocated across more than one program.
"Indirect Cost Rate" means the ratio, expressed as a percentage, of the Indirect Costs to a Direct
Cost base as approved by the Contractor's Cognizant Agency.
"Information and Communication Technology" or "ICT" means information technology and other
equipment, systems, technologies, or processes, for which the principal function is the creation,
manipulation, storage, display, receipt, or transmission of electronic data and information, as well as
any associated content. Examples include computers and peripheral equipment; information kiosks
and transaction machines; telecommunications equipment; customer premises equipment;
multifunction office machines; software; applications; websites; videos; and electronic documents.
"LHJ Claiming Manual" or "Manual" means the HCA document or its successor including any
updates, that describes how the Contractor must manage their MAC program and provides program
guidance.
"Limited Data Set(s)" means a Data set that meets the requirements of 45 C.F.R. §§ 164.514(e)(2)
and 164.514(e)(3).
"Linkage" means connecting Clients to Medicaid Covered Services.
"Local Matching Funds" means the Contractor's non-federal tax dollars that are not otherwise
obligated and are designated or certified to match the FFP rate of reimbursement.
"MAC Activity" or "Allowable Activity" or "Reimbursable Activity" or "Claimable Activity"
means an activity that is administrative in nature, and necessary for the proper and efficient
administration for the Medicaid state plan which must be in compliance as described in
applicable federal, state, HCA and CMS Regulations, the CAP, Manual, and this Agreement.
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"Medicaid Administrative Claiming" or "MAC" means the source of funding for reimbursements
provided in this Agreement shared between the Contractor and the Federal Financial Participation
(FFP).
"Medicaid Covered Services" means the array of federally required and Washington State
legislatively appropriated medical and social services available to Medicaid Clients through the State
Medicaid Plan (Apple Health).
"Medicaid Eligibility Rate" or "MER" means the proportional share of Medicaid individuals to the
total number of individuals in the target population (Contractor's jurisdiction) as defined in the CAP,
Manual and this Agreement.
"Minimum Necessary" means the least amount of PHI necessary to accomplish the purpose for
which the PHI is needed.
"Monitoring" means review of a Contractor's MAC program to ensure program integrity.
"Office of Management and Budget" or "OMB" means a division under the Executive Office of the
President of the United States.
"Operating Expense" means those costs incurred by the Contractor to perform business
activities and includes both Direct Costs and Indirect Costs. Only operating expenses
necessary to operate the Contractor's MAC program are allowable for FFP reimbursement.
"Outreach" means activities undertaken by the Contractor to inform individuals, families and
community members within its jurisdiction about Services available and encourage access to these
Services.
"Permissible Use" means only those uses authorized in this Contract and as specifically defined
herein.
"Personal Information" means information identifiable to any person, including, but not limited to,
information that relates to a person's name, health, finances, education, business, use or receipt of
governmental services or other activities, addresses (including or excluding zip code), telephone
numbers, social security numbers, driver's license numbers, credit card numbers, any other
identifying numbers, and any financial identifiers.
"Position Description" means a document summary of specific dutes and responsibilites assigned
to a staff position.
"Proprietary Information" refers to any information which has commercial value and is either: (1)
technical information, including patent, copyright, trade secret, and other Proprietary Information,
techniques, sketches, drawings, models, inventions, know-how, processes, apparatus, equipment,
algorithms, software programs, software source documents, and formulae related to the current,
future, and proposed products and services; or (2) non-technical information relating to products,
including without limitation pricing, margins, merchandising plans and strategies, finances, financial
and accounting Data and information, suppliers, customers, customer lists, purchasing Data, sales
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and marketing plans, future business plans, and any other information which is proprietary and
confidential. Contractor's Proprietary Information is information owned by Contractor to which
Contractor claims a protectable interest under law.
"Protected Health Information" or "PHI" means information that relates to the provision of health
care to an Individual; the past, present, or future physical or mental health or condition of an
Individual; or past, present or future payment for provision of health care to an Individual. 45 C.F.R.
160 and 164. PHI includes demographic information that identifies the Individual or about which
there is reasonable basis to believe, can be used to identify the Individual. 45 C.F.R. 160.103. PHI is
information transmitted, maintained, or stored in any form or medium. 45 C.F.R. 164.501. PHI does
not include education records covered by the Family Educational Rights and Privacy Act, as
amended, 20 USC 1232g(a)(4)(b)(iv).
"Random Moment Time Study" or "RMTS" or "System" or "Time Study" means an electronic
System that quantifies the daily activities of eligible time study Participants through a statistically
valid sampling methodology and allocates allowable participant costs to the MAC program. The
System calculates the amount of FFP reimbursement based on the Contractors RMTS results, staff
costs, MER, costs and other applicable calculations as described in the CAP, Manual and this
Agreement.
"RCW" means the Revised Code of Washington. All references in this Contract to RCW chapters or
sections include any successor, amended, or replacement statute. Pertinent RCW chapters can be
accessed at: http.//apps leq.wa.gov/rcw/.
"Regulation" means any federal, state, or local Regulation, rule, or ordinance
"RMTS Consortium" or "RMTS Consortia" or "Consortium" or "Consortia" means a group
of Contractors who have organized together based on similar duties their staff perform,
organizational structure, type of programs, scope of work, or regional working relationships and
will participate in a single time study together in order to achieve statistical validity.
"RMTS Coordinator" means an employee of the Contractor who is assigned to be the time study
liaison between HCA and the Contractor for purposes of this Agreement. The Contractor may assign
the fiscal and RMTS coordinator roles to the same staff if desired.
"Skilled Professional Medical Personnel" or "SPMP" means an individual who has completed a
two-or-more-year program leading to an academic degree or certificate in a medically related
profession, demonstrated by possession of a medical license, certificate or other document issued
by a recognized National or State medical licensure or certifying organization or a degree in a
medical field issued by a college or university certified by a professional medical organization.
"State Fiscal Year" or "SFY" means a twelve (12) month period beginning on July 1st of one
calendar year and ending on June 30th of the following calendar year. The SFY is broken into four (4)
Billing Quarters.
"State Medicaid Plan" means the comprehensive written commitment by HCA, submitted under
1902(a) of the Social Security Act and approved by CMS, to administer the Washington State
Medicaid program in accordance with federal and state requirements.
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"Statement of Work" or"SOW" means a detailed description of the work activities the Contractor is
required to perform under the terms and conditions of this Contract, including the deliverables and
timeline, and is included as Attachment 1.
"Subcontractor" means a person or entity that is not in the employment of the Contractor, who is
performing all or part of the business activities under this Agreement under a separate contract with
Contractor. The term "Subcontractor" means subcontractor(s) of any tier.
"Sub-unit" means an individual cost center or budget unit within a budget unit (LHJ).
"Successor" means any entity or individual which, through amalgamation, consolidation, or other
legal succession becomes invested with rights and assumes burdens of the first contractor/vendor or
any person who succeeds to the office, rights, responsibilities or place of another.
