HomeMy WebLinkAboutAgreement A-14-677-1 with Central CA Faculty Medical Group.pdfAgreement No.14-677-1
1 ASSIGNMENT OF AGREEMENT
2 WHEREAS, on November 4, 2014, an Agreement, identified as Agreement No. 14-677 (Exhibit
3 "A") attached hereto and incorporated herein (the "Agreement"), was entered into by and between the
4 COUNTY OF FRESNO, a Political Subdivision ofthe State of California, hereinafter referred to as
5 "COUNTY," and CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, a California for-
6 profit corporation, hereinafter referred to as "CONTRACTOR" (collectively the "parties").
7 WHEREAS, under said Agreement, the CONTRACTOR is required to commence performance
8 thereunder on December 1, 2014, and shall end its performance on November 30, 2019, unless
9 terminated sooner as provided elsewhere under said Agreement; and
1 0 WHEREAS, said Agreement allows for assignment thereof with written consent of the
11 COUNTY; and
12 WHEREAS, CONTRACTOR wishes to assign the Agreement to UNIVERSITY FACULTY
13 ASSOCIATES, INC., a California non-profit corporation, hereinafter referred to as "UFA;" and
1 4 WHEREAS, UF A represents that it is qualified to accept the assignment of rights and
15 delegation of obligations of CONTRACTOR under said Agreement and agrees to each and every term
16 and condition of said Agreement.
17 NOW THEREFORE, it is agreed by all parties that the Agreement shall be transferred from
18 CONTRACTOR to UF A as follows:
19 1. CONTRACTOR does hereby transfer, assign all of CONTRACTOR rights and interests
2 0 in, and delegate all of CONTRACTOR obligations under (hereinafter referred to as "Assign" or any
21 derivative thereof, e.g., "Assignment") said Agreement to UF A and UF A does hereby accept from
2 2 CONTRACTOR such Assignment of said Agreement.
23 2. By execution of this Assignment of Agreement, the COUNTY consents to this
2 4 Assignment of said Agreement from CONTRACTOR to UF A.
25 3. By this Assignment of said Agreement, UF A agrees without qualification or reservation
2 6 of right, to perform each and every one of CONTRACTOR's obligations under said Agreement as
2 7 though UF A were the signatory party of said Agreement in lieu of CONTRACTOR.
28 4. UFA's liability under said Agreement shall be limited to that liability it shall incur
- 1 -COUN1Y OF FRESNO
Fresno, CA
arising from or in connection with UF A performance or failure to perform it.~ obligations under said
2 Agreement upon and after the ell'ective date of this Assignment of Agreement. COl\TRACTOR will
3 remain liable under said Agreement to that liability it shall incur arising from or in connection with
4 COKTRACTOR 's performance or failure to perform its obligations provided pursuant to the terms of
5 the Agreement through \-fay 15. 2015.
6 5. COU~TY shall make pa)ment to CO~TRACTOR for services rendered through May
7 15,2015 pursuant to the terms of the Agreement. COUl\TY shall make payment to U.FA for services
8 rendered beginning May 16, 20 15 pursuant to the terms of the Agreement.
This instrument shall be effective May 16, 2015. 9
lC
6.
7. The persons having authority to give and receive notices under this Agreement and their
11 address are the following:
::..2
::.3
15
16
17 Ill
18 ill
19 1/J
2C Ill
21 ill
22 Ill
23 !II
24 Ill
25 lll
2 6 /ll
27 Ill
28 ///
COCNTY
Director, County of Fresno
Department of Public Health
P.O. Box 11867
Fresno, CA 93 775
CONTRACTOR
Cniversity Faculty Associates. Inc.
Attn: Joyce Fie1ds·Keene, CEO
2625 E. Divisadero
Fresno. CA 93 721
-2 -COUt-.:'J Y 01, FRJ~SNO
Jlrc~no, C:\
1 I1\ WITNESS WHEREOF, the undersigned hereby acknowledge execution of this Assignment
2 of Agreement by their signatures.
3
4 UNIVERSITY F ACI;IJTY ASSOCIATES, INC.
5
6 By:
7
8 Print Name: Randall G. Stern, MD
g Title: .:_Pre=:si~d~en~t ______ _
Chainnan of the Board, or
:. 0 President, or any Vice President
:.2
:3
l4
15
16
17
18
19
20
21
22
23
25
26
27
28
Date:
By: .. ---· .. t;~
Print Name: Gene Ka}lsen, :\olD
Title: Secretm:y
Date:
Secretary (of Corporation). or
Chief Financial Officer, or
any Assistant Treasurer
Mailing Address:
2625 E. Divisadero Street
Fresno, CA 93721-1431
COUNTY OF FRESNO
Date:
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By~~-~
Date: '<6 / t L I lor;-
PLEASE SEE ADDITIONAL
SIGSATURE PAGE ATTACHED
COUVI'Y OF FRESNO
hcsnu,C,\
1 CENTRAL CALIFORNIA FA CUI~ TY MEDICAL GROUP
2
3
5
6
7
8
9
10
11
12
13
14
15
16
17
t
Print Name: Karl Van Gundy. MD
Title: President
Date:
Chairman of the Board, or
President. or any Vice President
By:~~
Print Name: Michael Peterso~ YID
Title: Secretary
Secretary (of Corporation), or
Chief Financial Officer, or
any Assistant Treasurer
18 Date:
19
20
21
22
23
24
25
26
27
28
PLEASE SEE ADDITIONAL
SlGNATCRE PAGE ATTACHED
-4 -COUI\TYOJI FRJ:S""O
l'f\'>1110, c:. \
1 APPROVED AS TO I .EGAL FOR\1:
2
DA~IEL CEDERBORG, COU)lTY COUNSEl,
"'\ _)
6
REVIEWED A.l\D RECO.\tME~DED
7 FOR APPROVAL:
8
9
10
11
12
13
lS
16
17
18
19
2C
21
22
23
24
25
26
27
28
/''l .· J //.· _(-·-~-~ / __..
. (_ /)" ~ '-:-/ _____ /.------_----By . // ..
David Pomaville~ Di~to;:: ··-----.~-0~-
Department of Public Health
Fund/Subclass: 0001/10000
Organization: 5240
Account/Program: 7295
SLA
Date: ____ _
Date: 7Lt 0 /z o/J ~
COl.NTY ( >F ~~~l~Sl'\0
Fresno.(,-\
EXHIBIT A
AGREEMENT NO. 14-677
AGREEMENT FOR PROVISION OF SPECIALTY AND/OR PRIMARY
PROFESSIONAL MEDICAL SERVICES AND EMERGENCY CARE
This Agreement is made and entered into this ~ay of }\)~ ....... ~ , 2014, by
and between the COUNTY OF FRESNO, a Political Subdivision of the State of California
("COUNTY") and CENTRAL CALIFORNIA FACULTY MEDICAL GROUP ("CCFMG"), a
California corporation. COUNTY and CCFMG are referred to herein, collectively, as "Parties",
or "Party" individually.
W I TN E S S E T H:
Whereas, the COUNTY is responsible for the provision of medical services necessary to
avoid suffering or endangerment to life or health to indigent lawful residents of the COUNTY,
who are not otherwise relieved by their family and friends, by their own means or by state
hospitals or other state/private institutions under Welfare and Institutions Code section 17000,
and thereby has adopted and directly administers a Medically Indigent Service Program
("MISP") (attached hereto as Exhibit 1 and incorporated by this reference, herein) for eligible
individuals (hereinafter referred to as "MISP beneficiary" or "MISP beneficiaries"); and
Whereas, the COUNTY desires to make available to MISP beneficiaries specialty
professional medical services, including adult primary care services (collectively, "specialty
and/or primary professional medical services"), provided in Exhibit 2, attached hereto and
incorporated by this reference, herein, and emergency care; and
Whereas, CCFMG, desires to provide specialty and/or primary professional medical
services, identified in Exhibit 2, herein, and emergency care to MISP beneficiaries enrolled by
the COUNTY.
Now, therefore, COUNTY and CCFMG, in consideration ofthe covenants, agreements,
and promises hereinafter set forth, agree as follows:
SECTION I-RESPONSIBILITIES OF CCFMG
1.1 Specialty and/or Primary Professional Medical Services: CCFMG, shall exclusively
perform specialty and/or primary professional medical services, identified in Exhibit 2, to
any MISP beneficiaries who do not qualify for Medi-Cal and are in need of such service(s)
to avoid suffering or endangerment to life or health in exchange for COUNTY's payment
under Section III, below. CCFMG, shall not perform any specialty and/or primary
professional medical service to any MISP beneficiary until the COUNTY's Department of
Public Health ("DPH") Director, or his/her designee, confirms to CCFMG in writing or
through the COUNTY's electronic MISP enrollment system (to which CCFMG shall have
read-only access) that such person is currently enrolled in the COUNTY's MISP.
1.2 Standard of Medical Care: CCFMG must perform specialty and/or primary professional
medical services in Exhibit 2 and emergency care, in accordance with acceptable medical
standards within Fresno County, California.
