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AMENDMENT No. 01
To
CONTRACT No. 2014007
BETWEEN
COUNTY OF MERCED
AND
COUNTY OF FRESNO
AGREEMENT NO. 13-713-1
THIS Amendment to Contract No. 2014007, is executed by and between the County of Merced, a
political subdivision of the State of California, (hereinafter called "MERCED"), and County of Fresno
(hereinafter called "FRESNO.).
10 This Amendment is hereby annexed to and made a part of the printed part of the Agreement to which it
11 is attached, or modifies the existing Agreement betw~n the parties. In each instance in which the
12 provisions of this Amendment shall contradict or be inconsistent with the provisions of the printed portion
13 of the original Agreement and any previous amendments, the provision of this Amendment shall prevail
14 and govern and the contradicted or inconsistent provisions shall be deemed amended accordingly. Both
15 parties agree that there is new and adequate consideration for this Amendment.
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17 This Amendment shall be deemed to have been duly approved when executed by both parties to the
18 original Agreement. Once duly approved, this Amendment shall become effective as of the date signed
19 by the Chairman of the Merced County Board of Supervisors.
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21 MODIFICATIONS:
22 a). That the existing Agreement No. 2014007, Section 5, Page 4, beginning on Line 23, with the
23 word "MERCED" and ending on Page 5, Line 24, with the word "amendment" be deleted and the
24 following inserted in its place.
25 "MERCED rates for services provided pursuant to the terms and conditions of this Agreement
26 are as follows:
27 For the period of July 1, 2013through September14, 2013:
28 Psychiatric Health Facility (PHF) Rate per Consumer (Acute and Non-Acute):
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1 MERCED shall bill FRESNO the difference between MERCED'S Published PHF Charge
2 of $673.10 per client per day and any reimbursements received from the State Medi-
3 Cal billing process or any other payer sources. MERCED shall include an explanation of
4 any benefits received from other payer sources with each bill.
5 Administrative Overhead Charge (15%) per Consumer (Acute and Non-Acute)
6 MERCED shall additionally bill FRESNO $100.97 per client per day, which is 15% of
7 MERCED'S Published PHF Charge.
8 For the period of September 15,2013 through November 8, 2014:
9 Psychiatric Health Facility (PHF) Rate per Consumer (Acute and Non-Acute)
10 MERCED shall bill FRESNO the difference between MERCED'S Published PHF Charge
11 of $814.49 per client per day and any reimbursements received from the State Medi-
12 Cal billing process or any other payer sources. MERCED shall include an explanation of
13 any benefits received from other payer sources with each bill.
14 Administrative Overhead Charge (15%) per Consumer (Acute and Non-Acute)
15 MERCED shall bill FRESNO $122.17 per client per day, which is 15% of MERCED'S
16 Published PHF Charge.
17 For the period of November 9, 2014 through June 30, 2016:
18 Psychiatric Health Facility (PHF) Rate per Consumer (Acute and Non-Acute)
19 MERCED shall bill FRESNO the difference between MERCED'S Published PHF Charge
20 of $938.35 per client per day and any reimbursements received from the State Medi-
21 Cal billing process or any other payer sources. MERCED shall include a~ explanation of
22 any benefits received from other payer sources with each bill.
23 Administrative Overhead Charge (15%) per Consumer (Acute and Non-Acute)
24 MERCED shall additionally bill FRESNO $140.75 per client per day, which is 15% of
25 MERCED'S Published PHF Charge.
26 The rate structure utilized to negotiate this Agreement is inclusive of all services defined as
27 psychiatric inpatient services in Title 9, Chapter 11 of the Welfare and Institutions Code and does not
28 include non-hospital based physician or psychological services. It is understood by FRESNO and
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MERCED that MERCED'S Published PHF Charge is established based on actual costs reported in
2 MERCED'S most recent Cost Report submitted to the State Department of Health Care Services.
3 MERCED will notify FRESNO of any rate adjustment(s), and said rate adjustment(s) will be made by
4 written amendment to this agreement and signed by both parties hereto. Any rate adjustment(s) shall
5 not result in an increase to the maximum compensation of the Agreement stated in Section 6 (g), unless
6 set forth in the written amendment."
' 7 b). That all references in existing Agreement No. 2014007 to "Exhibit A" shall be changed to read
8 "Revised Exhibit A", where appropriate, attached hereto and incorporated by reference.
9 Except as herein modified, all terms and conditions in said Agreement as heretofore approved
1 o remain unchanged and in full force and effect.
11 [Signature page follows]
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COUNTY OF MERCED
A Political Subdivision of the
State of California
By
Chairperson, Board of Supervisors
Date
APPROVED AS TO LEGAL FORM:
JAMES N FINCHER
MERCED COUNTY COUNSEL
By ________________________ __
Deputy
MERCED COUNTY MENTAL HEALTH
REVIEWED AND RECOMMENDED FOR
APPROVAL:
By ______________________ ___
Yvonnia Brown, Acting Director
Budget Unit: 41500
Expenditure Account: 96828
Mode of Service: 05
Service Function: 20
Provider #2415
Legal Entity #00024
NPI: 1013030808
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COUNTY OF FRESNO
A Political Subdivision of the
State of California
Date.____:_~ /:u_......_}/_5 __
BERNICE E. SEIDEL, Clerk
Board of Supervisors
APPROVED AS TO LEGAL FORM:
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-
CONTROLLER/TREASURER-TAX
COLLECTOR
By~~~\~
RECOMMENDED FOR APPROVAL
By ~-7kl-edtf-
Dawan Utecht, Director
Department of Behavioral Health
Fund/Subclass: 0001/1 0000
Organization: 56302666 ($75,000)
Account/Program: 7295/0
REVISED EXHIBIT A
s
MEfiCEDA~
Yvonnia Brown
Mental Health Services
P.O. Box 2087
Merced, CA 95344-1046
(209) 381-6800
www.co.merced.ca.us
COUNTY DEPARTMENT OF MENTAL HEALTH
Service and Payment Authorization Form
I authorize the admission of (patient's name)-----------------
a County resident for psychiatric hospitalization at Marie Green
Psychiatric Center located at 300 E. 15th Street in Merced, California.
__________ County will be responsible for the following:
D
By:
1) Transportation of the patient to and from Marie Green Psychiatric Center.
2) Payment of Services rendered to the client at the rate of $673.10 per client per day
plus $100.97 per client per day Administrative Overhead costs during the period of
July 1, 2013 to September 14,2013.
3) Payment of Services rendered to the client at the rate of$814.49 per client per day
plus $122.17 per client per day Administrative Overhead costs during the period of
September 15, 2013 to November 8, 2014.
4) Payment of Services rendered to the client at the rated of $938.35 per client per day
plus $140.75 per client per day Administrative Overhead costs during the period of
November 9, 2014 to June 30, 2016
5) If the Client has Medi-Cal, placing County will be responsible to cover all charges
not reimbursed by the State or other payer source.
6) Placement of patient post discharge.
7) Provision of at least one guard if necessary.
8) Ensure that all medications are sent with patient and/or reimburse the cost of any
medical medication ordered or provided during the patient's stay at Marie Green
Psychiatric Center.
9) Payment of$76 for History and Physical, if ordered by the attending psychiatrist.
Authorization Approved D Authorization Denied
_________ County
(Please Print)
Signature:---------------
Please provide reason(s) if authorization is denied.
Document completed by:--------------
MCDMHStaff
Revised March 2015