"USC" means the United States Code. All references in this Contract to USC chapters or sections
will include any successor, amended, or replacement statute. The USC may be accessed at
http.//uscode.house.govr.
"WAC" means the Washington Administrative Code. All references to WAC chapters or sections will
include any successor, amended, or replacement Regulation. Pertinent WACs may be accessed at:
http://app.leq wa qov/wac/.
2. STATEMENT OF WORK
Contractor will furnish the necessary personnel, equipment, material and/or service(s) and otherwise
do all things necessary for or incidental to the performance of work set forth in Attachment 1.
3. PERIOD OF PERFORMANCE
Subject to its other provisions, the period of performance of this Contract will commence on January
1, 2026, and be completed on December 31, 2029, unless terminated sooner or extended upon
written agreement between the parties.
4. PAYMENT
Compensation for the work provided in accordance with this Agreement has been established under
the terms of RCW 39.34.130. Compensation for services will be based on the following rates or in
accordance with the following terms.
4.1. Source of Funds for Administrative Claiming are as follows:
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4.1.1. Fifty percent (50%) of funds is received from the United States Department of
Health and Human Services under Medical Assistance Program CFDA 93.778;
and
4.1.2. Fifty percent (50%) is received from the Contractor's Local Matching Funds.
4.2. Source of funds for Administrative Claiming for appropriately documented Skilled Professional
Medical Personnel and appropriately documented Interpreter staff Administrative Claiming are
as follows:
4.2.1 Seventy-five percent (75%) of funds is received from the United States
Department of Health and Human Services under Medical Assistance Program
CFDA 93.778; and
4.2.2. Twenty-five percent (25%) is received from the contractor's local matching funds.
4.3. Local matching funds must meet CPE requirements and must be in the Contractor's budget
and under the Contractor's control. These funds cannot be contributed by or certified by
healthcare providers or subcontractors.
4.4. HCA will not issue reimbursement for any quarters where HCA receives credible evidence or
suspected evidence of a system failure that has the potential to impact the integrity of the
reimbursement request. This includes but is not limited to failures related to the time study,
MER calculation, claim calculation, or reconciliation.
4.4.1. HCA will pursue corrective action as needed and will restore payment after any
issues related to the reimbursement request are resolved, and the requested
amount is accurate.
5. BILLING PROCEDURE
5.1. Contractor must submit accurate invoices to the HCA Contract Manager for all amounts to be
paid by HCA via e-mail to the HCA Contract Manager email address listed on the cover of this
Agreement. Include the HCA Contract number in the subject line of the email.
5.2. All invoices will be reviewed and must be approved by the Contract Manager or designee prior
to payment.
5.3. Contractor shall only submit invoices for Services or deliverables as permitted by this section
of the Contract. The Contractor shall not bill HCA for Services performed under this Contract,
and HCA shall not pay the Contractor, if the Contractor is entitled to payment or has been or
will be paid by any other source, including grants, for such Services or deliverables.
5.4. Contractor must submit properly itemized invoices to include the following information, as
applicable:
5.4.1. The HCA Contract number;
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5.4.2. Contractor name, address, phone number;
5.4.3. Description of Services;
5.4.4. Date(s) of delivery;
5.4.5. Net invoice price for each item;
5.4.6. Applicable taxes;
5.4.7. Total invoice price; and
5.4.8. Payment terms and any available prompt payment discount.
5.5. HCA will return incorrect or incomplete invoices for correction and reissue. The Agreement
number must appear on all invoices, bills of lading, packages, and correspondence relating to
this Agreement.
5.6. Payment will be considered timely if made within thirty (30) calendar days of receipt of
properly completed invoices. Payment will be directly deposited in the bank account or sent to
the address Contractor designated in this Agreement.
5.7. Upon expiration or termination any claims for payment for costs due and payable under this
Agreement that are incurred prior to the expiration date must be submitted by Contractor
within sixty (60) calendar days after the expiration date. There will be no obligation to pay any
claims that are submitted sixty-one (61) or more calendar days after the expiration date
("Belated Claims"). Belated Claims will be paid at HCA's sole discretion, and any such
potential payment is contingent upon the availability of funds.
6. ACCESSIBILITY
6.1. REQUIREMENTS AND STANDARDS. Each information and communication technology (ICT)
product or service furnished under this Contract shall be accessible to and usable by
individuals with disabilities in accordance with the Americans with Disabilities Act (ADA) and
other applicable Federal and State laws and policies, including OCIO Policy 188, et seq. For
purposes of this clause, Contractor shall be considered in compliance with the ADA and other
applicable Federal and State laws if it satisfies the requirements (including exceptions)
specified in the regulations implementing Section 508 of the Rehabilitation Act, including the
Web Content Accessibility Guidelines (WCAG) 2.1 Level AA Success Criteria and
Conformance Requirements (2008), which are incorporated by reference, and the functional
performance criteria.
6.2. DOCUMENTATION. Contractor shall maintain and retain, subject to review by HCA, full
documentation of the measures taken to ensure compliance with the applicable requirements
and functional performance criteria, including records of any testing or simulations conducted.
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6.3. REMEDIATION. If the Contractor claims that its products or services satisfy the applicable
requirements and standards specified in this Section and it is later determined by HCA that any
furnished product or service is not in compliance with such requirements and standards, HCA
will promptly inform Contractor in writing of noncompliance. Contractor shall, at no additional
cost to HCA, repair or replace the non-compliant products or services within the period
specified by HCA. If the repair or replacement is not completed within the specified time, HCA
may cancel the contract, delivery, task order, or work order, or purchase line item without
termination liabilities or have any necessary changes made or repairs performed by employees
of HCA or by another contractor, and Contractor shall reimburse HCA for any expenses
incurred thereby.
6.4. INDEMNIFICATION. Contractor agrees to indemnify and hold harmless HCA from any claim
arising out of failure to comply with the aforesaid requirements.
7. AGREEMENT CHANGES, MODIFICATIONS AND AMENDMENTS
This Agreement may be amended by mutual agreement of the parties. Such amendments are not
binding unless they are in writing and signed by an Authorized Representative of each party.
8. SUBCONTRACTING
Neither the Contractor nor any Subcontractor shall enter into subcontracts for any of the work
contemplated under this Agreement without obtaining HCA's prior written approval. HCA shall have
no responsibility for any action of any such Subcontractors.
9. ASSIGNMENT
The work to be provided under this Agreement, and any claim arising thereunder, is not assignable
or delegable by either party in whole or in part, without the express prior written consent of the other
party, which consent will not be unreasonably withheld.
10. CONTRACT MANAGEMENT
The Contract Manager for each of the parties, named on the face of this Contract, will be responsible
for and will be the contact person for all communications and billings regarding the performance of
this Agreement. Either party must notify the other party within thirty (30) days of change of Contract
Management. Changes in Contract Management shall require an amendment.
