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STANDARD AGREEMENT
FOR
CALIFORNIA HEALTHCARE FOR INDIGENTS PROGRAM FUNDING
FOR
FISCAL YEAR 2005-06
The State of California, by and through the Department of Health Services (hereinafter
called the "Department') and the County of Fresno (hereinafter called the
"County") in consideration of the covenants, conditions, agreements, and stipulations
hereinafter expressed, do hereby agree as follows:
This Agreement is entered into pursuant to the provisions in Welfare and Institutions(W&I)
Code, Section 16900 et seg. The definitions of terms used in this Agreement shall be
determined under W&I Code Section 16900 et seq. In the event of a subsequent statutory
amendment or Budget Act language to W&I Code Section 16900 et seq., the amended
statute shall be controlling.
As a condition of receiving California Healthcare for Indigents Program funds (hereinafter
called CHIP funds), the County agrees to all of the following statutory provisions:
GENERAL REQUIREMENTS
1. (a) CHIP funds shall be expended to supplement existing levels of services provided
and shall not be used to fund existing levels of services.
(Section 23 of Chapter 199, Statutes of 1996 - Assembly Bill [AB] 3487)
(b) CHIP funds shall not be used to support health services provided to persons
detained in a county or city jail or other correctional facility.
(W&I Code Section 16995)
(c) All providers receiving any CHIP funds shall not require a fee or charge before
they render medically necessary services to persons entitled to services
supported by CHIP funds.
(W&I Code Sections 16942(a) and 16804.1)
(d) Accepting CHIP funds does not relieve the County of its obligation to provide
indigent health care as required by W&I Code Section 17000.
(W&I Code Section 16995.1)
(e) Facilities receiving CHIP funds shall be required to provide individual notice at
the time treatment is sought as to the availability of reduced cost health care and
conspicuously post notices of the procedures for applying for reduced cost
health care in all emergency rooms and patient waiting rooms for services
supported by CHIP funds.
(W&I Code Sections 16942(a) and 16818)
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FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 2 of 18
2. (a) As a condition of receiving CHIP funds, the County shall provide, or arrange and
pay for, medically necessary follow-up treatment, including prescription drugs
and necessary follow-up dental treatment at least equal in scope and frequency
to dental services available to Medi-Cal eligible children of the same age,for any
condition detected as part of a Child Health and Disability Prevention (CHDP)
screen for any child eligible for services under Section 104395 of the Health and
Safety Code, if the child was screened by the County, or upon referral by a
CHDP Program provider, unless the child is eligible to receive care with no share
of cost under the Medi-Cal Program, or is covered under another publicly funded
program, or the services are payable under private insurance coverage.
(W&I Code Sections 16970(a) and (c))
(b) Noncounty hospitals which receive a formula allocation pursuant to
paragraph 10, and physicians who receive payment from the Physician Services
(PS) Account of the Emergency Medical Services (EMS) fund, established
pursuant to paragraph 25, shall not be required to comply with the CHDP
treatment provisions of paragraph 2(a) as a condition of receiving those
allocations or payments.
(W&I Code Section 16970(b)(1))
(c) Only providers which contract with the County and receive payments of
Noncounty Hospital Discretionary, Physician New Contracts, and Other Health
Services funds specified in paragraphs 12, 30, and 31 may be required to
comply with the CHDP treatment provisions of paragraph 2(a), as a condition of
receiving those payments.
(W&I Code Section 16970(b)(2))
(d) The CHDP treatment provisions of paragraph 2(a) shall be implemented in
consultation and coordination with the County's CHDP Programs.
(W&I Code Section 16970(d))
ADMINISTRATION OF FUNDS
3. Prior to transferring or expending any CHIP funds received, the County shall:
(a) Deposit the CHIP funds received in a special revenue fund or trust fund
(hereinafter called the Fund)established solely for the purposes of the provisions
of Part 4.7 (commencing with Section 16900) of Division 9 of the W&I Code.
(W&I Code Sections 16909(a) and (b))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 3 of 18
(b) Establish a Hospital Services Account in the Fund and deposit all hospital funds
received pursuant to paragraph 9 in that account. The County further assures
that it shall establish a Noncounty Hospital Subaccount in the Hospital Services
Account and deposit all Noncounty Hospital Formula and Discretionary funds
received pursuant to paragraphs 10 and 12, in that subaccount. If the County
owns and operates a county hospital; the County further assures that it shall
establish a County Hospital Subaccount in the Hospital Services Account and
deposit all County Hospital Discretionary funds received pursuant to paragraph
15, in that subaccount.