1.3 Licenses and Certification: CCFMG shall provide only qualified personnel who are
credentialed by CMC and maintain all required licenses, and board certification necessary
for the provision of services under this Agreement, for each particular specialty/area each
employee practices, required by the laws and regulations of the Federal, State of California,
and/or local governments, including any other applicable government agency or non-profit
organization, throughout the Term of this Agreement as set forth in Section 4.1 below.
1.4 Emergency Care: CCFMG acknowledge and agree that emergency care means:
A medical condition (including emergency labor and delivery) manifesting itself by
acute symptoms of sufficient severity, including severe pain, such that the absence of
immediate medical attention could reasonably be expected to result in any of the
following: (1) Placing the patient's health in serious jeopardy. (2) Serious
impairment to bodily functions. (3) Serious dysfunction to any bodily organ or part.
(Welf. & Inst. Code, §14007.5, subd. (d); 22 C.C.R. §51056, subd. (b); 42 U.S.C.
§ 1396b, subd. (v)(3); and 42 C.F.R. §440.255)
1.5 Emergency Care Services: CCFMG will only be eligible to receive compensation from
COUNTY for providing emergency care under Section III herein: (1) after they first seek
reimbursement for individuals who qualify for Medi-Cal or Restricted Medi-Cal; (2) the
person applies for MISP no later than thirty (30) calendar days from the first date he/she
receives the care (in accordance with the "Certification Period" in the MISP, Exhibit 1 ); and
(3) the COUNTY determines that such person would have qualified as a MISP beneficiary at
the time the emergency care was provided under the eligibility requirements within
Exhibit 1.
1.6 Medicare/Medi-Cal: CCFMG acknowledges that all medical staff are able to participate in
the Medicare and Medi-Cal (MAGI and Non-MAGI) programs under Titles XVIII and
XIX of the Social Security Act, and will continue to be able to participate in the Medicare
and Medi-Cal (MAGI and Non-MAGI) programs throughout the Term set forth under
Section 4.1, below.
1. 7 Comprehensive Hospital Services: CCFMG acknowledges and agrees that this Agreement
is only for the provision of specialty and/or primary professional medical services in Exhibit
2 and emergency care. Therefore, no compensation shall be provided to CCFMG for any
provision of comprehensive hospital services.
1.8 Service Performed At CMC Facilities: CCFMG shall exclusively provide services at the
Fresno Community Hospital and Medical Center ("CMC") facilities to MISP beneficiaries.
2
1.9 Referral of Comprehensive Hospital Services: To the extent CCFMG determines that an
MISP beneficiary needs hospital services, CCFMG shall refer the MISP beneficiary to CMC
to obtain such necessary services.
1.10 Financing: Except for compensation under Section III below, CCFMG shall, at their own
expense, be responsible for financing their operation and capital expenses and cash flow
requirements in providing services herein.
1.11 Eguipment and Supplies: CCFMG shall ensure that they have the necessary medical
equipment, supplies and pharmaceuticals when providing specialty and/or primary
professional medical services, herein, including emergency care to the extent permitted
under Sections 1.4-1.5, above.
1.12 No Right To Select MISP Beneficiaries: CCFMG shall not have the right to select the
persons who may enroll in the COUNTY's MISP.
1.13 Multilingual Services: CCFMG in collaboration with CMC shall ensure appropriate
capability for communicating with MISP beneficiaries who are hearing impaired, non-
English speaking and/or limited English speaking to the extent required by law and to the
extent reasonably required to provide such specialty and/or professional medical
services/emergency care.
1.14 No Treatment Permitted: CCFMG shall not provide treatment to any person under this
Agreement if such person: (1) is not a MISP beneficiary; (2) is not in need of specialty
and/or primary professional medical services or emergency care to avoid suffering or
endangerment to his/her life or health; or (3) seeks a medical service prohibited under the
MISP, Exhibit 1 herein.
1.15 Compliance With Legal Reguirements: In providing specialty and/or primary
professional medical services as set forth in Exhibit 2, herein, emergency care as set forth in
Sections 1.4 and 1.5, herein and providing necessary profession medical services, CCFMG
shall provide such services in accordance with all applicable laws and regulation of the
Federal, State of California and local governments, including but not limited to, any binding
relevant case law.
SECTION II-COUNTY RESPONSIBLITIES
2.1 Administrative Service: Throughout the Term ofthis Agreement set forth in Section 4.1,
COUNTY will be solely responsible for determining who is eligible to enroll in the MISP
(see MISP criteria, Exhibit 1). In doing so, COUNTY shall enroll persons in MISP through
its electronic MISP enrollment system, COUNTY shall provide CCFMG with read-only
access to the electronic MISP enrollment system, so that CCFMG may verify who is
currently enrolled in MISP prior to conducting non-emergency professional medical
services herein, or after conducting emergency service herein. For purpose of this
3
Agreement, COUNTY's DPH Director or his/her designee shall confirm in writing or
through the COUNTY's electronic MISP enrollment system to CCFMG whether a person
is currently a MISP beneficiary who would qualifY for specialty and/or primary professional
medical services under Exhibit 2, herein
2.2 Emergency Care: In the event CCFMC determines that a person does not qualifY for Medi-
Cal or Restricted Medi-Cal, but CCFMG perform emergency care, as defmed in Section 1.4
above, to such person, the person receiving such emergency care shall submit an MISP
application to COUNTY within thirty (30) calendar days of the first day he/she received
such care. COUNTY's DPH Director or his/her designee shall promptly thereafter
determine whether such person would have qualified for MISP (under Exhibit 1, herein) at
the time the emergency care was provided. If COUNTY fmds the person would have
qualified for MISP (under Exhibit 1, herein) at the time he/she received such emergency
care, COUNTY shall inform CCFMG in writing and compensate CCFMG for providing
such service in accordance with Section III, below.
SECTION III -COMPENSATION
3.1 CCFMG Reimbursement for Specialty and/or Primarv Professional Medical Services:
3.1.1 Negotiated Service Rates: For the Term of this Agreement set forth in Section
4.1, specialty and/or primary professional medical services rendered hereunder by
CCFMG to MISP beneficiaries shall be reimbursed according to the negotiated
fee for service rates in Exhibit 3, attached hereto and incorporated by this
reference, herein.
3.1.2 Share of MISP Beneficiary Cost Will be Deducted: MISP beneficiaries between
the income range of 139% to 224% ofthe federal poverty level (and who meet the
other MISP eligibility criteria) are permitted to obtain necessary specialty and/or
primary professional medical services under the MISP if they pay for a certain
share of the cost as set forth in the COUNTY's MISP. (See Pages 5 to 6 in
Exhibit 1 ). CCFMG shall be responsible to obtain the MISP beneficiaries share
of cost if it provides specialty and/or primary professional medical services to
MISP beneficiaries, herein. COUNTY shall deduct the MISP beneficiaries' share
of cost from invoices provided by CCFMG under this Agreement.
3.1.3 Compensation Contingencies: CCFMG shall only be entitled to reimbursement
for specialty and/or primary professional medical services under this Section 3.1,
if: (1) the medical services provided to MISP beneficiaries are medically
necessary to avoid suffering or endangerment to life or health; (2) prior to
providing non-emergency specialty and/or primary professional medical services
CCFMG is notified by COUNTY in writing or through the COUNTY's electronic
MISP enrollment system that the person to receive such service is enrolled in the
MISP and, therefore, qualified to receive such care; (3) the MISP beneficiary does
not qualifY for Medi-Cal; and (4) prior to providing non-emergency specialty
4
and/or primary professional medical services written authorization is obtained
from COUNTY to perform the particular service.
3.2 CCFMG's Reimbursement for Emergency Care:
3.2.1 Negotiated Service Rates: For the Term of this Agreement set forth in Section
4.1, emergency care rendered hereunder by CCFM G, to MISP beneficiaries shall
be reimbursed according to the negotiated fee for service rates in Exhibit 3,
attached hereto and incorporated by this reference, herein.
3 .2.2 Share of MISP Beneficiary Cost Will be Deducted: MISP beneficiaries between
the income range of 139% to 224% ofthe federal poverty level (and who meet the
other MISP eligibility criteria) are permitted to obtain emergency care under the
MISP if they pay for a certain share of the cost as set forth in the COUNTY's
MISP. (See Pages 5 to 6 in Exhibit 1). CCFMG shall be responsible to obtain the
MISP beneficiaries share of cost if it provides emergency care to MISP
beneficiaries, herein. COUNTY shall deduct the MISP beneficiaries' share of cost
from invoices provided by CCFMG under this Agreement.
3 .2.3 Compensation Contingencies: CCFMG shall only be entitled to reimbursement
for emergency care under this Section 3.2, if: (1) ifthe person who received
emergency care, or his/her authorized agent, applies for MISP no later than thirty
(30) calendar days from the first date he/she receives emergency care (in
accordance with the "Certification Period") in the MISP, Exhibit 1; and (2) the
COUNTY determines that such person would have qualified to enroll in MISP at
the time the emergency care was provided under the MISP eligibility
requirements in Exhibit 1.