11. DISALLOWED COSTS
The Contractor is responsible for any audit exceptions or disallowed costs incurred by its own
organization or that of its Subcontractors.
12. DISPUTES
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.,.
In the event that a dispute arises under this Agreement, it will be determined by a dispute board in
the following manner: Each party to this Agreement will appoint one member to the dispute board.
The members so appointed will jointly appoint an additional member to the dispute board. The
dispute board will review the facts, Agreement terms and applicable statutes and rules and make a
determination of the dispute. The dispute board will thereafter decide the dispute with the majority
prevailing. The determination of the dispute board will be final and binding on the parties hereto. As
an alternative to this process, either of the parties may request intervention by the Governor, as
provided by RCW 43.17.330, in which event the Governor's process will control.
13. GOVERNANCE
This Agreement is entered into pursuant to and under the authority granted by the laws of the state of
Washington and any applicable federal laws. The provisions of this Agreement will be construed to
conform to those laws.
In the event of an inconsistency in the terms of this Agreement, or between its terms and any
applicable statute or rule, the inconsistency will be resolved by giving precedence in the following
order:
13.1. Applicable Federal and State of Washington statutes and regulations;
13.2. Attachment 1: Statement of Work; and
13.3. Any other provisions of the agreement, including materials incorporated by reference
14. INDEPENDENT CAPACITY
The employees or agents of each party who are engaged in the performance of this Agreement will
not be considered for any purpose to be employees or agents of the other party.
15. RECORDS MAINTENANCE
15.1. The parties to this Agreement will each maintain books, records, documents and other
evidence which sufficiently and properly reflect all direct and indirect costs expended by either
party in the performance of the services described herein. These records will be subject to
inspection, review or audit by personnel of both parties, other personnel duly authorized by
either party, the Office of the State Auditor, and federal officials so authorized by law. All
books, records, documents, and other material relevant to this Agreement will be retained for
six years after expiration and the Office of the State Auditor, federal auditors, and any persons
duly authorized by the parties will have full access and the right to examine any of these
materials during this period.
15.2. Records and other documents, in any medium, furnished by one party to this Agreement to
the other party, will remain the property of the furnishing party, unless otherwise agreed. The
receiving party will not disclose or make available this material to any third parties without first
giving notice to the furnishing party and giving it a reasonable opportunity to respond. Each
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party will use reasonable security procedures and protections to assure that records and
documents provided by the other party are not erroneously disclosed to third parties.
16. RIGHTS IN DATA
Unless otherwise provided, data which originates from this Agreement will be "works for hire" as
defined by the U.S. Copyright Act of 1976 and will be owned by HCA. Data will include, but not be
limited to, reports, documents, pamphlets, advertisements, books, magazines, surveys, studies,
computer programs, films, tapes and/or sound reproductions. Ownership includes the right to
copyright, patent, register and the ability to transfer these rights.
17. CONFIDENTIALITY
Each party agrees not to divulge, publish or otherwise make known to unauthorized persons
confidential information accessed under this Agreement. Contractor agrees that all materials
containing confidential information received pursuant to this Agreement, including, but not limited to
information derived from or containing patient records, claimant file and medical case management
report information, relations with HCA's clients and its employees, and any other information which
may be classified as confidential, shall not be disclosed to other persons without HCA's written
consent except as may be required by law.
18. SEVERABILITY
If any provision of this Agreement or any provision of any document incorporated by reference will be
held invalid, such invalidity will not affect the other provisions of this Agreement, which can be given
effect without the invalid provision if such remainder conforms to the requirements of applicable law
and the fundamental purpose of this agreement, and to this end the provisions of this Agreement are
declared to be severable.
19. FUNDING AVAILABILITY
HCA's ability to make payments is contingent on funding availability. In the event funding from state,
federal, or other sources is withdrawn, reduced, or limited in any way after the effective date and
prior to completion or expiration date of this Agreement, HCA, at its sole discretion, may elect to
terminate the Agreement, in whole or part, or to renegotiate the Agreement subject to new funding
limitations and conditions. HCA may also elect to suspend performance of the Agreement until HCA
determines the funding insufficiency is resolved. HCA may exercise any of these options with no
notification restrictions.
20. TERMINATION
Either party may terminate this Agreement upon 30-days' prior written notification to the other party. If
this Agreement is so terminated, the parties will be liable only for performance rendered or costs
incurred in accordance with the terms of this Agreement prior to the effective date of termination.
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21. TERMINATION FOR CAUSE
If for any cause, either party does not fulfill in a timely and proper manner its obligations under this
Agreement, or if either party violates any of these terms and conditions, the aggrieved party will give
the other party written notice of such failure or violation. The responsible party will be given the
opportunity to correct the violation or failure within 30 days. If failure or violation is not corrected, this
Agreement may be terminated immediately by written notice of the aggrieved party to the other.
22. WAIVER
A failure by either party to exercise its rights under this Agreement will not preclude that party from
subsequent exercise of such rights and will not constitute a waiver of any other rights under this
Agreement unless stated to be such in a writing signed by an Authorized Representative of the party
and attached to the original Agreement.
23. ALL WRITINGS CONTAINED HEREIN
This Agreement contains all the terms and conditions agreed upon by the parties. No other
understandings, oral or otherwise, regarding the subject matter of this Agreement will be deemed to
exist or to bind any of the parties hereto.
24. SURVIVORSHIP
The terms, conditions and warranties contained in this Agreement that by their sense and context are
intended to survive the completion of the performance, expiration or termination of this Agreement
shall so survive. In addition, the terms of the sections titled Rights in Data, Confidentiality, Disputes
and Records Maintenance shall survive the termination of this Agreement.
Attachments
Attachment 1: Statement of Work
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ATTACHMENT 1: STATEMENT OF WORK
The purpose of this Agreement is to support Medicaid related outreach and linkage activities
performed by Local Health Jurisdictions (LHJ) to Washington State residents who live within its
jurisdiction. These activities assist residents who have no or inadequate medical coverage, and
includes explaining the benefits of the Medicaid program, assisting them in the Medicaid
application and renewal processes, and linking them to Medicaid covered services. This
Agreement provides a process for partially reimbursing the Contractor for allowable and
reasonable expenses associated with the time its staff spend performing Medicaid
Administrative Claiming (MAC) activities.
The Contractor must provide staff and perform all activities necessary to do the work outlined in
this Agreement.
1. Contractor Responsibilities
The Contractor is responsible for monitoring its MAC program to ensure compliance with all
applicable laws, regulations and guidelines specific to the MAC program as described in this
Agreement and comply with all roles, responsibilities, limitations, restrictions, and
documentation requirements described in the CAP, Manual, associated federal and state
regulations, and this Agreement. Only expenses that are reasonable and allowable, are
permitted for reimbursement. HCA expects the MAC program to be managed similarly to
other federal awards and expects the RMTS and Fiscal coordinators to report to, or work
closely, with an administrator assigned oversight authority of the LHJ.