(W&I Code Sections 16909(a) and (b))
(c) Establish a PS Account in the Fund and deposit all PS funds received pursuant
to paragraph 24 in that account. The County further assures that it shall
establish an EMS Subaccount in the PS Account and deposit all PS funds
proposed for expenditure pursuant to paragraph 25, in that subaccount prior to
transferring the funds to any other account. If the County chooses to expend
Physician New Contracts funds pursuant to paragraph 30, the County assures
that it shall establish a Physician New Contracts Subaccount in the PS Account
and deposit all Physician New Contracts funds proposed for expenditure
pursuant to paragraph 30, in that subaccount.
(W&I Code Sections 16909(a) and (b))
(d) Establish an Other Health Services Account in the Fund and deposit all Other
Health Services funds received pursuant to paragraph 31, in that subaccount.
(W&I Code Sections 16909(a) and (b))
INTEREST EARNINGS ON THE FUND
4. (a) All interest earned on the Fund and on each account or subaccount shall be
accrued to the benefit of the Fund, account, or subaccount, respectively, and all
accrued interest shall be expended for the same purposes as the other funds in
the Fund, accounts, or subaccounts, respectively.
(W&I Code Section 16909(c)(1))
(b) All interest or other increments earned on the Noncounty Hospitals Subaccount
shall be expended on noncounty hospitals pursuant to the provisions of
paragraphs 10 and 12.
(W&I Code Section 16909(c)(2))
FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 4 of 18
ADMINISTRATIVE COSTS
5. County administrative costs associated with the administration of the Fund and each
account or subaccount shall be reimbursed from the Fund, account, or subaccount,
respectively. The County further assures that it shall not reduce or utilize Noncounty
Hospital Formula funds received pursuant to paragraph 10, to offset the costs of
administering the Noncounty Hospital Services Subaccount.
(W&1 Code Sections 16909.1 and 16946(b)(1)(E))
REPORTING
6. (a) Information on programs and services which shall receive CHIP funds shall be
included in the County's Description of Proposed Expenditures of CHIP Funds
and shall be subject to review and approval by the Department for compliance
with Part 4.7 (commencing with Section 16900) of Division 9 of the W&I Code.
(W&I Code Section 16980(b)(1))
(b) Indigent health care program demographic, expenditure, and utilization data shall
be reported as specified by the Department pursuant to the provisions of
W&I Code Section 16915 and the procedures specified by the Department.
(W&I Code Section 16915)
(c) Services, associated costs, and socio-demographic characteristics of persons
served under W&I Code Section 17000 and persons supported in whole or in
part by CHIP funds shall be incorporated into the reports required pursuant to
W&I Code Section 16915.
(W&I Code Section 16942(c))
(d) The County shall include an estimate of, and the costs and funding arrangement
for, dental services in its Description of Proposed Expenditures of CHIP Funds.
(W&I Code Section 16980(b)(2))
(e) The County shall submit reports which display cost and utilization data for each
account in the Fund as specified in the W&I Code Section 16909 to the
Department on a preliminary annual and a final annual basis, in a form
prescribed by the Department.
(W&I Code Section 16909(d))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 5 of 18
(f) The County shall provide the Department with information the Department
deems necessary to determine compliance with the provisions of Part 4.7
(commencing with Section 16900) of Division 9 of the W&I Code. The
information shall be provided according to the procedures and due dates
established by the Department.
(W&I Code Section 16981(a))
FISCAL ASSURANCES
7. (a) CHIP funds shall be accounted for as revenue in the Description of Proposed
Expenditures of CHIP Funds and in other information required by the
Department.
(W&I Code Sections 16990(c) and 16981)
(b) CHIP funds shall not be used as county matching funds for any other program
requiring a county match.
(W&I Code Section 16990(c))
(c) The County shall, at a minimum, maintain a level of financial support of county
funds for health services as specified in W&I Code Section 16990. This amount
shall not include any county funds expended pursuant to W&I Code
Section 16809.3. Net disproportionate share hospital revenues shall be included
in computing county financial maintenance of effort only as specified in the W&I
Code Section 16990.5.