3.3 Maximum Compensation: In no event shall total compensation and any other payment for
services performed under this Agreement be in excessive of Two Million, Three Hundred
Forty-Seven, Seven Hundred Thirty-Two Dollars ($2,347,732) for the entire three (3) year
period of this Agreement. If this Agreement is extended for an additional one ( 1) year
period after the first three (3) years of this Agreement, pursuant to Section 4.1, in no event
shall total compensation and any other payment for the services performed under this
Agreement be in excess of Three Million, Ninety-Seven Thousand, Seven Hundred Thirty-
Two Dollars ($3,097,732) for the entire four (4) year period of this Agreement. If this
Agreement is extended for an additional one ( 1) year period after the first four ( 4) years of
this Agreement, pursuant to Section 4.1, in no event shall total compensation and any other
payment for the services performed under this Agreement be in excess of Three Million,
Eight Hundred Forty-Seven Thousand, Seven Hundred Thirty-Two Dollars ($3,847,732) for
the entire five ( 5) year period of this Agreement.
CCFMG agrees to provide County with written notice, in accordance with Section 7.1, when
it has expended costs under this Agreement in the amount of eight-five percent (85%) of the
maximum compensation limit for the base three (3) year period, so that County may take
necessary action to either amend this Agreement to increase the maximum compensation
5
limits herein or terminate this Agreement pursuant to Section 4.2. If this Agreement is
extended for an additional one (1) year period after the first three (3) years of this
Agreement, pursuant to Section 4.1, CCFMG agrees to provide County with written notice,
in accordance with Section 7.1 , when it has expended costs under this Agreement in the
amount of eight-five percent (85%) of the maximum compensation limit for the four (4)
year period of the Agreement. If this Agreement is extended for an additional one (1 ) year
period after the first four (4) years of this Agreement, pursuant to Section 4.1, CCFMG
agrees to provide County with written notice, in accordance with Section 7.1, when it has
expended costs under this Agreement in the amount of eight-five percent (85%) of the
maximum compensation limit for the five (5) year period of the Agreement.
3.4 Billing: After CCFMG renders professional medical services to MISP beneficiaries herein
and meet the contingencies in Sections 3.1-3.2, herein, to obtain such compensation,
CCFMG shall submit to COUNTY invoices that contain: (1) the date(s) of service; (2) full
and complete descriptions of each service provided; (3) the cost of each service provided;
(4) the Medicare codes utilized to determine cost of service; and (5) the name and current
contact information of the MISP beneficiary who received such services.
Claims shall be submitted to County electronically or on a HCF A-1500 billing form.
CCFMG, agrees to submit invoices/claims to COUNTY for services referred under this
Agreement no later than ninety (90) days after the service was delivered or ninety (90) days
after an MISP beneficiary has been discharged from a CMC facility, whichever is later.
COUNTY agrees to pay CCFMG, subject to the contingencies in Sections 3.1 and 3.2 herein,
forty-five (45) calendar days after receipt and verification of the invoices from CCFMG.
Invoices shall be submitted to County of Fresno, Department of Public Health, P.O. Box
11867, Fresno, CA 93775, Attention: DPH Director. Invoices shall include the amount due
for professional medical services listed under Exhibit 2, herein.
COUNTY agrees that invoices submitted by CCFMG shall be presumed to be coded and billed
correctly pursuant to the current Medicare regulations and guidance located at:
http:/ /www.cms.gov/Medicare/Medicare.html
SECTION IV-TERM & TERMINATION
4.1 Term: This Agreement shall become effective at 12:00 a.m. on December 1, 2014 and
shall terminate on 11:59 p.m. on November 30, 2017.
This Agreement may be extended by COUNTY for up to two (2) additional,
successive twelve (12) month periods upon the same terms and conditions set forth
herein. Each such extension period will be contingent upon both Parties mutual
consent to continue this Agreement for the then successive twelve {12) month
period at least ninety (90) calendar days prior to each successive twelve (12)
month extension period. Notwithstanding anything to the contrary in this Section
6
4.1, either Party may terminate this Agreement in accordance with Section 4.2,
below.
4.2 Termination:
4.2.1 Non-Allocation of Funds: The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating
government agency. Should sufficient funds not be allocated, the services
provided may be modified, or this Agreement terminated at any time by giving
CCCFMG at least ninety (90) calendar days advance written notice.
4.2.2 Suspension: If a substantial part of the services which CCFMG has agreed to
provide hereunder is interrupted due to a catastrophic event beyond the control of
CCFMG, COUNTY may elect to terminate this Agreement upon ten (10) days
prior written notice to CCFMG.
4.2.3 Material Breach of Contract: Except for the foregoing in Sections 4.2.1 and 4.2.2
herein, this Agreement may be terminated by either Party should the other Party
materially default in the performance of this Agreement. Either Party, upon
issuing at least a ninety (90) calendar day prior written notice to the other Party,
may terminate this Agreement upon the material breach of this Agreement by the
other Party. The defaulting Party shall have forty (40) calendar days from the
receipt of notice to correct the basis for termination and resolve the dispute in
accordance with Section VIII below. If so, corrected to the reasonable
satisfaction of the non-defaulting Party, this Agreement shall continue according
to the terms and conditions herein.
4.2.4 Without Cause: This Agreement may be terminated by either Party without cause
upon either Party issuing at least a ninety (90) calendar day written notice of
termination to the other Party.
Upon termination or expiration of this Agreement, each Party shall continue to
remain liable for their own obligations or liabilities, as indicated herein,
originating prior to termination of this Agreement.
SECTION V-MODIFICATION AND ASSIGNMENT
5.1 Modification: Any matters of this Agreement may be modified by the written consent of all
Parties without, in any way, affecting the remainder.
5.2 Non-Assignment: This Agreement is personal in nature and the rights or duties hereunder
shall not be transferred, delegated, or assigned by either Party, without the prior written
consent of the other Party.
7
5.3 Subcontractors: CCFMG may subcontract the performance of certain services of this
Agreement to other third party agents, only if CCFMG obtains the prior written approval
from COUNTY. Any subcontractor will be subject to all applicable provisions of this
Agreement, and all applicable State of California and Federal regulations. CCFMG will be
responsible for informing any subcontractors, and requiring any subcontractors to comply
with all the terms and conditions of this Agreement and of all the Federal and State of
California law requirements incorporated herein. CCFMG shall be responsible to COUNTY
for the performance of any subcontractor. The use of subcontractors by CCFMG shall not
entitle CCFMG to any additional compensation or other payment than is provided for under
this Agreement.
SECTION VI-INDEPENDENT CONTRACTOR
6.1 Independent Contractor: In the performance of the work, duties, obligations assumed by
CCFMG under this Agreement, it is mutually understood and agreed that CCFMG officers,
agents, and employees will at all times be acting and performing as an independent
contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venture, partner, or associate of COUNTY. Furthermore, COUNTY shall
have no right to control or supervise or direct the manner or method by which CCFMG shall
perform their work and function. However, COUNTY shall retain the right to administer
this Agreement so as to verify that CCFMG is performing its obligations in accordance with
the terms and conditions thereof. COUNTY and CCFMG shall comply with all applicable
provisions of law and the rules and regulations, if any, of governmental authorities having
jurisdiction over matters which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CCFMG shall have absolutely no right to
employment rights and benefits available to COUNTY employees. CCFMG shall be solely
liable and responsible for providing to, or on behalf of, its employees all legally -required
employee benefits. In addition, CCFMG shall be solely responsible and save COUNTY
harmless from all matters relating to the payment ofCCFMG's employees, including
compliance with Social Security withholding and all other regulations governing such
matters. It is acknowledged that during the term of this Agreement, CCFMC may be
providing services to others unrelated to the COUNTY or to this Agreement.
SECTION VII -NOTICES
7.1 Notices: Any notice required to be given pursuant to the terms and provisions of this
Agreement shall be in writing and may either be personally delivered or sent by registered
or certified mail in the United States Postal Service, return receipt requested, postage
prepaid, addressed to each party at the address which follows:
8
CCFMG:
Central California Faculty Medical Group
Attn: Joyce Fields Keene, CEO
Title Chief Executive Officer
Address 2625 E. Divisadero
Fresno, CA 93721
COUNTY:
Director, County of Fresno
Department of Public Health
P.O. Box 11867
Fresno, CA 93775
SECTION VIII-CONTRACT DISPUTE RESOLUTION
8.1 Dispute Resolution: If any claim, dispute, or controversy (any or all of which shall be
hereinafter referred to as dispute) shall arise between the Parties with respect to the making,
construction, terms, or interpretation of this Agreement or any breach thereof, or the rights
or obligations of any Party hereto, the Parties shall seek, in good faith, to informally resolve
their dispute( s) to the maximum extent possible. If any dispute between the Parties cannot
be resolved informally within twenty (20) calendar days, the Parties may agree to settle the
dispute by non-binding mediation, unless the Parties mutually agree otherwise. The
mediator shall be mutually selected by the Parties, but in the case of disagreement, the
mediator shall be selected by lot from among two (2) nominations provided by each Party.