The Contractor must:
1.1 Provide the necessary staff to perform the allowable MAC activities described in
the Cost Allocation Plan (CAP), and perform the work necessary to ensure all
applicable laws, regulations and guidelines specific to the MAC program and this
Agreement are in compliance including but not limited to:
1.1.1. Code of Federal Regulation (CFR) Title 42 and Title 45;
1.1.2. 1903(w)(6)(A) of the Social Security Act;
1.1.3. Delivering Services in School-Based Settings: A Comprehensive Guide
to Medicaid Services and Administrative Claiming 2023;
1.1.4. Revised Code of Washington (RCW);
1.1.5. The LHJ MAC Claiming Manual;
1.1.6. HCA-approved LHJ MAC training documents;
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1.1.7. 2 CFR 225 Cost Principles for State, Local, and Indian Tribal
Governments;
1.1.8. OMB Compliance Supplements;
1.1.9. Washington State Medicaid Plan; and
1.1.10. Secretary of State (SOS) records retention schedule.
1.2 Maintain documentation to support each administrative claim submitted to HCA for
reimbursement as required by federal, state, HCA and CMS Regulations, the CAP,
the Manual and this Agreement. The documentation must be sufficiently detailed in
order to determine whether the activities are necessary for the proper and efficient
administration of the Medicaid State Plan and support the appropriateness of the
administrative claim.
The Contractor must:
1.2.1 Maintain all documentation related to staff participation in the RMTS
according to section 1902(a)(4) of the Act and 42 CFR § 431.17; see
also 45 CFR § 74.53 and 42 CFR §433.32(a) (requiring source
documentation to support accounting records) and 45 CFR § 74.20 and
42 CFR § 433.32(b and c) (retention period for records) and as
described in Delivering Services in School-Based Settings A
Comprehensive Guide to Medicaid Services and Administrative
Claiming 2023;
1.2.2. Maintain all documentation related to MAC claiming, according to
section 1902(a)(4) of the Act and 42 CFR § 431.17; see also 45 CFR §
74.53 and 42 CFR § 433.32(a) (requiring source documentation to
support accounting records) and 45 CFR § 74.20 and 42 CFR §
433.32(b and c) (retention period for records) and as described in
Delivering Services in School-Based Settings. A Comprehensive Guide
to Medicaid Services and Administrative Claiming 2023;
1.2.3. Comply with the SOS records retention schedule;
1.2.4. Assure all documentation is immediately accessible and available, must
be in a useful and readable format, and must be stored electronically
within the System at every opportunity as determined by HCA;
1.2.5. Provide any and all information and documentation requested by HCA
within thirty (30) business days, or within a written, mutually agreed
upon time frame; and
1.2.6. Submit any Audit related to its MAC program to HCA within thirty (30)
business days of receipt of the final report. This includes but is not
limited to SAO Audits, OMB Circular Compliance Supplement Audits,
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Federal Reviews or Federal Audits. The contractor must provide to
HCA, any corrective action related to MAC findings and questioned
costs within thirty (30) business days of submission.
1.3. Abide by all roles, responsibilities, limitations, restrictions, and documentation
requirements including but not limited to those described in the CAP, the Manual,
and this Agreement.
1.4. Only include staff in the claimed reimbursement (through the RMTS or direct
charge method) who are eligible to participate. The Contractor is prohibited from
including any staff in the RMTS or the claimed reimbursement unless their job
positions comply with the criteria described in the CAP, the Manual, and this
Agreement.
Staff who may be eligible to be included in the RMTS or claimed reimbursement
must:
1.4.1. Not be included in another MAC time study or reimbursement claim;
1.4.2 Be directly employed or contracted by the LHJ, or an HCA approved
Subcontractor;
1.4.3. Be reasonably expected to perform MAC related activities;
1.4.4 Have all federal dollars appropriately off-set according to the CAP and
Manual;
1.4.5 Not be included in the calculation of an indirect cost rate that is used to
calculate FFP reimbursement;
1.4.6 Not include any Federally Qualified Health Clinic (FQHC) staff(or
expenses) whose costs are included in the FQHC cost report; and
1.4.7. Be job positions that fit within these job categories: nurses, other
medical professionals, other professional classifications, community
outreach and linkage classifications, manager/supervisor/administrator
classifications, or administrative support classifications as described in
the CAP and Manual.
1.5. Designate staff for an RMTS Coordinator and a Fiscal Coordinator to be
responsible for daily oversight and management of the Contractor's MAC program.
1.5.1. The RMTS and Fiscal Coordinator roles may be assumed by one
individual if desired.
1.5.2. The Contractor must submit contact information to the HCA Contract
Manager for each coordinator, including their assigned role, name,
telephone number, fax number, email, and address prior to participation
in the MAC program, within seven (7) calendar days of the change.
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1.5.3. The Contractor must ensure the Coordinators accurately perform all
responsibilities listed in the CAP, the Manual, and this Agreement.
Including but not limited to the following:
1.5.3.1. The Coordinators must participate in any scheduled RMTS
consortium conference calls; and
1.5.3.2. The Coordinators must ensure federal, state, and HCA MAC
policies are implemented.
1.6 Certify all data entered into the System is true and accurate, and based on actual
expenditures incurred during the period of performance of the invoice. This
certification must be maintained within the System. This includes, but is not limited
to: calendaring, Staff/Participant lists, salary and benefits, direct charges or other
claimed costs, indirect rate, MER, and any other data used to generate a claim to
HCA for reimbursement.
1.7. Verify all data that is determined necessary to be stored electronically within the
System or other associated websites, or databases as described in the CAP,
Manual and this Agreement is physically entered and stored according to the SOS
Retention Schedule. This data includes, but is not limited to: calendaring,
Staff/Participant lists, salary and benefits, direct charges or other claimed costs,
indirect rate, MER, and any other data used to generate a claim to HCA for
reimbursement.
1.8 Prepare an annual MER proposal by using HCA form 13-954 (Medicaid
Administrative Claiming Local Health Jurisdiction Medicaid Eligibility Rate
Proposal) to include the MER calculation and formula, the data sources used to
determine the MER, the data collection process, the Contractor's monitoring
process to ensure accuracy of the MER and any other relevant information.
1.8.1 The proposal must be submitted to HCA no later than December first of
each year.
1.8.2 The proposal must be updated and re-submitted if the data source or
collection, calculations, or monitoring changes thirty (30) business days
prior to the change.
1.9 Submit a quarterly CPE certification identifying the revenue account codes as
found in the BARS manual with each invoice validating the accuracy of the CPE.
1.10. Submit an annual certificate of indirect costs by using HCA form 02-568 (Certificate
of Indirect Costs) that certifies the accuracy of indirect cost rate proposal submitted
to their Cognizant Agency each January.
1.11. Certify the accuracy of all data used to determine a quarterly MAC reimbursement
by signing the Al 9 by an Authorized Representative. This certification extends to
all RMTS data, MER data and financial data.