(W&I Code Sections 16990 and 16990.5)
(d) In accordance with procedures established by the Department,the County may,
upon notifying the Department of the transfers authorized pursuant to W&I Code
Section 17600.20, reduce the level of financial maintenance of effort specified in
subparagraph (c) above by the amount of funds transferred from the Health
Account of the Local Revenue Fund pursuant to W&I Code Section 17600.20 for
FY 2005-06.
(W&I Code Section 16990(a)(2))
(e) If the County desires to use any of its CHIP allocation for programs and costs not
associated with county health services as defined in W&I Code Section 16801,
the County, as a condition of using its allocation for these purposes, shall
maintain an amount of county funding for those programs and costs at least
equal to FY 1988-89 levels.
(W&I Code Section 16990(b))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 6 of 18
RECOUPMENTIWITHHOLD
8. (a) In the event financial support of county funds for health services is less than the
amount specified in paragraph 7(c), the Department shall recover the amount of
the difference from the CHIP funds provided to the County proportionately from
the Hospital Services Account, the PS Account, and the Other Health Services
Account.
(W&I Code Sections 16981(b) and 16990(d))
(b) In the event financial support of county funds for programs and costs not
associated with county health services as defined in W&I Code Section 16801 is
less than the FY 1988-89 levels for those services, the Department shall recover
the amount of the difference from the CHIP funds provided to the County.
(W&I Code Sections 16981(b) and 16990(b))
(c) CHIP funds shall be returned to the Department if they are not encumbered or
expended within the fiscal year according to this Standard Agreement, and the
requirements of Chapter 5 (commencing with Section 16940) of Part 4.7 of
Division 9 of the W&I Code.
(W&I Code Section 16981(b))
(d) The Department shall withhold payment of any funds specified in this Standard
Agreement and W&I Code Section 16900 et seq., if any of the reports specified
in this Standard Agreement and W&i Code Section 16900 et sea., have not been
received from the County by the dates specified therein, unless an extension for
submission of such reports is formally granted by the Department. Any funds
withheld from the County pursuant to this Article shall be released upon receipt
of the required reports by the Department.
(W&I Code Sections 16916 and 16942)
(e) The Department shall conduct fiscal and program reviews to ensure county
compliance with the provisions of this Standard Agreement. The Department
may withhold funds, up to the total amount of funds allocated under this
Standard Agreement, if the county fails to correct deficiencies in the program
after receiving written notice of noncompliance from the Department.
(W&I Code Section 16981(a))
HOSPITAL SERVICES
9. The County agrees to expend all of its FY 2005-06 Hospital Services allocation
received pursuant to W&I Code Section 16943 to support uncompensated services
provided during FY 2005-06 by county and noncounty hospitals.
(W&I Code Sections 16941 and 16943(b)(c)(e) and (f))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 7 of 18
NONCOUNTY HOSPITAL FORMULA FUNDS
10. The County agrees to allocate all of its FY 2005-06 Noncounty Hospital Formula
allocation received pursuant to paragraph (1) of subdivision (b) of W&I Code Section
16946, to noncounty hospitals within the County in amounts determined pursuant to
paragraph (1) of subdivision (b) of W&I Code Section 16946 for support of services
provided by noncounty hospitals to any eligible patient treated at any time during the
FY 2005-06.
(W&I Code Sections 16945, 16946(a)(1) and (b)(1)(A))
11. (a) Each noncounty hospital's share of Noncounty Hospital Formula funds specified
in paragraph 10 shall be distributed to each noncounty hospital within ten (10)
working days of receipt of monthly CHIP payments.
(W&I Code Section 16948(a))
(b) Each noncounty hospital shall provide posted and individual notices pursuant to
W&I Code Section 16818 for the duration of any quarter during which funds
allocated pursuant to paragraph (1) of subdivision (b) of W&I Code Section
16946 are used.
(W&I Code Section 16946(b)(1)(D))
(c) Each noncounty hospital shall account for the funds on a quarterly basis.