All costs and fees required by the mediator shall be split equally by the Parties; otherwise
each Party shall bear its own costs of medication. If mediation fails to resolve the dispute
within twenty (20) calendar days, each Party reserves the right to resolve the dispute in any
manner provided by law or in equity in Fresno, California.
SECTION IX-MISCELLANEOUS PROVISIONS
9.1 Indemnification: CCFMG agrees to indemnify, save, hold harmless, and at COUNTY's
request, defend the COUNTY, its officers, agents, and employees, from any and all costs
and expenses, damages, liabilities, claims and losses occurring or resulting to COUNTY in
connection with the performance, or failure to perform, by CCFMG, officers, agents, or
employees under this Agreement, and from any and all costs and expenses, damages,
liabilities, claims, and losses occurring or resulting to any person, firm, or corporation who
may be injured or damaged by the performance, or failure to perform, of CCFMG agents, or
employees under this Agreement.
COUNTY agrees to protect, defend, indemnify and hold harmless, and at CCFMG's
request, defend CCFMG, its officers, agents, and employees, from any and all costs and
expenses, damages, liabilities, claims and losses occurring or resulting to CCFMG in
9
connection with the performance, or failure to perform, by COUNTY, and its officers,
agents, or employees under this Agreement, and from any and all costs and expenses,
damages, liabilities, claims, and losses occurring or resulting to any person, firm, or
corporation who may be injured or damaged by the performance, or failure to perform, of
COUNTY, its officers, agents, or employees under this Agreement.
9.2 Insurance: Without limiting a Party's right to obtain indemnification from the other Party
or any third parties, CCFMG, at its sole expense, shall maintain in full force and effect, the
following insurance policies throughout the term of this Agreement:
9 .2.1 Commercial General Liability: Commercial General Liability Insurance
with limits of not less than One Million Dollars ($1,000,000) per
occurrence and an annual aggregate of Two Million Dollars ($2,000,000).
This policy shall be issued on a per occurrence basis. COUNTY may
require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground
(XCU), fire legal liability or any other liability insurance deemed
necessary because of the nature of the Agreement.
9.2.2 Professional Liability: If CCFMG employs licensed professional staff
(e.g., PhD, MD, PA, NP, RN, LCSW, LMFT, LPCC) in providing
services, Professional Liability Insurance with limits of not less than Three
Million Dollars ($3,000,000) per occurrence, Five Million Dollars
($5,000,000) annual aggregate.
This coverage shall be issued on a per claim basis. CCFMG agrees that it
shall maintain, at its sole expense, in full force and effect for a period of
five (5) years following the termination of this Agreement, one or more
policies of professional liability insurance with limits of coverage as
specified herein.
9.2.3 Workers' Compensation: A policy of Workers' Compensation Insurance
for CCFMG's employees as required by the California Labor Code.
CCFMG shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents and
employees, individually and collectively, as additional insured, but only
insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any
other insurance, or self-insurance, maintained by the COUNTY, its
officers, agents and employees shall be excess only and not contributing
with insurance provided under CCFMG's policies herein. This insurance
shall not be cancelled or changed without a minimum of thirty (30) days
advance written notice given to COUNTY.
10
Within thirty (30) days from the date CCFMG executes this Agreement,
CCFMG shall provide certificates of insurance and endorsements as stated
above for all of the foregoing policies, as required herein, to the County of
Fresno, Department of Public Health, P.O. Box 11867, Fresno, California
93775, Attention: Contracts Section-6th Floor, stating that such insurance
coverage have been obtained and are in full force; that the County of
Fresno, its officers, agents and employees will not be responsible for any
premiums on the policies; that such Commercial General Liability
insurance names the County of Fresno, its officers, agents and employees,
individually and collectively, as additional insured, but only insofar as the
operations under this Agreement are concerned; that such coverage for
additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents
and employees, shall be excess only and not contributing with insurance
provided under CCFMG's policies herein; and that this insurance shall not
be cancelled or changed without a minimum of thirty (30) days advance,
written notice given to COUNTY.
In the event CCFMG fails to keep in effect at all times insurance coverage
as herein provided, COUNTY may, in addition to other remedies it may
have, suspend or terminate this Agreement upon the occurrence of such
event.
All policies shall be with admitted insurers licensed to do business in the
State of California. Insurance purchased shall be from companies
possessing a current A.M. Best, Inc. rating of A FSC VII or better.
9.3 Non-Discrimination: During the performance of this Agreement, CCFMG shall unlawfully
discriminate against any employee or applicant for employment, or recipient of services,
because of race, religious creed, color, national origin, ancestry, physical disability, mental
disability, medical condition, genetic information, marital status, sex, gender, gender
identity, gender expression, age, sexual orientation, or military and veteran status, pursuant
to all applicable State of California and Federal statutes and regulations.
9.4 Records: Upon CCFMG's commencement of comprehensive professional services and
emergency care pursuant to this Agreement on 12:00 a.m. December 1, 2014, CCFMG
agrees to document services rendered to patient in medical records in accordance with all
applicable State and Federal laws, rules, and regulations for services performed at CMC.
Additionally, to the extent CCFMG controls medical health record, CCFMG agrees to
maintain and keep confidential adequate and complete medical health care records on each
MISP beneficiary patient it serves pursuant to any applicable accreditation standards, State
of California and Federal laws and regulations.
In addition, CCFMG shall maintain complete and accurate financial records with respect to
the services rendered herein. All such records shall be prepared in accordance with
generally accepted accounting procedures, shall be clearly identified, and shall be kept
II
readily accessible and available for inspection, as described in Section 9.5, herein. All such
records shall be retained by CCFMG and kept accessible as required by State of California
and Federal law.
9.5 Audits: CCFMG shall at any time during business hours, and as often as the COUNTY may
deem necessary, make available to the COUNTY for examination of all its records and data
with respect to the matters covered by this Agreement. CCFMG shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all of its records and data necessary to
ensure CCFMG's compliance with the terms of this Agreement.
If this Agreement exceeds ten thousand dollars ($10,000.00), CCFMG shall be subject to the
examination and audit of the Auditor General for a period of three (3) years after final
payment under contract. (Gov't Code, §8546.7).
9.6 Disclosure of Self-Dealing Transactions: This provision is only applicable if CCFMG is
operating as a corporation (a for-profit or non-profit corporation}, or if during the term of
this Agreement, CCFMG changes its status to operate as a corporation.
Members of CCFMG's Board of Directors shall disclose any self-dealing transactions that
they are a party to while CCFMG is providing goods or performing services under this
Agreement. A self-dealing transaction shall mean a transaction to which CCFMG is a party
and in which one or more of its directors has a material financial interest. Members of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by
completing and signing a Self-Dealing Transaction Disclosure Form, attached hereto as
Exhibit 4 and incorporated herein by this reference and submitting it to the COUNTY prior
to commencing with the self-dealing transaction or immediately thereafter.
9. 7 Severability: In the event any provision of this Agreement is or becomes invalid or
unenforceable, the remainder of the provisions shall remain in full force and effect.
9.8 No Third Party Beneficiaries: This Agreement has been entered into solely for the benefit
of the Parties hereto. Nothing in this Agreement is intended to benefit or confer any rights
or remedies on any other person or parties.
9.9 Authority: Each party represents and warrants to the other that it has full and complete
authority, corporate, legal, and otherwise, to enter into this Agreement and that the
individuals executing this Agreement on its behalf are duly authorized to do so.
9.10 Governing Law: The validity of this Agreement and any of its terms and provisions, as
well as the rights and duties of the parties hereunder, shall be interpreted and construed
pursuant to and in accordance with the laws of the State of California. Legal venue shall
reside in Fresno County.
9.ll Entire Agreement: This Agreement, including Exhibits 1 through 4, herein, constitutes the
entire agreement between CCFMG and COUNTY with respect to the subject matter hereof
and supersedes all previous Agreements, negotiations, proposals, commitments, writings,
12
advertisements, publications, and understanding of any nature whatsoever unless expressly
included in this Agreement.
13
IN WITNESS WHEREOF, the parties have affixed their signatures as of the date below
written:
CENTRAL CALIFORNIA FACULTY
MEDICAL GROUP
e: ;})yc.e f1etds-keene....
Title: 4V
Chairman of the Board, or
President, or any Vice President
Date: I 0 /I f3 / I 4 -----------------------
By:~~
Print Name: M1'tNtJ W. ~
Title: CtFtfl'
Secretary (of Corporation or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
14
COUNTY OF FRESNO
By: c&7SU;::sors
Date: \ \-l\ -\'-\
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By:~,~~
Date: l\-~·k\4
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
APPROVED AS TO LEGAL FORM:
DANIEL C. CEDERBORG, COUNTY COUNSEL
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
By: C0c ~-
REVIEWED AND RECOMMENDED FOR APPROVAL:
David Pomaville, Director
Department of Public Health
Fund/Subclass: 000111 0000
Organization: 5240
Account No: 7295
CK
15
EXHIBIT 1
County of Fresno's Medically Indigent Service Program Resolution No. 14-308 attached hereto.