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1.12. Complete a one hundred percent (100%) code review of all RMTS moments to
ensure the code and narrative correlate, within forty five (45) calendar days after
the end of the quarter.
1.13. Finalize and certify the accuracy of the 10% quality assurance review no more than
10 (ten) calendar days after the 10% review is received.
1.14. Monitor the RMTS non response rate, identify and take corrective action to resolve
any deficiencies in staff responses.
Corrective action must:
1.14.1. Be implemented within ten (10) business days; and
1.14.2. Be documented and available to HCA upon request.
1.15. Use a System that is statistically valid and in compliance with all state, and federal
laws and Regulations whether through a third-party or other means as stated in the
CAP.
1.16. Not participate in a time study or claiming process for the HCA MAC program with
any entity that does not have an executed agreement with HCA.
1.17. Not participate in an RMTS consortium without prior written approval from HCA
and express, written approval of the Consortia organization and membership.
1.18. If identified as a Lead Agency for the RMTS Consortium, the Contractor must
perform the Lead Agency duties described in the CAP and Manual and participate
in the current statewide LHJ Steering Committee, including attending LHJ MAC
work group meetings hosted by HCA.
1.19. Ensure all interpreter staff have been tested and certified by Washington State
Department of Social and Health Services (DSHS) as defined by DSHS. The
Contractor is prohibited from claiming the enhanced seventy five percent (75%)
rate for any interpretation activities unless:
1.19.1. The staff has been certified by DSHS;
1.19.2. The MAC activities performed are part of the staffs assigned job duties;
and
1.19.3. The allowable MAC activity was performed on behalf of children under
twenty one (21).
1.20. Ensure all Coordinators and Participants have completed and have certified their
understanding of the training prior to participating in the MAC program, and
annually thereafter. The contractor is prohibited from allowing any staff to
participate in the program unless they have completed and have certified their
understanding of the training.
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The Contractor must:
1.20.1. Ensure all Coordinators receive HCA approved training prior to
participation;
1.20.2. Only use training materials that have been approved in writing by HCA;;
1.20.3. Ensure all Participants certify completion of the online training before
performing any duties within the System or participating in the RMTS;
1.20.4. Ensure all Participants fully understand each RMTS Activity Code and
how to answer moments according to what activity they were doing
during the interval of the sampled moment;
1.20.5 Train all Participants to maintain proper documentation for MAC related
activities; and
1.20.6 Track the completion and certification of training within the System, and
must be available upon request by HCA.
1.21. Comply with all HCA revisions to RMTS/claiming requirements as described in the
CAP and Manual.
1.22. Only use the RMTS Activity Codes (or their successors) in the CAP or Manual as
approved by HCA, for participation in MAC.
2. Documentation and Forms
2.1. Contractor must use all forms and documentation as outlined in this Contract and
within the Manual, including but not limited to the following:
2.1.1. Utilize the RMTS System for the time study and claims calculation;
2.1.2 Utilize the current State of Washington A19-1A Invoice Voucher (A19)
produced by the System for submitting quarterly A19s to HCA;
2.1.3 Provide, maintain, and have available all supporting documentation for
the time study and claiming in a readable and usable format as required
in this Contract and Manual; and
2.1.4 Create and maintain quarterly documents reconciling all costs claimed
for each A19.
2.2. Submit all Audit reports within thirty (30) calendar days of issuance to HCA
including, but not limited to State Auditor Office (SAO) Audits, OMB Circular A-133
Single Audit Guidance, Federal Reviews, or Federal Audits.
2.2.1. Submit to HCA any corrective action related to MAC findings and
questioned costs within thirty (30) calendar days of submission.
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2.3. Maintenance of Records
During the term of any contract and for six (6) years following the termination or
expiration of the Contract, the parties must maintain records sufficient to:
2.3.1. Document performance of all acts required by any Contract and
applicable statutes, Regulations, and rules;
2.3.2 Substantiate the Contractor's statement of its organization's structure,
tax status, administrative capabilities, and performance;
2.3.3 Demonstrate accounting procedures, practices, and records which
sufficiently and properly document all invoices, expenditures, and
payments;
2.3.4 Maintain all documentation related to MAC claiming and staff
participation in the RMTS according to section 1902(a) (4) of the Act
and 42 CFR 431.17. See also 45 CFR 74.53 and 42 CFR 433.32(a),
requiring source documentation to support accounting records, and 45
CFR 74.20 and 42 CFR 433.32(b) and (c), retention period for records,
and as described in Delivering Services in School-Based Settings' A
Comprehensive Guide to Medicaid Services and Administrative
Claiming; and
2.3.5. Provide any and all information and documentation as requested by
HCA, state and/or federal Auditors and reviewers in a readable and
usable format.
3. Billing and Claiming
The Contractor must submit invoices for reimbursement to HCA for review and approval
within one hundred twenty (120) calendar days following the end of each Billing Quarter.
Upon approval, the Contractor must submit a signed A19-1A invoice voucher within thirty (30)
calendar days.
3.1. Invoices submitted after one hundred twenty (120) calendar days following the end
of the Billing Quarter may result in corrective action.
3.2 HCA will not offset negative balances against future Al 9s. The Contractor must
immediately remit a check to HCA for any funds requiring repayment.
3.3. HCA is not a recovery agent and any overpayments that are at or beyond the one
hundred eighty (180) calendar day mark will be turned over to the Office of
Financial Recovery (OFR).
3.4. HCA will not seek reimbursement for any invoice received after the 23rd month of
the two-year federal filing deadline.
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Health Care Authority Attachment 5
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3.4.1 Contractor must not bill and HCA must not pay for Services performed
under this Contract if the Contractor has charged or will charge another
agency of the State of Washington or any other party for the same
Services.
4. Calculating the FFP and Generating an Invoice
The Contractor is responsible for ensuring all data (including all RMTS and financial data)
used to calculate the amount of FFP submitted to HCA for reimbursement is accurate, based
on actual expenses incurred during the period of performance, and complies with all federal,
state, HCA and CMS Regulations, the CAP, Manual, and this Agreement. The Contractor
must certify the accuracy of all data used to calculate the amount of FFP by an Authorized
Representative signing the A19-1A Invoice Voucher (A19). The Contractor must use a
System that is statistically valid and in compliance with all state, and federal laws and
Regulations whether through a third- party or other means as stated in the CAP to calculate
the amount of FFP and generate a claim.
4.1. The Contractor must submit invoices to HCA for FFP on a quarterly basis.
4.2. All data used to calculate the FFP must be from the same period of service.
4.3. All data used to calculate the FFP must be the actual cost/expenditure and not
approximated.
4.4. The FFP is determined by calculating the total adjusted costs, multiplying these
costs by the adjusted RMTS results, and the applicable Medicaid Eligibility Rate
(MER), adding any direct charges, and then applying the appropriate FFP rate.
