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Home My WebLink AboutBack-Up Documentsapd agency for persons with disabilities State of Florida Ron Desantis Tuesday, March 16, 2021 Governor ■■ Barbara Palmer CITY OF MIAMI Director C/O ADINE M. SADIN ME 4560 NW 4TH TER State Office MIAMI Florida, 33126 4030 Esplanade Way Suite 380 Tallahassee, FL 32399-noGn Provider # 024990496 M M MWSA Renewal 1st Notice Northwest Region 4030 Esplanade Way Suite280 Dear: ADINE M. SADIN Tallahassee, FL 32399-2949 ■■ This letter is to notify you that your Medicaid Waiver Services Northeast Region Agreement (MWSA) with the Agency for Persons with Disabilities 3631 Hodges Boulevard (APD) Developmental Disabilities Waiver Program (DDWP) is Jacksonville, FL 32224 going to expire on June 30, 2021. In order to continue to receive ME payment for services rendered through the DDWP, you must Central Region 400 West Robinson Street submit the documents listed below within 30 calendar days from Suite S430 the date of this letter. Orlando, FL 32801 Documents to be submitted: ■■ Suncoast Region ' Signed Medicaid Waiver Service Agreement 1313 North Tampa Street Suite 515 • Declaration Page of General/Professional Liability Tampa, FL 33602 Insurance ME Must list APD as a Certificate Holder Southeast Region 111 South Sapodilla Avenue • Level 11 Background Screening Suite 204 APD General "line item" with an eligible status in the West Palm Beach, FL 33401 Agency for Healthcare Administration {AHCA) Care ■ ■ Provider Background Screening Clearinghouse Southern Region 401 NW2ndAvenue ■ Local Criminal Records Check Suite South 811 Obtained through local law enforcement agencies Miami, FL 33128 ■ Copy of professional license or certificate (if applicable) http-.//apdcares.org Failure to submit the requested items along with the signed MWSA will result in the non -renewal of your agreement with the DDWP. Please be aware that you are not entitled to receive payment for services rendered after the expiration date of your MWSA. Please submit your documents via e-mail to Cristina.Quintero@apdcares.org Southernopenenroment(a)apdcares.org Sincerely, Cristina Quintero Administrative Secretary APD State of Florida http:llapdcares.org Medicaid Waiver Services Contract'21-'22 ADT Jul.'21 Aug.'21 I Sept.'21 Oct.'21 Nov.'21 Dec.'21 JJan.'22 Feb.'22 Mar.'22 Apr.'22 May'22 IJun.'22 ITOTAL Potential Mo. $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 $23,166.00 Potential YTD $23,166.00 $46,332.00 $69,498.00 $92,664.00 $115,830.00 $138,996.00 $162,162.00 $185,328.00 $208,494.00 $231,660.00 $254,826.00 $277,992.00 $277,992.00 Projected Mo. $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 $20,849.40 Actual +/- Proi Mo. Projected YTD $20,849.401 $41,698.801 $62,548.201 $83,397.601 $104,247.001 $125,096.401 $145,945.801 $166,795.201 $187,644.601 $208,494.001 $229,343.401 $250,192.80 $250,192.80 Actual YTD +/- YTD Notes: Number of participants 39 Hourly rate $4.95 6 hour daily rate $29.70 Avg. days per month 20 Projected absentism 10% S'` "' P. CITY OF MIAMI `y CERTIFICATE OF SELF INSURANCE COVERAGE ,t"w- INSURED: CITY OF MIAMI, A POLITICAL SUBDIVISION OF THE STATE OF FLORIDA, ITS EMPLOYEES, AGENTS AND OFFICIALS April 14, 2021 SELF INSURED EVIDENCE OF COVERAGE This Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend, nor alter the coverages or defense afforded by the self-insurance plans below. Type of Coverage Effective Expiration Limits of Liability - in Thousands Date Date GENERAL LIABILITY Bodily Injury, (X) Comprehensive Property Damage (X) Premises/Operations Personal Injury (X) Products/Completed Operations Until Combined (X) Contractual 10/1/90 canceled $200 per Claimant $300 (X) Independent Contractors or per Occurrence (X) Broad Form Property Damage revoked (X) Personal Injury Self -Insured in accordance with 5.768.28 F.S. (X) Errors & Omissions AUTOMOBILE LIABILITY Bodily Injury (X) Any Auto Property Damage O All Owned Autos 10/1/90 Until Combined (Private Passenger Autos) canceled $200 per Claimant $300 O All Owned Autos or per Occurrence (Other than Private Passenger) revoked (X) Hired Autos Self -Insured in accordance with S.768.28 F..S. (X) Non Owned Autos WORKERS COMPENSATION AND 10/1/90 Until WC Statutory Limits - Florida EMPLOYERS LIABILITY canceled or revoked Self -Insured in accordance with 5.440 F.S. BLANKET DISHONESTY BOND 10/1/90 Until $25 Per Occurrence canceled or (Including faithful performance, revoked Self -Insured in accordance with S.768.28 F.S. money & securities & depositors forgery) DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL/ITEMS: Re: MEDICARE WAIVER AGREEMENT CANCELLATION: Should any of the above described coverages be cancelled before the expiration thereof, the issuing City will endeavor to mail 10 days written notice to the Certificate Holder named, but failure to mail such notice shall impose no obligation, or liability of any kind upon the City its agents, or representatives. DP 01 N.W. 2ndAvenue suites-ll FRANK GOMEZ iami, Florida 33128 Frank Gomez Property & Casualty Manager/Ann Marie Sharpe, Director of Risk Management Risk Management Department, 444 SW 2nd Ave, Miami, FL 33130 (305) 416-1740