RESOlUTION NO 14-308
1\HORI rnr ROo\RO OF SIIPFR\'ISORS
OJ I Ul· COUNTY OF rRFS!\0
S I A Tl or ('ALII-OR:'Iil:\
I Hf MH>It AU. Y INIJIGI:.!'Io I ~ ! St~RVIO·S PRU(jJCAM Of HU )
6 , couN n ~n tRE~:~.t·Lt.L __________ )
RFSOII <TIUN FS IARUSHI!\ti
POl JCY GOVF.R"IN<I
IIIC•IBIUIY Rlrtl:S. PAYML::"oil
UFnRMII'I;A TION PI AN. AM>
SCOPF OF SFRVICFS
I
7 i
8
Q
10
II
12
n
14
IS
16
17 \
Ill
21
24
'A'HFRI· AS. Ilk-PaliL'tll Prot«tion and Afl(•rdabk ( '.tn" t\~1 ('1he 1\CA .. )
llfld the Calitimaia Putiml Pmlci."IKJfl and Affixdablc Cu.n: Act r'the CACA -)ltd effa:t
Januar~ I. ::!01·$. •hN:h opandcd Pvkdi·Cal ch.:ih•lif) limits and olfcred ccrtaan health
catt c:cwcnq.'<' opli(-.t'l thnH~tth Co\<~'1'1.-d ( 'ahfimtia. lrkludt~ laX cmlib and cust shunng
su~ for eligible indi,·iduah ("'<lthc:r hcatlh care (•rtion..,·),
Wllt-.Rh\S. Weltm and lnstitutiOIIS Code: Scct1011 11flClO. t'l J:rq •
~res~~ Cuunl) ol f-resno f'tht tounty"l K' pro,·kk mediCal sen ices to all1ndipt
ptnClns \l!bo arc IM4-ful ~s fttnt-m. and who are nor othcr\l!ise .. ~lic"c:d hy lhcir
rclaU\cs or fll('nds. by their own mean~. or hy state ht:•spit.ah nr Olhc:r Slate or pri"*
instituti<ms .. ;
WJIFREAS. a "lawful rc!>idcnt" is a ~non who j, either a l 7nitc:d Stales
citv.en l)f lawtull) adnunait,> permanl!ntly or temporaril} 1\.>sidc an the llnited States:
and
\\HI Rt·AS. the ( ·,-.,y m«h its Welfare atid llllllitulions Code S«tKtn
17000, C'l '~II ohliJUlklns tluoup,h lb Mcdlalll) lndi!,>ent Sen-ices Progmmi .. MISP"'):
WIIERI!AS. the CHUI1t} has Jft\'tously adopted ehgtbihl) cntena 1m its
MISP and has arncmk-d s&Kh chgththt) .:ntena lrom ume 1o time;
Wtii:RI:AS. due to the impl.mlelllalion of the ACA and the l'A<. "A. man~
partidpants m the \11SP and c.:cn.ain non-rartidJWtnh are eligible li• urher health carr
27 ' Ofl(ions a.~ of January I, 2014: and
28 I WIII-'Rf·AS. the Hoard has d«tdal that the existing MISP eligibility
16
n.:ut>JrY ~,f· l'lott:swo
t'JetHI(J, ~A
7
8
9
II
cntrna needs kl ~ mod1f1Cd to R:flcct the ~.n nf hc:alth care cowragc due In
impk:rlk:nlaliun vf tbc A('A and tbc CA('A.
~()\\. UII:RfFC>RF. Rr IT R[SOIVEU.that C'ff«tl\'.: ll«anber I.
2014.1111 pnor resl>hlliuns of~ Uuard thai established ~~~~11Mht!l cnlena fur the MLY
.ue repealc:d. pru\ Ida!. ho\\en·r. !hal such repeal shall not anect any ri@ht ur dann
which rna) hau· accrual In J'R!'Slk• Count) lhereinalier ··count) ''l pur..w11111 to thrnle
Rf: II FI'R IllER RFSOI. Vt·:thhat. ctlc:~:1i\'dle\·c:~nbet I. 201-1. the
follctwt~ policy shall gtwcm pro\'il'ion li•r medical care li.tr mcdic.tlly indi(la1l J1Cf50ll\
in 1-R:"SDD• C ounl)
I. All medical care required to tiC' pro~·idc:d pursuant to Ibis J'f'Or,nU1l shall be
I~ ra•d a1 Medi.( 'alr.ttcs or contracted rates and require pri<tr authclriTalton h)· the Count)·
l ~ \ a5 a conditinn ttf reimburscmmt
All pcrsrms mU!lt not be elir.ihlc: for Medi-C'al or othcT public health OJR
16 3. All pcnoru ftll be digihlc for care pursuant w this ~lutioo without
17 : dtsenminatton oo the haMs of age. ancestry. color. nat tonal on gin. race. rcligxm. se,,
II sexual orienlalt<tn. mantal sl.lnls. t'thnac group ldentifJCatJOn. genettc rntormation.
19 disability. or political alliliatioo
:!0
ll
,I :2
~-... \ I
I
24
25
26
j
27 I
28
4. All ~ms m 1'1Ced of cmcr[l~)' mcdil;<ll sen ices. which shall be:
wnsil'tcnt with lhc definition of cmc.Tttcncy scniccs b :tel funh in Titk: 22. ('aJit4.trnia
Cock of Regulation.". Sc....:tion 510$6 (hereanalt~ '"Section 51056"1. ~ang. as of the
cfak hefwf, bui ~"Ct to future ameOOJ'I\\.'IllS of ~'Ctlon 5 1056. those medical !lef'VIC'eS
~red titr the alle\'iation of severe pain. or immediate diagnosis and ttatment ol
unfOf'e!la:n m.:diclll conditions which. if not imlll4.-diately ~ and treated. would
lead to di:r.ahility 'tr dl:ath; an ~lamination h~ an appropnate health professioul kl
<k.-tcnninc whether or not such an Clllergefl(;)' situation exists
5. All person:s m need of folio'~ -up medi"al care dm .. "ctty rclated to an
17
COUNTY 01' JP1UL.<;NC>
Fr'l>ano. CA
1: :1
!I
"' !I -1!
;!
_, il
;j ,, .. II
'\
(l
7
H
Q
IU
II
12 ,!
13 !l
14ll
15 11
16 H
n\
II
19
:!0 !
" 21 !
11 I
'
C'~"T~Jk:)
6. An,. Ia~ II!! ~~iJI."nt of the (\Jtmt~ ot he!llu ~~t.bll 1s :l>ld:. or in1un:d m:id m
lK\.'d of mafical care and "'ho is a '"'--dkal indtgcnt mcantnl! a penon ~btl 1~ 001
l."hl!iNc tOr Mc:dKaw or Mcd1-C. 'al. who •~ not, l•.lf' ~'(l(lli ..-:~1 • ro\·CRd tbr~
('cn·m~ California. priutc in'lur.mce. a ~'lthlc: third pat't) or othl.,.ue rdJC."'\.al
and \\>hll lnt'C'I'i tfko r ~· ( 'ount) Ma.iiuJiy lndi~l l·ligihilit~ ( "ntma and P~mcnt
l>etaminaliun t'lan ana: hal hcrctulL'io Attaclvnc-nt '"A''. and im-orpuratcd hen:in by tht.s
rctcrcncc. prondcd that pn>\ision of an, <~uch medical :;er.·ic~ shall he sunra;11o
liabthty tar paym&.'flt herrof pursuant to th.e pnwtSJOOS of 50Ud Anadmwm "A". Md
turdwr pruvtded that a "'riuen Wlti\.:T nt the stati.IW of hmttatiOfts be s1ped by a per!IOil
ohhpkd in ordn ro ~1m-payment of the ,·ost of such indtgcnl aid and rnmbunement
Ill the Cl1Uf1t)' to the nlcnl rennilled hy law
7. McdK:al catt for lawful residcnL't shall be limned to the extent reqwn:d
wilder Welt~ and lnstitutiuns Cock Se4.1ion 17000 . .:1 :.t''l·· to pru'load.: subsi!knu: la-cl
mediad ~C:C'll necessary· tu avoid unn«eS!Ial1 suAerin~ or~ lo life or
health. and shall include tlw scope of sen ices as ..:.cmlained m the f'n-:1o110 ('uunty
Medical I) lndip.cnl Sen-ices r•rogram Sl,'O(Ie of ServK.'t'S ~'d hereto as Attachment
"IC and incorporated twrein ~Y this reterelk~e: with the udusion ... t spedfied ~
idmlil~ in Attachmmt ··u-.
8. An~ lawful n:sidcnt of fn:sno Count) ~~to"bo ~~denial MISP or who as
MISP eh!!ible and i!-denied a f\.'qiK.'Stcd rm."dt..-:al scrvic..-..-: t5 entitled ttl an arpeal &\ !let
tonh m Attaclt.n1cnt -A· ~ll(m XII
~"\ I .'!! ... 1
24 i , .... ,
::!5 ! //.'
i :6 .......
21 /11
28 ;,·;
' "(iood <. ww;" rdaiftt! 1o d~ibdily for the ._.JSP shall indudc plt}-siul Mid mcas.J ~it) .