4.5. The invoice must be generated within one hundred twenty (120) business days of
the end of the quarter and generated based on following five components:
4.5.1. Cost pool construction;
4.5.2. Calculating allowable Medicaid administrative time via the System or
direct charge method and documentation;
4.5.3. Calculation and application of the pertinent MER;
4.5.4. Calculation and application of the indirect cost rate; and
4.5.5. Application of the appropriate FFP rate.
4.6. Cost Pool Construction
4.6.1. The Contractor must comply with all federal, state, HCA and CMS
Regulations, the CAP, Manual, and this Agreement when constructing
cost pools.
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4.6.2. The Contractor is prohibited from including any unallowable costs in any
cost pool.
4.6.3. The Contractor must include all costs used to calculate the FFP
reimbursement to one of these six (6) cost pools:
4.6.3.1. Cost Pool 1: MAC SPMP;
4.6.3.2. Cost Pool 2: MAC Non-SPMP;
4.6.3.3. Cost Pool 3a and 3b: Non-MAC;
4.6.3.4. Cost Pool 4: MAC Direct Charge — enhanced;
4.6.3.5. Cost Pool 5: MAC Direct Charge — non-enhanced; and
4.6.3.6. Cost Pool 6: Allocated.
4.6.4. Costs included in the calculation of an indirect cost rate are prohibited
from being assigned to any of the six cost pools except by application of
the indirect cost rate.
4.6.5. All costs assigned to each cost pool must be allowable and comply with
cost pool and allowability descriptions in the CAP and Manual.
4.7 Calculating Allowable Medicaid Administrative Time
The Contractor must:
4.7.1 Use only the RMTS or the Direct Charge method to calculate the
percent of reimbursable time.
4.7.2 Use the RMTS for all eligible staff who are not certified as a Single Cost
Objective.
4.7.3. Use the RMTS results produced by the System
4.7.4. Will not alter the RMTS results and will certify the accuracy of the data
by signing the Al 9 by an authorized Contractor representative.
4.7.5. Use only the Direct Charge method for staff who are certified as a
Single Cost Objective.
4.7.5.1. These staff are required to document their daily work
activities in fifteen (15) minute increments.
4.7.5.1.1. Daily logs must be maintained according to the
SOS record's retention schedule.
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4.7.5.1.2. All daily logs must have a quarterly summary
rolling up all time over the quarter.
4.7.5.2 These staff must complete a single cost objective
certification quarterly using an HCA approved form
4.7.5.3 Each single cost objective staff must be reported individually
on the invoice.
4.7.5.4 The invoice must report the name, the actual amount of time
spent performing allowable MAC activities, and total dollar
amount claimed for reimbursement for each staff.
4.8. Direct Charge for Interpretation Service Contracts
The Contractor may only direct charge for a portion of the Interpretation Service
contracts and only for allowable interpretation activities as described in this
Agreement.
4.8.1 Services direct charged must be for interpretation activities identified as
allowable activities within the Manual, the CAP, and this Agreement.
The Contractor is prohibited from including any other portion of an
Interpretation Services Contract in the calculation for FFP
reimbursement.
4.8.2. Each interpretation activity must be documented to HCA's satisfaction,
in fifteen (15) minute increments, using a patient encounter form that
includes, at minimum, the following data elements:
4.8.2.1. Appointment time/duration;
4.8.2.2. Client Name/ID/transaction information;
4.8.2.3. Interpreter Agency;
4.8.2.4. Interpreter Name or Employee ID;
4.8.2.5. Language/communication type;
4.8.2.6. Requestor or nurse name; and
4.8.2.7. The forms must be maintained according to SOS Record's
retention schedule.
4.8.3. The above data from all patient encounter forms, except Client Name/ID
Information, must be transferred onto a single spreadsheet that is
searchable and sortable must be available upon request. When
requested, the data will be provided in a readable, usable, mutually
agreed upon format.
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4.8.4 The invoice must report a summary for each Interpretation Service
contract including the names of the interpreting staff, the total amount of
time spent performing allowable MAC activities, and total dollar amount
claimed for reimbursement.
4.8.5. The Contractor is prohibited from altering the information on the patient
encounter forms and certifies the accuracy of the data entered into the
spreadsheet and the System by signing the A19 by an Authorized
Representative.
4.9. Calculation and Application of the Pertinent MER
4.9.1. All MERs must be calculated quarterly and match the methodology
outlined in the contractor's annual MER proposal.
4.9.2. All MERs must be based on the quarter claimed
4.9.3. All MAC activities that benefit the Contractors Clients directly and are
performed within a program that identifies Clients may use a Client-
based MER as described in the CAP and Manual.
4.9.4 All MAC activities that benefit the Contractor's Clients directly and are
performed within a program that operates a primary care or specialty
clinic may use a clinic-based MER as described in the CAP and
Manual.
4.9.5 All MAC activities that benefit a larger population in the geographical
region served by the Contractor, or in programs that do not identify
Clients or collect demographic data may use the modified county-wide
MER.
4.9.6. The Contractor is required to collect and maintain demographic data
used to determine Medicaid enrollment for all Clients served within
budget units whose costs are included in the FFP reimbursement. The
Contractor is prohibited from including clients from any budget unit that
is not allowable within the MAC program.
4.10. Demographic Data Requirements for the Client MER:
4.10.1. All data related to Medicaid enrollment and the MER must be
maintained according to the SOS records retention schedule.
4.10.2. The information collected must be sufficiently detailed to determine
Medicaid enrollment through HCA's ProviderOne System.
4.10.3. The information must be entered in the Contractor's Client information
System or database.
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4.10.4 The Contractor must produce a single electronic list of all unduplicated
Clients served over the quarter within thirty (30) business days of the
end of the quarter.
4.10.5 The Contractor is prohibited from including the same Client more than
once (duplicating) on the quarterly list.
4.10.6. The Contractor must submit the quarterly list to either their third party
System operator or other System operator which calculates the Client-
based and clinic-based MER.
4.11. Calculation and Application of the Indirect Cost Rate
All indirect cost rates must be developed in accordance with all applicable
regulations and guidelines including the 2 CFR Chapter I, Chapter II, part 200, et al
(OMNI Circular).
The Contractor will ensure the following:
4.11.1. Have an indirect cost rate proposal approved by their Cognizant
Agency;
4.11.2. Certify the accuracy of the indirect cost rate annually using HCA form
02-568 Certificate of Indirect Costs;
4.11.3. Verify all costs submitted to HCA for reimbursement are not duplicated
through the indirect rate or any other mechanism; and
4.11.4. The Contractor is prohibited from requesting duplicate FFP for any cost.
4.12. Application of the Appropriate FFP Rate
The Contractor is:
4.12.1 Permitted to claim seventy five percent (75%) enhanced FFP only for
specific allowable MAC activities accurately reported to SPMP or
Interpretation Activity Codes as described in the CAP and Manual;
4.12.2 Required to verify the accuracy of activities reported to Activity Codes
12b, 12c, 7c and 7d;
4.12.3. Prohibited from claiming seventy five percent (75%) FFP for any other
activities.