(W&I Code Section 16946(b)(1)(B))
NONCOUNTY HOSPITAL DISCRETIONARY FUNDS
12. The County agrees to distribute all of its FY 2005-06 Noncounty Hospital Discretionary
allocation received pursuant to paragraph (2) of subdivision (b) of W&I Code
Section 16946 to noncounty hospitals to maintain access to emergency care and to
purchase other necessary hospital services provided during FY 2005-06.
(W&I Code Sections 16945 and 16946(b)(2)(A)(i))
13. The funds specified in paragraph 12 shall be distributed only after consulting with
those hospitals and considering the following:
(a) The historic and projected patterns of care provided by hospitals, by geographic
catchment areas within both urban and nonurban areas.
(W&I Code Section 16946(b)(2)(B)(i))
(b) The unique costs associated with treating disproportionate numbers of severely
ill, indigent patients.
(W&I Code Section 16946(b)(2)(B)(i))
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FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 8 of 18
(c) The disproportionate losses sustained by hospitals in the provision of care.
(W&I Code Section 16946(b)(2)(B)(i))
(d) The patterns of care of its residents provided by level I trauma care hospitals in
contiguous counties and the County may make proportionate allocations to those
trauma centers.
(W&I Code Section 16946(b)(2)(B)(ii))
(e) The use of those funds to meet emergency room patient needs and follow-up
treatment, including the need for special hospital services.
(W&I Code Section 16949(c))
14. When contracting with hospitals in neighboring counties for emergency care, the
County shall not impose conditions to accept transfers that it does not impose on
hospitals within its own boundaries.
(W&I Code Section 16946(b)(2)(A)(ii))
COUNTY HOSPITAL. FUNDS
15. The County agrees to expend all of its FY 2005-06 County Hospital allocation
received pursuant to subdivision (c) of W&I Code Section 16946 for payment or
support of services provided in county or noncounty hospitals as determined by the
County during FY 2005-06.
(W&I Code Sections 16945, 16946(a)(2) and (c))
REQUIREMENTS
16. As a condition of receiving the Hospital Services funds specified under paragraph 9,
each county and noncounty hospital shall be required to do all of the following:
(a) Maintain the same number and classification of emergency room permits and
trauma facility designations as existed on January 1, 1990. This condition shall
be deemed to be met for any hospital that maintained two special permits for
basic emergency services on July 1, 1989, if each of the emergency rooms was
located on separate campuses of the hospital and was located not more than
two miles from the other emergency room. This condition shall also be deemed
to be met even if one of the emergency room permits is surrendered after July 1,
1989.
(W&I Code Sections 16946(d)(1)(A) and (B)(i) and (ii)
FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 9 of 18
(b) In a county that comprises not more than one-half of one percent (1%) of the
total state population and in which there is a county hospital and a noncounty
hospital with emergency room permits located within two miles of each other, the
county hospital may surrender its emergency room permit without penalty for
violation of subparagraph (a) above provided all requirements of W&I Code
Section 16946(h) are met. If the Department determines that the County is not
in compliance with the requirements of subdivision (h) of W&I Code Section
16946 it shall require the County to recover funds and deny further payments
pursuant to subdivision (e) of W&I Code Section 16946, until compliance is
resumed.
(W&I Code Section 16946(h))
(c) Provide data and reports on the use and expenditure of all funds received in a
form and according to procedures specified by the County and the Department.
(W&I Code Section 16946(d)(2))
(d) Assure that Noncounty Hospital Discretionary and County Hospital Discretionary
funds received pursuant to paragraphs 12 and 15 are used only for services for
persons who cannot afford to pay for those services, and for whom payment
shall not be made through any private coverage or by any program funded in
whole or in part by the federal government.
(W&I Code Section 16946(d)(3))
(e) Assure that Noncounty Hospital Formula funds allocated pursuant to
paragraph 10 are used only for patients who cannot afford to pay or who meet
the Office of Statewide Health Planning and Development's (OSHPD) definition
of charity care, as prescribed under subdivision (d) of Section 128740 of the
Health and Safety Code and for whom payment shall not be made through any
private coverage or by any program funded in whole or in part by the federal
government.
(W&I Code Sections 16946(d)(3) and 16908.5)
(f) Cease all current and waive all future collection efforts, by itself and by its
agents, to obtain any payment from the patient with respect to whom the
services funded with funds specified in paragraph 9 were rendered within ninety
(90) days of the receipt of those funds.