....,..., ....... ,,.. h.onlo:llip ~ituatio. .. , . \
18
,,
,I
i!
ll ll
1 i 1 THE FOREGOING was passed and adopted o, the following 110te of me Board of
2 !jSupeMsofs of ltle County of Fresno this 19"' day of AugUII 20l4 lo-Wit
II
3 I
4 !
s I
6 !
7 I
8
9
i
AYES
NOES
ABSENT
10 i
i 11 !AlTEST
12 I BERNICE E SEIDEL
None
i Clent. Board of Supen~isora
13 i
Deputy
19 AGlfdlA lftM NO •
A£SOUITION NO 14-301t
20
21
22!
23 I
24
25
26
27
28
~-
19
Attachment A
Lf{f~Q_!."(>tfJIIJYMf..DICAI.l.Y IXr>l<ii'.NJ U.l<iiBIIIJ\' CRJI.I:-JUA
ANl> PA YMENJ f)t!t.RMINA liON Pl.At-.
the ehgihiht) critcm listed hdo" sba!l be tk'lemtined by appn~ documenw) pmuf
ltclusaJ to pro1.ide d<lCu~· proof as basrs tor .kfla;aJ of 1-n:sno Cuunl) Medic.tlly lndJFftl
S..-nicn J•mgrom (MlSP) eli~ihdtt~. If an applia.mt ;.,. unahk tu rnwidc: such humcntary
proof. eliitjf»Jit) Wll he ddt:m~i~'<f h) dn:lmttit'll "rtb the: t''C<'f1lKan oi citizcmhip or
tmm~tion statiK MISP '"' onl~ a"ailablc k•la"hd rnidmts 11@C!C 14,1 thmu,h 64
FXIIAl SilO\ Of OliH:R 111-.\1 flf('ARI: OPTK)NS
HW' l'aucnll-'rottttJOR and Affordabk Care Act I'"ACA''t and the Ca.lilt,..ma Patten~
Protection and Affordable Care Ad ("CAL\"). expand"! Mcdi-<'al CCl\"eTaje and pro"idc:s
health C<UC aJ\C~ thnttagh the: E.11changc (i e. ( rm:red California) ("other health care
options'"). and was impk'rnC1lk.'d tll'l January I, 2014. .1\ti such, pt11ft:ipants tn the MISt'
and certain non-purti..:ipanl1 hcumc: eligihk (()r other health care option! as of January I.
2014.
l'artk:IJIIIOfs in~ MISP who larlto ,wull in thr:!IC: other hc:ahh cart' options a1 the: time of
open enroll~! ur who filii to appi) under Cm'Crt'd Califi.qia's Qualify1ft8 Life I:-.\'Ctll5
for Sp«1al Enrollment ltk:ludlnt~ appl~ation Uftdcr l·xa:pci(lnaJ Cirt'umtnances or '111-ho
lllilto pay the premiwns (lfan).tll'ltho!ic nthc:r health~ oprions. abscnc good cause.
will he dia.'l'llltinuc.'d 11.'> panidprnl' in the MISP
1\cw or reapplying perticipants in the= MISP who fail to enroll in dle&c other Malth can:
optintls at the time of open enrollment or who tul to apply under(~ ('aJifomia's
Qualif)int:t l.ifc Events for Spc:c:ial 1-.nrullment includit11 application I8Jdet bceptiOftal
ClrcwnstarM:cN or ~ho fail kl pa)· the pmntwns (if 41t)) on those other health au't'
options. illbsl.."'ll good c.wse. will nut he digilllc: tu piU1icipatc in lftr MISP.
"(jood cause" n:laUnJ!t to chgJbtht) lOr the MISP !!hall include physical and mental
incapacity. ill~s. hospitalizatj(1n, or hardshir situations.
Oooi.l cause shall be: dc:tcnnincd by the: Oire-ctor Qf the fkpartmcnt of Pubht: Hcalrh
(-Oin:ctor'') or his.'her de<>ignec
II. RESJL>l--NCl:
A f'resno Count} Resident if> delined ou an)· lawful rt'sidmf of the County offrt"Sil(l as
rhe term '1awful resii.lenl'' is defined m the Wdliue and Jnscitutioo:~ \•'Ide.
For purp.l!iC!I uf digibihty for the MJSP, roidmcy ios estaNishcd b):
l"erstJib \\hu arc cirhct tnitcd Stales citu.c:n." '" la"fully olldrniucd ,,, rcrmanmtl)· tlr
temporarily reside an tbe llnlk'd States: iDd
20
Attachment A
Phy~iul pr~c. if there: i:o. no prcliCnt intc:nhnn oflcav·m~ Fresno Counly. un~llthe
applicant maintain' a homt: fc•r him 'bene: If tlUl.'>lde the County: m
l.l\ in, in h~ Count, at the tunc of' appiK.ation. and DOC recet\ in~: JnedK;al aui5f.ln!X
trom another county
Ac~ ~~tion to dcmonstrak cirizm."'ip or immipant Slalus tndl.ldc! a bintJ
cmiticae. J'IISSJVIfl or vi'i.'t. cenifKalc nf I'.S Citi7emhir or crniftcate of I r .S
Naturalization
Ill PERSONAl PROPF:R ry
A. PF.RSOI'AI. PROPFRfY 1.1\fJTArJO!IiS.
llouiehoiJ Su.c Lim1t
1 $3.000
2 Sl.OOU
3 $3.1~(1
4 s.uoo
:'i iJ.450
6 SJ.600
7 $1.750
8 SJ,qoo
9 S4.0SO
10 S·COO
It Pf-:RSONAI. PROPI:R I Y 10 IU: INCU IOU>:
Cash and chccu on hand (except tar cumnt month's income). \tontbJy income
1s subtracted trom property in the month it as n.-cci\>cd.
2 Nonra:urring lump ..urn paymc:nb.
l Hank ac:counl'l (ched.i11[t, !<1\~os. de:.' eliccpl for C\IITc:nf month's income
4 Prnmissol) notes
5. Stocks. bolll.b. tllha ncaotiabk 5a:uritics.
6 Ca.<ih w~r value-of hfe irKUr:~nee polic~.
7 Net 'l>alue ,lf trailer!'. hltaL~ camp::ri. recreational vdlicleli and mobile homes not
used as client·, rcsidc:tk:c
It One motor \ehicle is cXt.'111pl up tu $4,650 in \·.aluc. The 001 '1.-aluc: uf 1111 uthc..T can
is nun-eln.-mpt pcrlklftal proper1)'.
9 Net value of PIOJ".'f't) 1ft Nwnba-5 7 and II ablwe shall be detenntnc:d by the
market value publa!Jied in the Kefle} Blue BooL whi\.."h is also availabk on-line at
the Kclk)' Blue: lkd 's "-ehslre: http:.'""'-"'·.Jtbb.qxJJi, or the rnllltel value
determined by The: National AutcJ fkalen As5()Ciatc:d Guide: ~ite at
htJD:-':'wM\·,ftfdaeu~ ... om.~ . .upx. or similar method. at County's
discretion. Ins eocumbnmces of m:ord.
I 0. kwclry \·aluc:d ov·cr S I 00 with the exception of wc:ddtng and cngagcnk."'l1 nn~s
and heirlooms.
II . One rnoalble bunal tund t'lf' 1\'\'ocable prepwd bunal ron~t with a value over
$1.000.
21
C. PERSONAl PROPERTY TORt-: fXCI.f ron>.
f'ri no: -raJ rcstdcnc c
2. Personal property u.'IQJ in husi~ c.1r trade:.
1 Personal effcct:r;.
4. HtiU~Id itcrm
5 IR;\s. KfO(iJis. and other wort-related pension plans.
6 IITC\fl\:ahlc hurial trmt'\ ,., !ITC\'C1Cahk pn-patd hurial conti1Kts
7. UuriaJ Sf*'<' lh."'DS
8 Musi~al i"'"rumc:flts
Q Rcueatinn ik'm"
10. l.iH-mod,, ~IUIIJ)·. or ~n•ps.
A UJK hment 1\
II. Counwhlc pntpm~ equal let tht-olmttunt ufbmefih p.id under a stalc~cniftcd.
lung·k."ml care i~o;ur-.ul\:c Jluliq
12 l.ifc insurance ~,Ji4:wcs.
11 One motor vchi<:lc is exempt ur to S4.t.SO in value
J>erS()fl;ll prop:n} m e~cess of limns wrults in u~ltg1bilny tar the MISt•.
IV KfAJ. J>ft()f'fK JY
A. REAL PROJ>I RlY UMII .~ liO~S.
Property .. ·aluc t'i the markc:t value on propcny· tax lllatemnl1 less encumbrances of
record.
I"C ) l [ · Propen)· i~ to be determined tn a«Ofdance WJth Med•..("aJ regulations
wnh the exn-ption of the following ~lions which do 1101 apply.