4.12.4 Permitted to claim fifty percent (50%) for all other accurately reported
MAC Activity Codes; and
4.12.5 Required to certify the accuracy of the FFP claimed for reimbursement
by signing the A19.
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4.13. Certified Public Expenditures
The MAC invoice must document that there are adequate non-federal, local
matching funds to support the costs of allowable MAC activities and be used as
CPE.
The Contractor is:
4.13.1 Prohibited from using any source of funds as CPE that do not comply
with federal, state, HCA and CMS Regulations, the CAP, Manual, and
this Agreement;
4.13.2 Required to certify all sources of funds used as for CPE are accurate;
allowable, and in compliance with all federal, state, HCA and CMS
Regulations, the CAP, Manual, and this Agreement quarterly by
completing a Certified Public Expenditure Local Match Certification
quarterly and by signing the A19;
4.13.3 Required to use the Budgeting, Accounting and Reporting System
(BARS manual) prescribed accounting and reporting for local
governments to identify and document the revenue account codes for
all local matching funds reported as CPE;
4.13.4. Required to ensure the source of all CPE funds are not federal tax
money and are not used as a match for federal money (by the
Contractor or any other agency);
4.13.5 Only permitted to use these funds to supplement, not supplant the
amount of federal, state and local funds otherwise expended or services
provided under this Agreement;
4.13.6. Required to have funds available for MAC activities and the funds must
be within the Contractor's control and budget;
4.13.7 Prohibited from using provider-related donations or impermissible heath
care related tax source for CPE;
4.13.8. Prohibited from using any private donations or non-public funds as a
source for CPE without authorization from CMS' Center for Medicaid
and State Operations' National Institutional Reimbursement Team
(NIRT);
4.13.9. Prohibited from requiring or allowing private non-profits to participate in
the financing of the non-federal share of expenditures;
4.13.10. Prohibited from allowing non-governmental units to voluntarily provide,
or be contractually required to provide, any portion of the non-federal
share of the Medicaid expenditures;
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4.13.11. Prohibited from using funds payable under this Agreement for lobbying
activities of any nature. The Contractor certifies that no state or federal
funds payable under this Agreement shall be paid to any person or
organization to influence, or attempt to influence, either directly or
indirectly, an officer or employee of a state or federal agency, or an
officer or member of any state or federal legislative body or committee
regarding the award, amendment, modification, extension, or renewal of
a state or federal contract grant;
4.13.12 Required to expend the total computable cost to Subcontractors for
performance of allowable MAC activities;
4.13.13. Prohibited from submitting a request for FFP reimbursement to HCA
until they have actually incurred the total computable cost; and
4.13.14. Prohibited from requiring the Subcontractor to provide the non-federal
share of the payment, or return any portion of the total computable cost
to the Contractor.
4.14. Revenue Offset
Federal or other unallowable funds that paid for MAC activities must be offset in
the MAC invoice.
The Contractor is
4.14.1 Prohibited from submitting a request for FFP reimbursement to HCA
unless all funds are appropriately offset according to all federal, state,
HCA and CMS Regulations, the CAP, Manual and this Agreement;
4.14.2. Required to certify the accuracy of the funds that are offset and the
accuracy of the requested FFP reimbursement by signing the A19;
4.14.3. Required to ensure there is no duplication in FFP reimbursement
between programs or cost objectives;
4.14.4. Financially responsible for repayment of any duplicated funds;
4.14.5 Required to provide documentation that Coordinators have been trained
and fully understands the scope of work and terms of each funding
source; and
4.14.6 Required to perform an assessment to determine whether each cost
objective contained within the MAC budget unit(s) has potential to
overlap with MAC;
4.14.7 The Contractor is prohibited from using any source of funds contained
within the MAC budget unit until they have been assessed and
determined appropriate;
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4.14.8 The Contractor must complete the assessment as frequently as
necessary to ensure proper allocation of cost, but at least annually and
must be available upon request.
4.14.9. If the assessment determines any portion of the scope of work overlaps
with MAC activities, the entire cost objective is deemed to overlap and
is prohibited from being used as CPE; and
4.14.10. Required to identify costs that must be offset, and verify the remaining
net costs are allowable for inclusion in the MAC program and eligible for
FFP reimbursement.
5. Skilled Professional Medical Personnel (SPMP) Requirements
Contractor staff who have completed a two-or-more-year program leading to an academic
degree or certificate in a medically related profession, demonstrated by possession of a
medical license, certificate or other document issued by a recognized National or State
medical licensure or certifying organization, or a degree in a medical field issued by a college
or university certified by a professional medical organization are eligible for a seventy five
percent (75%) enhanced reimbursement for specific MAC activities. Years of experience in
the administration, direction, or implementation of the Medicaid program is not considered the
equivalent of professional training in a field of medical care. The Contractor is permitted to
perform SPMP activities as directed by HCA's Chief Medical Officer(CMO) to assist in
achieving HCA's goals and administering the Medicaid State Plan.
The Contractor must:
5.1 Monitor and ensure that FFP reimbursement for SPMP activities are in compliance
with all federal, state, HCA and CMS Regulations, the CAP, Manual and this
Agreement. Federal requirements include 42 CFR § 432.2, 432.45, 432.50, and
433.15.
5 2. Have all forms and documents supporting the designation of an SPMP entered into
the System and retained according to the SOS record's retention schedule.
5.3 Not, and is prohibited from, requesting seventy five percent (75%) enhanced
reimbursement for:
5.3.1. Any staff who are not certified as an SPMP, as stated above;
5.3.2. Any staff whose position descriptions do not require certified SPMP
duties or responsibilities;
5.3.3. Any staff who are not directly employed by the Contractor;
5.3.4. Medical assistance expenditures;
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5.3.5. Any SPMP activities that are not directed by HCA's CMO and explicitly
described in this Agreement (All other allowable MAC activities
performed by an SPMP are eligible for 50% FFP); and
5.3.6. Any activities that are not directly related to the administration of the
State Medicaid plan.
5.4 Contribute to a quarterly SPMP report as needed by HCA and/or WSALPHO.
Provide details and additional information needed for the report as requested by
HCA and/or WSALPHO, within a mutually agreed upon time frame.
5.5 Participate in program planning and policy development meetings as requested by
HCA.
5.5.1. The meetings will include discussions related to, but not limited to,
reviewing the SPMP reports and related topics or the effectiveness of
the activities performed in support of HCA's goals and the Medicaid
State Plan.
5.6 Comply with any changes to the allowable SPMP activities as directed by the
CMO.
5.6.1 Failure to comply with CMO directives may result in termination of
SPMP participation in the MAC program.
5.7 Monitor and ensure that all activities reimbursed at the seventy five percent (75%)
enhanced FFP are in support of the Medicaid State Plan and fall within the
categories below. All other allowable MAC activities performed by an SPMP are
eligible for fifty percent (50%) FFP.