(W&I Code Section 16947(a))
(g) Notify the County if the hospital receives payment from a patient or responsible
third-party payer and reimburse the County in an amount equal to the amount
collected from the patient or third-party payer, but not more than the amount of
the payment received from the County for the patient's care.
(W&I Code Section 16947(c))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 10 of 18
17. As a condition of receiving the hospital funds specified under paragraph 9, each
noncounty hospital shall be required to report to the County within thirty (30) days
after the receipt of Noncounty Hospital Formula funds distributed pursuant to
paragraph 10, information on patients for whom the distributions shall be used,
pursuant to the requirements of W&I Code Section 16909 (d) and (e).
(W&I Code Section 16948(b))
18. Hospitals receiving Noncounty Hospital Discretionary funds under paragraph 12 shall
be required to report to the County and OSHPD on any reduction in hospital
emergency room specialist capabilities below the level which was provided at that
facility on October 2, 1989.
(W&I Code Section 16949(d))
RECOVERY, WITHHOLD, AND SUSPENSION OF PAYMENTS TO HOSPITALS
19. The County shall recover from any county or noncounty hospital:
(a) That portion of funds received which equal the ratio of the number of months the
hospital violates the provisions of paragraph 16(a) to twelve (12) months.
(W&I Code Section 16946(e)(1)(A))
(b) All funds received if the hospital violates the provisions of paragraph 16(c).
(W&1 Code Section 16946(e)(1)(B))
(c) The difference between the amount received and the amount which the hospital
can document that the funds were used according to the provisions of
paragraphs 16(d) and 16(e) on a monthly basis.
(W&I Code Section 16946(e)(1)(C))
20. Further payment of funds may be denied to a hospital which has violated the
provisions of paragraphs 16 through 18 until the hospital demonstrates compliance.
(W&I Code Section 16946(e)(2))
21. Payments to any noncounty hospital shall be suspended if the hospital fails to provide
the information required in paragraph 17.
(W&I Code Section 16948(c))
REALLOCATION AND REDISTRIBUTION
22. Funds withheld or recovered pursuant to paragraph 19 may be reallocated and
distributed according to the Noncounty Hospital Discretionary provisions contained in
paragraphs 12 and 13.
(W&I Code Section 16946(f))
FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 11 of 18
23. Noncounty Hospital Formula and Discretionary funds available for allocation or
distribution pursuant to paragraphs 10 and 12, which are not expended because a
hospital does not participate shall be redistributed pursuant to the Noncounty Hospital
Discretionary provisions contained in paragraph 12. If no noncounty hospitals remain
to participate, the County may distribute the unexpended funds pursuant to the
County Hospital Discretionary provisions contained in paragraph 15.
(W&I Code Section 16946(g))
PHYSICIAN SERVICES
24. The County agrees to expend all of its FY 2005-06 PS allocation received pursuant to
subdivision (a) of W&I Code Section 16950, for the support of or payment for
uncompensated services provided during FY 2005-06 by a licensed physician.
(W&I Code Sections 16908, 16941, and 16950(a))
EMERGENCY MEDICAL SERVICES FUND - PHYSICIAN SERVICES ACCOUNT
25. As a condition of receiving CHIP funds, the County shall:
(a) Establish an EMS fund as authorized by subdivision (a) of Health and Safety
Code Section 1797.98a. This shall not be interpreted to require the County to
impose the assessment authorized by Section 1465.5 of the Penal Code.
(W&I Code Section 16951)
(b) Establish a PS Account within the EMS fund and deposit in the PS Account at
least fifty percent (50%) of the PS amount specified in paragraph 24 and any j
other funds appropriated by the Legislature for the purposes of the PS Account
of the EMS fund.
(W&I Code Sections 16950(c) and 16952(a)(1))
(c) Funds deposited in the PS Account in the EMS fund are exempt from the
percentage allocations set forth in subdivision (a) of Section 1797.98a of the
Health and Safety Code.
(W&I Code Section 16952(b)(1))
EMERGENCY MEDICAL SERVICES FUND - PHYSICIAN SERVICES ACCOUNT
PURPOSE AND USE OF FUNDS
26. The PS Account in the EMS fund shall be used to reimburse physicians for.losses
incurred for services provided during FY 2005-06 and the County shall:
(W&I Code Section 16952(f))
FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 12 of 18
(a) Limit reimbursement to emergency services, as defined in W&I Code Section
16953, obstetric services, as defined in W&I Code Section 16905.5, and
pediatric services, as defined in W&I Code Section 16907.5.
