HomeMy WebLinkAboutExhibit�tA
agency for persons with disabilities
State of Florida
Dick Scott December 2, 20I6
Governor
No RE: Waiver Provider Number 024990496 DUE DATE: December 31, 2016
Barbara
Palmer
Director Dear Provider,
0
Area 11 The Southern Region is moving into a 5 -year monthly agreement renewal pattern. The
111 111 agreement attached once finalized, will supersede the one you currently have with the end
401 NW 2^,, date of 6/30/2017. We thank you in advance for your cooperation in this matter.
Avenue
Suite S-811 Please sign, date, and submit the Medicaid Waiver Service Agreement Renewal and the
new "Attachment B" with your original signature to our office, along with the following
Aiami, Florida documents by or before the due date above to avoid agreement termination.
33128
111 ■ _ Valid AHCA Clearinghouse Background Screening Results – APD General
(305) 349- Required for the authorized signer/president of the company. If you do not currently
1478 have access to the AHCA Background Screening Clearinghouse, please follow the
Fax: instructions provided to you on our website: http:11apd nwIlor da.com1backgrorrnd-
(305) 377- screening/rc ig sten/
5028
_ Professional License(s) and/or Certifications:
111111 Needed for all services that require licensing or certification.
Toll Free: (i.e. All Therapies, Behavior Analysis, Behavior Assistant / Registered Behavior
(866) APD- Technicians, Nursing, Dietician, Licensed Specialized Mental Health Counselors.)
CARES
(866-273- _ Recent business report from www.sunbiz.org
2273)
_ Proof of General or Professional Liability insurance
Attach a copy of your insurance policies "Declaration Page". Please ensure APD
(including the State or Regional office address) is listed as the "CERTIFICATE
HOLDER" or listed under the "NOTICE OF CANCELATION" section in your
insurance policy/declaration page.
Required for providers of the following services:
Personal Supports, Respite, Companion, ADT, Residential Habilitation, Supported Livin
Coaching, and Specialized Mental Health Counselin .
— Auto Insurance Coverage
Valid driver license
Vehicle Registration
REQUIRED FOR APPROVED TRANSPORTATION PROVIDERS ONLY:
Auto Insurance Coverage (reflecting 100/300,000 coverage)
Valid driver license
— Vehicle Registration
PLEASE REVIEW THIS INSTRUCTIONAL LETTER CAREFULLY. FAILURE TO
RETURN ALL APPLICABLE DOCUMENT(S) INDICATED ABOVE WILL RESULT
IN TERMINATION / LAPSING OF YOUR CURRENT MEDICAID WAIVER
SERVICE AGREEMENT.
Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook
MEDICAID WAIVER SERVICES AGREEMENT
This Ag re em a nt is entered into between the Florida Agency for Persons with Disabilities, herei n a tte r
referred to as "APD," and City of Miami - Department of Parks & Recreation, hereinafter referred to as the
"Provider." Pursuant to the terms and conditions of this Agreement, APD authorizes the Provider to
furnish Home and Community -Based Services (HCBS) Medicaid waiver services to eligible APD
clients. and to receive payment for such services. Services may be authorized by multiple Region offices
for multiple service types and service locations within the respective region pursuant to the standards
specified in Florida's HCBS waivers The services that may be provided in any APD region or location
within a region are limited to the services that the respective Region office has authorized.
AGREEMENT DOCUMENTS:
A. The Medicaid Waiver Services Agreement consists of the terms and conditions specified in this
Agreement any attachments, and the following documents, which are incorporated by reference:
t. The Developmental Disabilities Individual Budgeting Medicaid Waiver Coverage and
Limitations Handbook. dated [insert date of current handbook), and any updates or
replacements thereto The Handbook can be found at the Medicaid fiscal agent's Web Portal:
http:l/www.mvmedicaid-florida.coml. Click on Public Information for Providers, then on Provider
Support, and then on Provider Handbooks. The Handbook provides the terms and conditions by
which the provider of Developmental Disabilities Individual Budgeting HCBS waiver services
agrees to be bound.
2. Attachment _, providing individually negotiated unit rates of payment for services not already
established and available on APD's.Web site: httpalwww.apdcares, org, as referenced in II.E., and
any other service or data requirements, as applicable.