~04(1()
50407
50408
"04()<J
50410
5<J411
50416
50417
50426
'\(1427
~0442
50453 5
50479
t.'tlllvcnion or T ransfcr of Proptrty
Con,·cnion of Propeny lrealment
Transfer uf Propc:ny Whi<:h Uoc:s lloOOl Result 10 Ineligibility
T nmsfcr nf Pmpcrt) Which Resuhs in Ineligibility
I nms*cr ot Property wtth Rc:ccntion ot l.de f.stale
J>ericd tlf lnehgibdiry [)ue to T ran:sfer of Pr._lfll.'ft)
I tiluatitlll Rcquiran.:nts
I tili7.arion ·· Oood Otusc
Propcny I 'sed tn Pun:ha.sc a I lome
< )lhef Real Pnlpefty
l.ift:' Eslale
Sa\·inp of a Child
Burial Trust nr Prq1aid Ruri&J ('ontl'liCt
8. REAL PROPFR IY I 0 JU: EXCU iOED
l>rinctpal ~ldence.
2 Real propcrt) usc:d in a htl<imc:s.'> or trade.
J
22
V. IM.'OMI: ·10 HE CONSil>t-Rl:f)
A. Net ~anungs llk'<mk' J'l C'OO!ndc.-red m dct~nnnwt~em of cligihtliry
I. Net QU'Ilintt5 frnm ~~f~mpluymmt il> dttcnnineti ITom the Ja.,t Stale lrK.-umc faA
return Thr nrt annual inc:tlfl'le "ill he.· a\-~~>d to dc:tt."''ttline the: prujccted cutren~
month!~ incomt".
n hduded ifk'<lltk' t(v MISP.
I. Ch11J Support PaJomcsth
1. Wonu.•r's Cum~uon
~-Vdn-.an .... lk'1k!lib
4. fdu.:atiullitl A '-'lslin.'C
:\. Fmrln)tm"nt and fraining Pmttram~
t.. F«kral I ax R~rimds and l:.ar-ned Income lw. ( 'red1t
7. Bon.t I ide Luans
IC SJ!Oft!!llr lnct~
'I foster t ·are l'a}'mcnts
10. "'""'xb Based Assistan\;c from Other Attcncies includin1 SSI and SSP
C. t•crsons w1th fl('lfl·eumpt iRCOm.:-m excess of 22•1% oflhc 2014 Federal Poverty
Ouiddn~"' cffl(il arc not eligible f,~r MISP unlclll' those pcnon!ii qu.aJif~ for a
li~WKial hardship waiver a'l described in Section X. herein.
VI. INCOME DFil::RMINA liON
A.
n
J
4
I.
2
l
4.
5.
b.
7.
K.
9.
\\'~and Salaril:ll
Tip
Commi~~on.."
Pmlit'l from Self-[mpluyn."fft
c~ru,. .. unearned mcomc includes the following.
' 'nanrk•ymmt c 1 ·nw
State Disability (St>l)*
SSA cl)i~lit}. Sunin1N, Rctiren~mt••
Retirement HRAs... 401(kl. Milital). Rnilmadt•
Rental Income
Pmsiom &nd Annuit~·
Oi'lridcnd Payment"
Per C.tp1ta lnbal Gaming l>rstributions
:\limon~
*As a t'Otltlitiell of eli&iWiit)· for MISP, atwnGn ••st apply for ••)'
• ......._. ._ dlcy are eatidetl to.
4
23
C 1\et munthl) im:c•m"·ul da<nt:~> feQ~'Slm~ rnedic:al!!Cnlc;cs as medically indigcat
(\"1W1t~ rc!<>idents w11t ~· ~·(lfnruted as fnllow~:
(ifi•:.s l.Ain-.xl Income:
( iUb..\ li D!;af~ lOJ;~
f-or I~ MISP applicant~ wbt\!le lotaJ nctllli..'Ofne is between (J and I JB~ of the: ~014
federal Po\'C'11) GuXklinc:o. I rP<;) ,,., their b.~td 5Ue. there will lie 00 shaft of cost.
for MISI' arrlic.mb Whtl'iC iocume is hclW\.'ell the upprr tJucsJaold of the no~ of C0$1
amount and 22.f-·o ofthc 2014 ~PO for houschc.•ld !!.ize. theA' lo\111 be a \iiSP share c1f coSI
M d~hcd in Sc\."1icm V, herem.
\1 SHARI-: c »-C.'( )S I
t\ person Feqi!Mling \flSP '-."ahh c;an: sen ICCS must parUCipalC in .1t saeming PfU"SS tc•
assess lus1her tirt.anciAI statw.. m.outcell. and housdk>ld stze lk't-ording kl the fOllowing
critena and payment dc:tennination 5Chedulc.
SOC linuts b~ Household Sw.··
~ti.1.flli9f c..'OSJ.D.LlERMl'l.:.t\IION Sctlt:l>UU:
.f l!lY.Id .. Sizc NoSIMn:~ Share of (.'ost
so -Sl,\43 SI.J44 · S1.181:t-
:! so -s1.soq SI.IJO · S~.937"
~ ~ -S2 .276 $1.277 -$'1.694·
4 SO · Sl.743 S2. 74-t -S4.45.l•
5 SO · S.l.210 $1,::!11. S5.:!JO•
" so. Hn7t. $1.'77-$5.%7•
7 SO · ).t.I.W 'S4.145-$0.7~7"
8 so . S4.bll $4,612-$7.484•
Cl so . s~.on $~.078 . $1 . .:!41•
IIJ su -s~.s.ts s~.S46. S9.ooo•
•Pmgrnm maximum litr huu~hold Sll.e
It a penon's local nee irx:umc falls at or bclolo\ the maximum allowable amount for 1\.n
Shan:-of Cost. the client is eligible ltl re«tve health ser"JC.eS \\1th oo share: of cost. 11M:
mcaximwn allulo\abk mnotWI ttf kltal nc1 income for no shan: of cost i!l I JJo,·;. of the :w 14
J-IJ(j for hmasc:hold stze (I c .. S I, \4\ fnr a holiK'hold si.t.c tlf onet.
If a p:r..tW1'"' lolalllL>t ioctlflle JS lWC'T the ~o Share of Cnsl lllllllimum alklWahlc amount..
but al or belu\\ the ma.ximwn allowable amount for Shan: of ( ·u~l. the! share of u~ ~
iklcrmiMCI by lltlhtractmg the maximum amount allowable No Share of CtlSI aftl(JUnl lOr
the chcnt's household ,.;,e frum the! dienb tcltal 11(:1 income (e.g .. for a household size of
one persoo· S 1.42S total net im:omc mmus S 1.343 '0 $82 share of cos& I.
5
24
I( an arplicant has a ~ ot Cl>:<t ur has llk:O~ a!'lo\·c: t~ share of co"t "mit of 224"'o 11f
lh&: t-·Po. ~1 !obc:o could 'jualll) tor a lin~ial hard,hir "'ai11eT a.<~ ~ribcd in Sa:tion X
belo"' that may lo"~Wr or chm~n.'tlc the-'lhare of emil. A J'lt"f'lllft·~ shan: ,,f ct~C j, caJcui.alcd
by subtracting ~ financial hardsh!Jiamount !Tom !he luluJ n-.1 inct)f~K'.
fot toxample. ,, the rlk-nf <;total "'"' income, .. \' .01'10 and ftko clit.'t'll paid noo kNrards an
allo"Moablc li!Wk'ial hardship. I~ the client's !!hare of u>st would be $35 7 •Sl.OOO minus
S300 mimi.'! SI .. 14J which is I~ rrogram l'llall:imum lt>r hu~JIOid St.l.C" .,,-ODe). however.
tJ ~ client paid SRUU tmunls an allowable financial hardship. the chmt 11\00td rhen
have no share of co~l (S:!.OOO millWi SHOO rnmus SLl4J "Mohk.ills t1w prognwn ma11imum
for household si.-c)
X t-IS:\P\('fM. IIARDSHIP \\.'\1\'I:R I'ROCI:SS
MISI' c-ligihtlil)l~ ha'!C(I urun an indi\idiJdl'~ actual monthly total~ income. for
penon'!! with a total net it11.:omc in c:xcC'S'\ ullhc no share ut '-'ost amount tor their tMtily
~uc ($1 .. "4-' for an indi\·idualt. a tinan.:ial h.nlidup "Mo&IVOLT is a' .Utable kl ck-duct currmt
costs of addJtionaltalles 1 i c pa)mcnts made nn past due t eder.U tlf State ta'4es ow~ch.
cmm·ordcrc:d pa}mmt~. and pa)mmt'i lor past mcdical debt Ci.e pursuant to a J1Dymc:nl
plan lo\1th mcdK:al pmvKkr tt>r Jllil.'l ~ i~:~ i. tor ~xamplc:. an indi,·idual v.ith a monthly
income ·~f$1 ,400. hut ~L-utrml court ,,ntcred pa)'lllftlt of $~1 (e,J child supplf1. alimony I
and medical debt pa)tnent ol $50 "uuld hav~ an adJusted tncmnc of S l .JOO per Jll(IOth
and could qu.~~lif) tl>r MJSr. r>ucumcntaliun of p~t)nwnts made pursuant to a linancial
hardship waiver .arc nc:c:~f) and "ill not he applied to tocal net income amoun1 hascd
on declaration
lht ti.nanctaf hard~hip wain:r wall nnl) h..•Brr!ied to the munch's inctmJe ln'el m which
the actual payment wa." rt1illk For eJU.Unpk. it 11 person has a current t'ourt (Jrdc:r to pay
S50 the month hc/U.C i~> ilfJPI~,ing for ~lsJ• and pro,·ldes documentation C\idt:nctfll
he!w made that payment lik.'flthe s~o would he subtracte-d from the pm;cm''J net inatme
for chat mtmth.