(W&I Code Section 16952(h)(1))
(b) Any physician may be reimbursed for up to 50 percent of the amount claimed
pursuant to Section 16955 for the initial cycle of reimbursements in a given year.
All funds remaining at the end of the fiscal year shall be distributed
proportionally, based on the dollar amount of claims submitted and paid to all
physicians who submitted qualifying claims during that year. Funds shall not be
disbursed in excess of the total amount of a qualified claim.
(W&I Code Section 16952(i))
(c) Not reimburse for physician services provided by physicians employed by county
hospitals.
(W&I Code Section 16952(b)(1))
(d) Not reimburse any physician who provides physician services in a primary care
clinic which receives funds pursuant to Part 4 of Division 106 of the Health and
Safety Code commencing with Section 124400.
(W&I Code Section 16952(b)(2))
(e) Limit reimbursement for losses incurred by any physician for services provided to
patients who do not have health insurance coverage for emergency services and
care, who cannot afford to pay for those services, and for whom payment shall
not be made through any private coverage or by any program funded in whole or
in part by the federal government, with the exception of claims submitted for
reimbursement through Section 1011 of the federal Medicare Prescription Drug,
Improvement and Modernization Act of 2003, and where all of the following
conditions have been met:
(W&I Code Sections 16952(f))
(i) The physician has inquired if there is a responsible third-party source of
payment.
(W&I Code Section 16955(a))
(ii) The physician has billed for payment of services.
(W&I Code Section 16955(b))
(iii) A period of not less than three months has passed from the date the
physician billed the patient or responsible third-party, during which time
the physician has made reasonable efforts to obtain reimbursement
and has not received reimbursement for any portion of the amount
billed, or the physician has received actual notification from the patient
or responsible third-party that no payment shall be made for the
services rendered by the physician.
(W&I Code Section 16955(c))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 13 of 18
(iv) The physician has stopped any current, and waives any future,
collection efforts to obtain reimbursement from the patient, upon receipt
of funds from the County PS Account in the County EMS fund.
(W&I Code Section 16955(d))
(f) Physicians shall be eligible to receive payment for patient care services provided
by, or in conjunction with, a properly credentialed nurse practitioner or
physician's assistant for care rendered under the direct supervision of a
physician and surgeon who is present in the facility where the patient is being
treated and who is available for immediate consultation. Payment shall be
limited to those claims that are substantiated by a medical record and that have
been reviewed and countersigned by the supervising physician and surgeon in
accordance with regulations established for the supervision of nurse practitioners
and physician assistants in California.
(W&I Code Section 16952(g))
EMERGENCY MEDICAL SERVICES FUND - PHYSICIAN SERVICES ACCOUNT
ADMINISTRATIVE COSTS
27. Costs of administering the account shall be reimbursed by the account based on
actual administrative costs, not to exceed 10 percent of the amount of the account.
(W&I Code Section 16952(d))
EMERGENCY MEDICAL SERVICES FUND - PHYSICIAN SERVICES ACCOUNT
EXPENDITURES
28. The County shall provide a reasonable basis for its estimate of PS Account funds in
the EMS fund which are encumbered to reimburse physicians losses incurred during
the fiscal year for which bills shall not be received until after the fiscal year and agrees
to expend or disencumber these funds prior to the submission of the report of actual
expenditures required by W&I Code Section 16980 (b).
(W&I Code Section 16952(a)(2))
EMERGENCY MEDICAL SERVICES FUND - PHYSICIAN SERVICES ACCOUNT
PROCEDURES
29. The County shall:
(a) Establish procedures and time schedules, and a fee schedule for submission
and processing of reimbursement claims submitted by physicians.
(W&I Code Sections 16953.3 and 16956(a))
FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 14 of 18
(b) Establish schedules for payment which shall provide for disbursement of the
funds available in the PS Account of the EMS fund periodically and at least
quarterly, if funds remain available for disbursement, to all physicians who have
submitted claims containing accurate and complete data for payment by the
dates established by the County.