B. Prior to executing this Agreement and furnishing any waiver services, the Provider must have
executed a Medicaid Provider Agreement with the Agency for Health Care Administration (ARCA) and be
issued a Medicaid provider number by AHCA. The Provider must at all times during the term of this
Agreement, maintain a current and valid Medicaid Provider Agreement with AHCA, and comply with the
terms and conditions of the Medicaid Provider Agreement.
l!. THE PROVIDER AGREES:
To comply with all of the terms and conditions contained within this Agreement, including all documents
incorporated by reference and any attachments.
A. Monitoring, Audits, Inspections, and Investigations
To permit persons duly authorized by APD, the Agency for Health Care Administration (AHCA), or
representatives of either, to monitor, audit, inspect, and investigate any recipient records, payroll and
expenditure records (ncluding electronic storage media), papers, documents, facilities, goods and
services of the Provider which are relevant to this Agreement, and to interview any recipients receiving
services and employees of the Provider to assure APD of the satisfactory performance of the terms and
conditions of this Agreement.
1. Following such monitoring. audit, inspection, or investigation, APD or its authorized representative,
will furnish to the Provider a written report of its findings and, if deficiencies are found, request
for development, by the Provider, a Plan of Remediation for needed corrections. The Provider
hereby agrees to correct all noted deficiencies identified by APD, AHCA, or their authorized
representatives within the specified period of time identified within the report documentation. Failure
to correct noted deficiencies within stated time frames may result in termination of this Agreement.
2. Upon demand. and at no additional cost to the APD, AHCA, or their authorized representatives,
the Provider will facilitate the duplication and transfer of any records or documents (including
electronic storage media). during the required retention period of six years after termination of the
Agreement, or if an audit has been initiated and audit findings have not been resolved at the end
of six years, the records shall be retained until resolution of the audit findings or any litigation
which may be based on the terms of this Agreement, at no additional cost to APD.
3_ To comply and cooperate immediately with APD requests for information, records. reports, and
documents deemed necessary to review the rate setting process to ensure that provider rates are
based on accurate information and reflect the existing operational requirements of each service.
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Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook
Any individual who knowingly misrepresents the information required in rate setting commits a felony of the third
degree, punishable as provided in sections 775.082 and 775.083, F.S.
4. To comply and cooperate immediately with any inspections, reviews, investigations or audits deemed necessary
by APD's Office of the Inspector General pursuant to section 20.055, F.S.
5. To include the aforementioned audit, inspections, investigations and record keeping requirements in all
subcontracts and assignments.
S. Confidentiality of Client Information
Not to use or disclose any information concerning a client receiving services under this Agreement for any purpose
prohibited by state or federal law or regulation, except with the written consent of a person legally authorized to give
that consent or when authorized by law. This includes compliance with: the Health Insurance Portability and
Accountability Act of 1996, 42 U.S.C. 1320d, and all applicable regulations provided in 45 CFR Parts 160, 162, and
164; and 42 CFR, Part 431, Subpart F, relating to the disclosure of information concerning Medicaid applicants and
recipients.
The computer hard drives used by APD Waiver Support Coordinators shall implement Full Disk Encryption software.
For other types of electronic data storage devices that store confidential APD consumer data, such data shall be
encrypted using a minimum of a 128 -bit encryption algorithm.
C. Indemnification
1. To be liable for and indemnify, defend, and hold APD, AHCA and all of their officers, agents, and employees
harmless from all claims, suits, judgments, or damages, including attorneys' fees and costs, arising out of any act,
actions, neglect, or omissions by the Provider, its agents, employees, or subcontractors during the performance or
operation of this Agreement or any subsequent modifications thereof, whether direct or indirect, and whether to any
person or tangible or intangible property. The Provider shall not be liable for that portion of any loss or damages
proximately caused by the negligent act or omission of APD or AHCA.
2. That its inability to evaluate its liability or its evaluation of liability shall not excuse the Provider's duty to defend
and to indemnify within 7 days after notice by APD or AHCA by certified mail. After the highest appeal taken is
exhausted, only an adjudication or judgment specifically finding the Provider not liable shall excuse performance of
this provision. The Provider shall pay all costs and fees, including attorneys' fees related to these obligations and
their enforcement by APD or AHCA. APD or AHCA's failure to notify the Provider of a claim shall not release the
Provider of these duties.