XI t.TRTIFIC A TION PI'RK)J)
Th"· \Xrtifte.11ion ,mod for reciricnts who'IC digibilit)· is dl!lcrmincd b) declaratiOft. wath
the exccpcKm of cill:r.cn~htp or ammi~ratiun statu..., :.hall he Jur a one-month per1od. wtlh a
retroactive proVIsion for the month i~l) preredeng the lll<lnth of applicalloo. The
ccniftcatioo p:riad fi1r ~ipicnl.'l 11\-lwse eligibility is detcrmiiM:d hy OOcumentary
c:\·idl..'1t~:l! shall he l"l•r a thr~·month period. w1th" rctroacti~·e rrovision for the one month
1nuncdtatel~ ~cding IM month of arrliustiun
XII l>fNIAI. All,! I> AI>MINIS IRA JIVE APPEAl. PROCI'SS
If' an applicant i:5 denied M ISP ch~tbilit) ti.lf iUI} tca50tl or if an MISP n."<:ipicnt is <fc:nicd
a re\j~ed medical !'lf:f"\'iu;. the-County shall pruvide wrilk.-n nutic:l! to the person
•nli.mnint:: hun/bet ottheJr nght I<' a l-air Administrati\>e A~nl. lfthe penon chooses to
llf1llC'II. hc:lshc mWit n.>quest a r~\ ic"' ofthat decision. m writing. ~ithin len I 101 wtri.int:
da)S of the date of the denial letter Hac: rcquc-s.~ mu~t ~ific..tl) ~ue-ttu ~ lhc
«b:ision and must explain wby the penon i~ di ... vlisftcd w1th lk <!a-lston. n~e requesl
6
25
l\ttachment A
mu!>l W!ill include iln) documentation the appellant wtsbcs ((I be rcv14.·w~'d b) the
Admirustro~tm: Arp:al Olliu:r (or fus:ber cksl~ •· I he d""tcmunauon of the
:\dmimstrall\'<' Arpc3l ( )flica (or hwll(.-r ~ip«" • dwll he !he final drci sion of !he
Count,_ and shall be pnwidc:d to the: appellant tn ~lihftJ. App:ah s#k)Uid be sent to tfl.:o
li•ll.-w•nt: addres.'l.
MISt• Admmtstratlve Appeal Otlker
l)qu'tnaent of Pubhc I kaJth
I :? :? I fulton Mall
Fn.•sno, CA 91721
If a ~m c.lc~ nell file an appeal r~'qtle'lt \o\'ithin ten ( 10• 'Wriiag da)s. the arpeal v.1.11
he denied unless it is fnund that gotld cuusc pn.~enkd the p.:non lnllkmg a timely
Jaf!J'."!'>I. Venfic:.ldion rhrnU8h documentation that an ilppCill cooJd aot be submitted
within the h:n (I 0) days leu a good cause t 'uch as serious illnes.'>. hospitalization.
incar«ration. or stmilar reason) and prcwntfd a timely appeal request &om being made
i"' ~'U.'Ssat).
XIII. COli~TY Alii>Jl ANU RH'OVt:R\' Of. H.:NI~
All f~CNM\S wht>Se eligibilit) is d~>tcnniiiOO by declaration. with the C)(teption of
verification of citi,.cnship or &nmugrant status. shall be subf«t to an audll conducted by
the: Count) to verify eligibility. All documt<ntation and appkatKin:S thall be subscri'-.-d
Uftder pe~wlty of perjury.
('ounry shaJI n.-quirc thai all applicants for MISP C\<:cutc a n:iml:lunianent ~~and
lien ackoowtedgement. I be purpose olthe reirnhunrment ~ and lic:t1
ad.nt~wledgcmcnt is to as.\ure ~'0\'eT:)' of funds if and when the MISP participant obtaim
funds sutlicsent to no lollJ!.Cr meet the definition of lndipt for purposes of the MISP.
As pan of the reimbuncrncnt agreement and lirn acknowledgmeRt. the applicant shall
v.'lli''c." in v.riting any statute of hmitataon relating to County's ~"0\>'ft'Y of fUnds npended
1m MISP .:arc lin the aprlicant
7
26
J\ltachmmt n
I;RI~SNO COt ll\ I Y \ti:UICALL.Y_!NPJ(iJJI!rT SEJ!VI((;s f>IKliH!A.M
S('OPE <!!:JiJ,R~lftS
To the extent requtml pursuam l<l V.dfarc and lnMituuons {"ode ~uon 17UU(l. d
xt''l .. to PfU\IIk subslsh."nn:t: k~el meilical S«\"ICcs ~ to a\"old ~.essar}
xuffmnv or c:ndana;~..-mcnt to lafc or health. tlw Sl:'~ nf ~n ices for the I· resno
Count} Medical!)' ln.ti.,tent Sen-ices f'rutrram IMI"'"I sh.lll include·
A. AduJt Prima~y ('~. mdudmJ;: scrcmmg tor ~ommuni~ d1seascs
H Spectalty car.: mdudcs. but is not ltmiled to:
:l.
4.
5.
6.
7
8.
fndocrinology
N~un•logy
l'ulmonu~}
( 'IUdit>lllt;)
( >rthopcdtc~
Ohsldrit.:li and Oyna:olog)
Otolaryngolo~t} (FNTI
lk-nnatolog)
9. ()nco~~
10. Oastroentcrok~y
II. <>rhthalmolog~
('. l~rnergency care sen· ices as defined under Title 22 of the ( 'aJiti11nia ('ode of
Rtgulati&Hbi Se\:tion 51056 as chose :tft'\'ices required tor aJie\'ialion of !oe\.~
pain. '" immediate: dJatPIOSis and treat~! of unfOreseen mcdK:aJ condition.'
whic.:h. ir not immcdiaJcly diaplSCd and treated. "uuld lead to disability or deaah
(). Inpatient llospitallz.ation
1~. Oulpatit--nt Surge!")
1-Rad1oktgy. including Compukri1AI l1•mo~raph) Wn Sam<~ lind Magnetic
Rnonancc lmagintt I MRI)
II. l>urahlc MedtcaJ f'quipmt'nt
Home I lcalth
K. Phy~ical and Occupational Therapy
27
Attachment H
l"'>lallun fur ln(c~·tio>us I )iscase
II I h.-lotio" mg shall (Oil~ltut-:-th..· hst ul ntt.'lh\.aJ ~'f\ h:o::~o tb.lt .m:.-'Jl'IX'iti~.:all~·
clld~'\J fwm !he ~USI'.
C Orllan I ransplan~:>
I. h-nilit~ TreatlllC'nts and R,·H·r>.:ll,, hunil) 1•1annmg Scn·Jc<'"· and lmpot~OC)
Scniu:s
I· 1\hoMJon
U. SltllcJ Nur!olll~ f auhtir:s illhll.ullf·l crm Clf'e Fltl:ilillo:"
Jt. Methadooc MatnlcnaJ11.:c W1d I >rug and A J.:ohol l reauncnt
I . !\dull l>a~ IIC'alth ~en icc~
28
Primary Care
Endocrinology
Neurology
Pulmonology
Cardiology
Orthopedics
Obstetrics and Gynecology
Ears Nose and Throat (ENT)
Dermatology
Oncology
Gastroenterology
Ophthalmology
EXHIBIT2
Other services that are agreed upon between CCFMG and the Director of Public Health
29
EXHIBIT3
Reimbursement for Specialty and/or Primary Professional Medical Services and
Emergency Care
Claims shall be submitted using the most recent version of Current Procedural Terminology
(CPT) codes. COUNTY will pay CCFMG on a fee for service basis, one hundred percent
(100%) of Medicare's Resource Based Relative Value Scale ("RBRVS") for the Area 99 in
effect at the time the service for CPT codes submitted under the following categories indicated
below:
CPT Code Allowed:
Medicine
Surgery
Radiology
Pathology
Family Practice
All other Medical Service
Unlisted Procedures
I 00% of Medicare allowable Area 99
I 00% of Medicare allowable Area 99
I 00% of Medicare allowable Area 99
I 00% of Medicare allowable Area 99
1 00% of Medicare allowable Area 99
100% of Medicare allowable Area 99
65% ofbilled charges
30
Exhibit 4
SELF-DEALING TRANSACOON DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"),
must disclose any self-dealing transactions that they are a party to while providing goods,
performing services, or both for the County. A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in which
one or more of its directors has a material financial interest. "
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(I) Enter board member's name, job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the Corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation's transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
31
32