(W&I Code Section 16956(b))
(c) Deny, at its discretion, claims which are not supported by records and recover
any reimbursement paid to any physician for claims which Lack supporting
records.
(W&i Code Section 16956(c))
(d) Require a listing of patient names to accompany a physician's claim, and give full
confidentiality protection to those names.
(W&I Code Section 16956(e))
(e) Require physicians to notify the administering agency if, after receiving payment
from the PS Account of the EMS fund, the physicians are reimbursed by patients
or responsible third-parties. In these instances, the County assures that it shall
reduce the physician's future payment of claims from the account or, in the event
there is not a subsequent submission of a claim for reimbursement within one
year, require the physicians to reimburse the PS Account of the EMS fund in an
amount equal to the amount collected from the patient or third-party payer but
not greater than the amount of reimbursement received from the PS Account of
the EMS fund for the patient's care.
(W&I Code Section 16958)
(f) Require physicians who submit claims for funding from the PS Account of the
EMS fund to keep and maintain records of the services rendered, the person to
whom services were rendered, and any additional information the administering
agency may require,for a period of three years after the services were provided.
(W&I Code Section 16957)
(g) Pursuant to Welfare and Institutions Code, section 16952.1, submit an annual
report to the Legislature by April 15 concerning the implementation and status of
the EMS Physician Services Account for the preceding fiscal year.
(W&I Code Section 16952.1)
(h) Any physician who submits any claim for reimbursement under this chapter
which is inaccurate or which is not supported by records may be excluded
from reimbursement of future claims under this chapter.
(W&I Code Section 16956(d))
FY 2005-06 CHIP Standard Agreement- County of Fresno
Page 15 of 18
(i) A listing of patient names shall accompany a physician's claim, and those
names shall be given full confidentiality protections by the administering
agency.
(W&I Code Section 16956(e))
Q) The administering agency shall not give preferential treatment to any facility,
physician, or category of physician and shall not engage in practices that
constitute a conflict of interest by favoring a facility or physician with which the
administering officer has an operational or financial relationship.
(W&I Code Section 16956(f))
(k) Payments shall be made only for emergency medical services provided on
the calendar day on which emergency medical services are first provided and
on the immediately following two calendar days.
(W&I Code Section 16956(g))
(1) Notwithstanding subdivision (g), if it is necessary to transfer the patient to a
second facility that provides for a higher level of care for the treatment of the
emergency condition, reimbursement shall be available for services provided
to the facility to which the patient was transferred on the calendar day of
transfer and on the immediately following two calendar days.
(W&I Code Section 16956(h))
NEW CONTRACTS
30. (a) The difference between the physician services amount received in paragraph 24
and the amount transferred to the PS Account of the EMS fund pursuant to
paragraph.25 shall be expended by the County to pay for new contracts during
FY 2005-06 with private physicians for provision of emergency, obstetric, and
pediatric services in facilities which are not owned or operated by a county, and
where access to those services has been severely restricted.
(W&I Code Section 16950(b))
(b) The County shall require physicians who receive funds specified in
subparagraph (a) to stop any current, and waive any future, collection efforts to
obtain reimbursement from the patient, upon receipt of funds from the County.
The contracts may provide for partial or full reimbursement for physician services
provided to patients who do not have health insurance coverage for emergency
services and care, who cannot afford to pay for those services, and for whom
payment shall not be made through any private coverage or by any program
funded in whole or in part by the federal government, with the exception of
claims submitted for reimbursement through Section 1011 of the federal
Medicare Prescription Drug, Improvement and Modernization Act of 2003.
(W&I Code Section 16950(b))
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 16 of 18
OTHER HEALTH SERVICES FUNDS - PURPOSE
31. The County agrees to expend all of its FY 2005-06 Other Health Services allocation
received pursuant to W&l Code Section 16960 to maintain and enhance health care
services which are:
(a) Provided during FY 2005-06.
(b) Specified in W&I Code Sections 14021 and 14132, and in former Division 1
(commencing with Section 100)and the Communicable Disease Prevention and
Control Act as set forth in subdivision (a) of Section 27, of the Health and Safety
Code.
(c) Provided to patients who cannot afford to pay for those services, and for whom
payment shall not be made through private coverage or by any program funded
in whole or in part by the federal government.