3. If the provider is an agency or subdivision of the State, its obligation to indemnify, defend, and hold harmless
shall be to the extent permitted by section 768.28, F.S. or other applicable law, and without waiving the limits of
sovereign immunity.
D. Insurance
To obtain and maintain at all times continuous and adequate liability insurance coverage during the term of this
Agreement. The Provider accepts full responsibility for identifying and determining the type and extent of liability
insurance necessary to provide reasonable financial protection for the Provider and APD clients served by the
Provider. At all times, the Provider shall maintain with APD a current certificate of insurance describing the types
and extent of liability insurance obtained pursuant to this Agreement. The Provider shall cause APD to be named
as a certificate holder under each policy of liability insurance maintained by the Provider pursuant to this Agreement.
The limits of coverage under each such policy shall not be interpreted as limiting the Providers liability and
obligations under this Agreement. All insurance policies shall be through insurers authorized or eligible to write
policies in Florida. Such coverage may be provided by a self-insurance program established and operating under
Florida law.
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Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook
E. Payment
Current rate information is available on the Medicaid fiscal agent's Web site at www.mymedicaid-florida.com. Select
Public Information for Providers, Provider Support, and then select Fee Schedules. The signatories recognize that
APD is limited by appropriation and acknowledge that Florida law requires ARCA and APD to make any adjustment
necessary to comply with the availability of moneys and any limitations or directions provided for in the General
Appropriations Act, including but not limited to adjusting fees, reimbursement rates, lengths of stay, number of visits,
or number of services, or limiting enrollment. (See sections 393.0661, 409.906, 409.908, F.S.)
F. Return of Funds
To be responsible for the timely correction of all billing or reimbursement errors resulting in an overpayment,
including reimbursement for services not properly authorized or documented. Reimbursement will be made pursuant
to the Florida Medicaid Provider Reimbursement Handbook, CMS -1500. Federal regulations, 42 CFR § 433.312,
require refund of overpayments within 60 days of discovery. AHCA will be the final authority regarding the timeliness
of the reimbursement process.
G. Independent Status
That the Provider acts at all times in the capacity of an independent service provider and not as an officer, employee,
or agent of APD, AHCA, or the State of Florida. The Provider shall not represent to others that it has the authority
to bind the APD or AHCA unless specifically authorized in writing to do so. In addition to the Provider, this is also
applicable to the Provider's officers, agents, employees, or subcontractors in performance of this Agreement.
H. Revocation of Licenses
In the event the Provider or any employee of the Provider is the holder of any license required to render the services
that are subject to this Agreement, the Provider must immediately notify APD if any such license is suspended or
revoked.
I. Change of Name or Ownership
The Provider shall notify APD and clients served of any change of name, or change, sale, or transfer of ownership
at least sixty (60) days prior to the change, sale, or transfer. Prior to the change, sale, or transfer, the Provider shall
complete the change of ownership process with Medicaid. Prior to, or contemporaneously with, the change, sale,
or transfer, the Provider must execute a new Medicaid Waiver Services Agreement to ensure no lapse in service
delivery. Clients receiving services will be given an opportunity to receive services from the new owner, purchaser,
or transferee, or to select another provider.
J. Public Records
The Provider shall: keep and maintain public records that ordinarily and necessarily would be required by APD in
order to perform the service under this Agreement; provide the public with access to public records on the same
terms and conditions that APD would provide the records, and at a cost that does not exceed the cost provided by
law; ensure that public records that are exempt or confidential and exempt from public records disclosure
requirements are not disclosed except as authorized by law; and, meet all requirements for retaining public records
and transfer, at no cost, to APD all public records in possession of the Provider upon termination of this Agreement,
and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure
requirements (all records stored electronically must be provided to the public agency in a format that is compatible
with the information technology systems of the public agency). If the Provider does not comply with a public records
request, APD shall enforce the contract provisions in accordance with the Agreement.
111. TERMINATION:
A. Termination of Agreement Without Cause
This Agreement may be terminated by either party without cause, upon no less than 30 calendar days' notice in
writing to the other party unless a lesser time is mutually agreed upon in writing by both parties. Said notice shall
be delivered by certified mail, return receipt requested, or in person with proof of delivery.