5.8 Comply with any changes to allowable SPMP activities as directed by the CMO
that may include, but is not limited to the following:
5.8.1. Clinical consultation with medical providers regarding best practices and
adequacy of medical care covered by Medicaid. Includes, but is not
limited to the following areas:
5.8.1.1. Pediatric immunization issues;
5.8.1.2 Access to Baby and Child Dentistry (ABCD) Emerging
treatment/therapies for high risk populations;
5.8.1.3. Coordination of Medicaid-covered medical services for
medically at-risk populations;
5.8.1.4. Medically fragile children;
5.8.1.5. High risk pregnant women;
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5.8.1.6. Homeless individuals; and
5.8.1.7. Individuals with multiple medical conditions.
5.8.2. Case staffing on the medical aspects of cases requiring Medicaid-
covered services including:
5.8.2.1. Medically involved children in foster care;
5.8.2.2. High risk pregnant women; and
5.8.2.3. Individual with communicable diseases requiring
extraordinary/non-standard medical care.
5.8.3. Planning and coordination with local medical providers to facilitate
earlier referrals and treatment for high-risk populations including but not
limited to the following:
5.8.3.1. Children in foster care;
5.8.3.2. Homeless individuals; and
5.8.3.3. Children with developmental delays or behavioral
challenges.
5.8.4. Providing medical consultation to the state regarding the Medicaid state
plan including the following:
5.8.4.1. Consultation with medical providers to improve birth
outcomes for Medicaid children; and
5.8.4.2. Consultation with school personnel to improve health
outcomes for children exhibiting developmental delays or
behavioral challenges due to medical condition, family
stress, or other factors.
5.8.5. Pediatric immunizations including but not limited to:
5.8.5.1. Clinical consultation with providers concerning strategies to
improve rates for pediatric immunizations.
5.9. Corrective Action Plan
5.10. HCA has the authority to require the Contractor to devise a Corrective Action Plan
whenever HCA concludes that the Contractor is out of compliance with any MAC
program requirements described in the CAP, Manual, or in the terms and
conditions of this Agreement. HCA will require a Corrective Action Plan if the
Contractor fails to address or correct any problems sufficiently and in a timely
manner, as determined by HCA.
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5.10.1. In the event HCA determines that the Contractor has failed to comply
with the terms and conditions of this Contract, HCA will notify the
Contractor in writing of the need to take corrective action.
5.10.2. The Contractor must develop and submit a Corrective Action Plan to
HCA for approval within thirty (30) calendar days of HCA's notification.
5.10.2.1. If corrective action is not taken within the time period agreed
to by both parties in writing, the Contract may be terminated
per Section 29, Termination for Cause.
5.10.3. If the Contractor fails to meet the requirements outlined in the
Corrective Action Plan, HCA may impose remedial actions including,
but not limited to:
5.10.3.1. Conducting more frequent reviews;
5.10.3.2. Delaying or denying payment of MAC claims;
5.10.3.3. Recouping of funds; or
5.10.3.4. Terminating the Contract.
5.10.4 Contractor actions that may result in HCA remedial actions include, but
are not limited to:
5.10.4.1. Repeated and/or uncorrected errors in financial reporting
and MAC invoicing;
5.10.4.2. Failure to maintain or provide adequate documentation;
5.10.4.3. Failure to certify quarterly invoices within 120 days after the
end of a quarter;
5.10.4.4. Failure to cooperate with state or federal staff;
5.10.4.5. Failure to provide accurate and timely information to state or
federal staff as required;
5.10.4.6. Failure to meet time study minimum RMTS response rates;
5.10.4.7. Failure to meet RMTS statistical validity requirements; and
5.10.4.8. Failure to comply with the terms and conditions of this
Agreement.
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6. Administrative Fee
HCA charges MAC contractors an Administrative Fee to offset HCA's costs for the
administration of the MAC program. The rate is based on the costs associated with the staff
effort spent on MAC related work for an entire State Fiscal Year(SFY) and is billed as a line
item on the quarterly claim form A-19-1A submitted by the MAC contractor. This cost is
divided by the dollar amount of administrative claims submitted by the participating
contractors in the MAC program for the same SFY. The calculated rate is used on the claims
for the subsequent SFY. At the end of the period, the rate used will be validated using the
actual claimed expenditures for that period and any variances will be settled with the
contractor during the second quarter of the new SFY.
7. HCA Responsibilities
Health Care Authority is responsible for performing oversight of the Contractor's MAC
program to ensure the effective administration of the MAC program and complying with all
roles, responsibilities; limitations, restrictions, and documentation requirements described in
the CAP, Manual, and this Agreement.
Including but not limited to the following:
7.1. Maintain oversight of the Contractor's MAC program and monitoring activities
including review of all components of the time study, claiming, training, or anything
MAC related.
7.2. Direct the MAC activities reimbursable at the enhanced seventy five percent (75%)
rate for all Skilled Professional Medical Personnel (SPMP) participating in the
Contractor's MAC program.
7.3 Review the Contractor's monitoring activities to ensure monitoring is occurring and
any identified issues are addressed as deemed appropriate by HCA.
This will include but is not limited to the following:
7.3.1. Review of time study responses;
7.3.2. Accuracy of coding;
7.3.3. Appropriateness of code changes; Sufficiency of backup
documentation; and
7.3.4. Non-response rates.
7.4. Verify the Contractor has entered all necessary data into the System and verify all
data entered was certified by the Contractor as accurate.
7.5. Review all claimed costs prior to issuing reimbursement to ensure they are
allowable, reasonable, and are supported by documentation that is sufficiently
detailed to permit HCA, CMS, or others to determine whether the costs are
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necessary for the proper and efficient administration of the state plan. This
includes but is not limited to; source documentation of staff costs, operating
expenses, and subcontracted vendor costs.
7.6 Review the RMTS Consortia organization and membership, including the Lead
Agency identified, annually and issuing an official notice of approval or denial.
7.7 Review all MAC related training materials prior to their use in the MAC program
and issuing an official notice of approval or denial. This includes multimedia video,
audio, digital, or other electronic sources, and paper based training materials.
7.8. Evaluate RMTS and claiming data prior to issuing quarterly reimbursements to
ensure the RMTS results and claimed costs are appropriate according to all
applicable laws, Regulations and guidelines specific to the MAC program. This
evaluation will also be used to identify trends, best practices for the MAC program,
quality assurance, training needs, areas in need of improvement, or other concerns
related to the MAC program and HCA's oversight responsibilities.
7.9 Issue corrective action plans as necessary and determined by HCA's oversight
capacity that includes but is not limited to, quarterly reviews of RMTS and claiming
data, the Contractor's failure to be in compliance with all applicable laws,
Regulations and guidelines specific to the MAC program and this Agreement, or
other quality assurance needs.
7.10. Produce and update the CAP; Manual, Contracts, training materials, or other MAC
related documentation as needed and make it available to the Contractor.
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