(W&I Code Sections 16941, 16960(a), and 16961)
OTHER HEALTH SERVICES FUNDS - CONSIDERATIONS AND LIMITATIONS
32. No more than five percent (5%) of the Other Health Services funds specified in
paragraph 31 or fifty thousand dollars ($50,000), whichever is greater, shall be
expended for costs related to the purchase of equipment and fixed assets and that no
single expenditure shall exceed ten thousand dollars ($10,000).
(W&I Code Section 16960(b))
33. Consideration shall be given to city public health departments within the County in the
use of Other Health Services funds specified in paragraph 31.
(W&I Code Section 16960(a))
CONTRACTUAL CONSIDERATIONS AND LIMITATIONS
34. The Department or County may terminate this Standard Agreement by giving at least
thirty (30) days written notice to the other party. The notification shall state the
effective date of termination.
35. Nothing in this Standard Agreement shall be interpreted to require additional
expenditures of County funds for health services beyond those required herein. Also,
nothing in this Standard Agreement shall be interpreted to relieve the County of its
other obligations to provide health care services to its residents.
36. The Standard Agreement may be amended to conform to any applicable changes in
the statutes governing the funds and programs covered in this Standard Agreement.
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 17 of 18
37. Section 86 of SB 391 (Chapter 294, Statutes of 1997) is hereby incorporated by
reference into this Standard Agreement. Reductions in appropriations for CHIP
pursuant to Section 86 shall be prorated among the CHIP Counties and the
allocations under paragraphs 9, 10, 12, 15, 24, and 31 shall be reduced accordingly
upon notification by the Department.
DISPUTE RESOLUTION PROCESS
38. A County grievance exists whenever the County believes there is a dispute arising
from Department's action in the administration of an agreement. If the County
believes there is a dispute or grievance between the County and Department, both
parties shall follow the procedure outlined below.
(a) The County should first discuss the' problem informally with the Department's
program manager. If the problem cannot be resolved at this stage, the County
shall direct its grievance together with any evidence, in writing, to the program
Branch Chief. The grievance shall state the issues in dispute, the legal authority
or other basis for the County's position and the remedy sought. The Branch Chief
shall make a determination on the problem within ten (10) working days after
receipt of the written communication from the County. The Branch Chief shall
respond in writing to the County indicating the decision and reasons therefore.
Should the County disagree with the Branch Chief's decision, the County may
appeal to the second level.
(b) The County must prepare a letter indicating the reasons for disagreement with
Branch Chiefs decision. The County shall include with the letter a copy of the
County's original statement of dispute with any supporting documents and a
copy of the Branch Chiefs response. This letter shall be sent to the Deputy
Director of the division in which the branch is organized within ten (10) working
days from receipt of the Branch Chiefs decision. The Deputy Director of the
division funding this agreement or his/her designee shall meet with the County
to review the issues raised. A written decision signed by the Deputy Director of
the division funding this agreement or his/her designee shall be returned to the
County within twenty (20) working days of receipt of the County's letter.
FY 2005-06 CHIP Standard Agreement - County of Fresno
Page 18 of 18
39. Unless otherwise stipulated by Department, dispute, grievance and/or appeal
correspondence shall be directed to the Department's program manager.
THIS STANDARD AGREEMENT FOR FUNDING HAS BEEN SIGNED BY THE COUNTY'S
GOVERNING BODY AND IS HEREBY EXECUTED.
State of California County of ,Fresno
Signature: Signature:
Name: Nancy E. Hayward Name: Phil Larson
Title: Chief, Office of County Health Services Title: Chairman, Board of Supervisors
-�[Date: 3 Date: ?/7/16,
ATTEST: i
BERNICE E. SEIDEL, ,Clerk,
Board of SuperVisors
Y Deputy
I
i
AGREEMENT BETWEEN THE COUNTY OF FRESNO AND THE STATE OF CALIFORNIA
No./Name: CALIFORNIA HEALTHCARE FOR INDIGENTS PROGRAM Term: FY 2005-06
APPROVED AS TO LEGAL FORM:
DENNIS A. MARSHALL, COUNTY COUNSEL
By
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P,A., AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
By
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Edward L. Moreno, , M.P.H.
Director-Health Of is r
Department of Cone ii i Health
Organization: 5242
Cost Center: N/A
Revenue Account : 3512