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Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook
B. Termination of Agreement With Cause
This Agreement may be terminated for the Provider's unacceptable performance, non-performance or misconduct upon
no less than 24 hours' notice in writing to the Provider. Waiver by either parity of any breach of any term or condition of
this Agreement shall not be construed as a waiver of any subsequent breach of any term or condition of this Agreement.
If APD determines that the Provider is not performing in accordance with any term or condition in this Agreement, APD
may, at its exclusive option, allow the Provider a period of time to achieve compliance. The provisions herein do not
limit APD's right to any other remedies at law or in equity.
C. Termination of Service Regions or Service Locations
When a Provider has been authorized to provide multiple service types within a region, or to provide services in multiple
regions, or at multiple locations within a region, the Provider's authorization for any individual service type, region, or
location may be revoked, without cause, upon 30 days' prior written notice, without terminating this Agreement.
IV. GOVERNING LAW.
This Agreement shall be construed, performed, and enforced in all respects in accordance with all the laws and rules
of the State of Florida, and any applicable federal laws and regulations.
V AGREEMENT DURATION.
This Agreement shall be effective 12/02/2016 or the date on which it has been signed by both parties, whichever is
later, and shall terminate on 11/3012021 which is no later than five years from the effective date.
VI. OFFICIAL REPRESENTATIVES (Names, Address, Telephone Number, and E-mail Address):
1. The Provider's contact person and street address where financial and administrative records are maintained is:
Name: Nadia Arguelles-Goicoechea
Telephone Number 305-960-4960
Address: 4560 NW 4 Terrace, Miami, FL 33126
E-mail Address: narguelles@miamigov.com
2. The representative of the Provider responsible for administration of the services under this Agreement is:
Name:
Telephone Number
Address:
E-mail Address:
4. The Agency for Persons with Disabilities contact person for this Agreement is:
Name: Hillary Jackson, Regional Program Supervisor -Southern Region
Telephone Number: 305-349-1478
Address: 401 NW 2nd Avenue, Suite 5-811, Miami, FL 33128
E-mail Address: Hillary.Jackson - apdcares.org
5. Upon change of the representative's names, addresses, telephone numbers, and e-mail addresses, by either party,
notice shall be provided in writing to the other party and the notification attached to the originals of this Agreement.
VII. INTEGRATED AGREEMENT:
Only this Agreement, any attachments referenced, the Medicaid Provider Agreement, the Developmental Disabilities
Individual Budgeting Medicaid Waiver Coverage and Limitations Handbook, which is incorporated into this
Agreement by reference, contain all the terms and conditions agreed upon by the parties.
There are no provisions, terms, conditions, or obligations other than those contained herein, and this Agreement shall
supersede all previous communications, representations, or agreements, either verbal or
September 2015 E-5
Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations
Handbook
written between the parties. If any term or provision of the Agreement is found to be illegal or
unenforceable, the remainder of the Agreement shall remain in full force and effect and such term
or provision shall be stricken.
The Provider, by signing below, attests that the Provider has received and read the entire
Agreement, inclusive of its attachments and documents as referenced in Section I, A., including
the service -specific requirements and for enrolled providers contained in the Developmental
Disabilities Individual Budgeting Medicaid Waiver Coverage and Limitations Handbook Waiver
Services Coverage and Limitations Handbook, and understands each section and paragraph.
IN WITNESS THEREOF, the parties hereto have caused this page Agreement to be executed by
their undersigned officials as duly authorized.
PROVIDER: City of Miami - Department of Parks & Recreation STATE OF FLORIDA,
SIGNED BY:
NAME:
AGENCY FOR PERSONS WITH DISABILITIES
SIGNED BY:
NAME: Evelyn Alvarez
TITLE: TITLE: Regional Operations Manager -Southern Region
DATE:
DATE:
MEDICAID PROVIDER ID: 024990496
(DD WAIVER)
AHCA Form 5000-3553, September 2015 (Incorporated by reference in Rule 59G-13.070)
September 2015
E-6
DD iBudget Waiver Services Agreement
The following rate(s) has been approved for use by the Provider. In order for the provider to bill for
individual services, the Providers must be in receipt of a current Service Authorization form from an
individual's Waiver Support Coordinator. The Service authorization form will indicate the rate approved
for individual services, and the frequency and intensity of the service that has been approved.
Approved Transportation Rate(s) (complete as appropriate for the provider)
Billing Method
Wheelchair Accessible Rate Non -Wheelchair Accessible
Rate
Non -Specified Rate
Trip
Mile
Month
120.77
Table may be expanded and headings modified to better reflect approved rates and method of payment
for the provider.
Page _ of
ATTACHMENT B TO THE
MEDICAID WAIVER SERVICES AGREEMENT
BETWEEN
AGENCY FOR PERSONS WITH DISABILITIES
AND
PROVIDER NAME
This Attachment B ("Attachment") is to the Medicaid Waiver Services Agreement ("Agreement") between
the Florida Agency for Persons with Disabilities ("APD") and City of Miami - Department of Parks &
Recreation("Provider") dated December 2, 2016.
1. Article I, Section A of the Agreement is modified by adding a new Subsection 3 thereto.
The new Subsection 3 shall read:
2. Attachment B, setting forth Provider's legal responsibilities with respect to Florida's
public records law, chapter 119, Florida Statutes.
3. Article II, Section J is hereby deleted in its entirety, and the following Section J is
substituted in lieu thereof:
J. Public Records—Section 119.0701, Florida Statutes
The Provider shall keep and maintain public records required by APD to perform the
service under this Agreement.
Upon request from APD's Custodian of Public Records, the Provider shall provide APD
with a copy of the requested records or allow the records to be inspected or copied
within a reasonable time at a cost that does not exceed the cost provided by law.
The Provider shall ensure that public records that are exempt or confidential and exempt
from public records disclosure requirements are not disclosed except as authorized by
law for the duration of the contract term and following completion of the Agreement if
the Provider does not transfer the records to APD.
Upon completion of the Agreement, the Provider shall transfer, at no cost, to APD all
public records in possession of the Provider or keep and maintain public records required
by APD to perform the service under this Agreement. If the Provider transfers all public
records to APD upon completion of the Agreement, the Provider shall destroy any
duplicate public records that are exempt or confidential and exempt from public records
disclosure requirements. If the Provider keeps and maintains public records upon
completion of the Agreement, the Provider shall meet all applicable requirements for
retaining public records. All records stored electronically must be provided to APD, upon
request from APD's Custodian of Public Records, in a format that is compatible with the
information technology systems of APD.
A request to inspect or copy public records relating to the Agreement must be made
directly to APD. If APD does not possess the requested records, APD shall immediately
notify the Provider of the request, and the Provider must provide the records to APD or
allow the records to be inspected or copied within a reasonable time. If the Provider
does not comply with APD's request for records, APD shall enforce the contract
provisions in accordance with the Agreement. If the Provider fails to provide the public
records to APD within a reasonable time, the Provider may be subject to penalties under
section 119.10, F.S.
If a civil action is filed against the Provider to compel the production of public records
relating to the Agreement, the court shall assess and award against the Provider the
reasonable costs of enforcement, including reasonable attorney fees, if (i) the court
determines that the Provider unlawfully refused to comply with the public records
request within a reasonable time; and (ii) at least 8 business days before filing the action,
the plaintiff provided written notice of the public records request, including a statement
that the Provider has not complied with the request, to APD and to the Provider. A
Provider who complies with a public records request within 8 business days after the
notice is sent is not liable for the reasonable costs of enforcement.
IF THE PROVIDER HAS QUESTIONS REGARDING THE APPLICATION OF
CHAPTER 119, F.S. TO THE PROVIDER'S DUTY TO PROVIDE PUBLIC
RECORDS RELATING TO THIS AGREEMENT,
CUSTODIAN OF PUBLIC RECORDS AT:
Agency's Public Records Coordination Office
Agency for Persons with Disabilities
4030 Esplanade Way, Suite 335
Tallahassee, FL 323990950
(850) 4101309
publicrecords@apdcares.org
CONTACT THE
This Attachment is hereby incorporated into and made a part of the Agreement.
PROVIDER: City of Miami - Department of Parks STATE OF FLORIDA
& Recreation AGENCY FOR PERSONS WITH DISABILITIES
By:
Printed Name:
By:
Printed Name: Evelyn Alvarez, ROM
Date:
Date:
Medicaid Provider ID: 024990496