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Agenda 09/23/2025 Item #16D 7 (County Manager to sign (a) the Directed Provider Payment Letter of Agreement in the amount of $23,084,530.00, (b) the Graduate Medical Education Program Letter of Agreement)9/23/2025 Item # 16.D.7 ID# 2025-2941 Executive Summary Recommendation to authorize the County Manager to sign (a) the Directed Provider Payment Letter of Agreement in the amount of $23,084,530.00, (b) the Graduate Medical Education Program Letter of Agreement for an estimated amount of $2,373,918.09 with the Agency for Health Care Administration for an estimated total not to exceed $25,458,448.09, (c) the required Provider Questionnaires, and (d) authorize the necessary Budget Amendments. Local Provider Fund (1130) OBJECTIVE: To continue support of area hospitals that provide health services to the low-income citizens of Collier County while advancing the County’s strategic objective of promoting access to health, wellness, and human services. CONSIDERATIONS: The County has been a long-standing participant in the Florida Agency’s for Health Care Administration (AHCA) Intergovernmental Transfer Program (IGT). A hospital-focused program was established by the Florida Legislature on FY21. To participate, counties assess hospitals and place funds into a Local Provider Participation Fund (LPPF). Collier’s LPPF funds both the Directed Payment Program (DPP) and the Graduate Medical Education Program (GME). Nationwide, and especially in Florida, hospitals continue to struggle with the shortfall in Medicaid reimbursement rates. Hospitals in Collier County provide millions of dollars of care to people who qualify for Medicaid annually. As a direct result of continued revenue shortfalls created by the Medicaid reimbursement rates, during the FY21 Florida Legislative session, Governor DeSantis, with the full support of the House and Senate, approved the establishment of the Direct Payment Program (DPP). This program is available to hospitals providing inpatient and outpatient services to Medicaid- managed care enrollees. It is the intent of the DPP to offset hospitals’ Medicaid shortfalls and improve the quality of care provided to the Florida Medicaid population. At the request of the hospitals annually, the County will impose a non-ad valorem assessment upon real property owned or used by the hospitals to help fund the non-federal share of the State’s Medicaid Program. This assessment will provide additional funding for Medicaid payments to close revenue shortfalls associated with the program. Leveraging additional federal support through the DPP and GME programs will directly benefit the services delivered to Medicaid- eligible people and support their ability to provide critical health care programs. It is necessary to continue the LPPF program to ensure that the hospitals will have the opportunity to secure all funds available in the upcoming state fiscal year. On June 22, 2021, the Board adopted Ordinance 2021-23, enabling the County to levy a uniform non-ad valorem special assessment, which is fairly and reasonably apportioned among the Hospitals’ property interests within the County’s jurisdictional limits, for the purpose of establishing and maintaining a system of funding for IGTs to support the non- federal share of Medicaid payments. Following passage of Ordinance 2021-23, the Board subsequently approved participation in the program in FY22 on September 27, 2022 (Agenda Item #16. D.5), FY23 on September 26, 2023 (Agenda Item #16. D.7), FY24 on September 10, 2024 (Agenda Item #16. D.11) and for FY25 on June 24, 2025 (Agenda Item #16. D.6). On June 24, 2025, the Board adopted Resolution No. 25-123 approving the Local Provider Participation Fund Special assessment for FY 2025 to be 1.74% of net inpatient revenue and 2.81% of net outpatient revenue. AHCA has determined that there will be a maximum of $25,415,167.00 from participating Hospitals. This amount, plus the carry- forward balance from prior LPPF special assessments, will be submitted to AHCA. The DPP and GME Letters of Agreement between Collier County and AHCA permit an IGT in an amount not to exceed $25,458,448.09. If at the end of the Fiscal Year, additional amounts remain in the LPPF, the Board is authorized to roll funds over to or make a refund to assessed properties in proportion to amounts paid during the Fiscal Year. DPP and GME Local Intergovernmental Transfers Program / Amount State Fiscal Year 2025-2026 LPPF DPP $23,084,530.00 Page 2392 of 3896 9/23/2025 Item # 16.D.7 ID# 2025-2941 GME $ 2,373,918.09 Total LOA Funding (not to exceed) $25,458,448.09 Advances the County’s strategic objective of promoting access to health, wellness, and human services. FISCAL IMPACT: The assessment of 1.74% of net inpatient hospital services and 2.81% of net outpatient hospital services revenue enacted by the resolution will take hospital funds collected through a non-ad valorem assessment and direct those dollars to the AHCA to fund the non-federal share of the State’s Medicaid Program, including the Medicaid Hospital Direct Payment Program and Graduate Medical Education Program. This funding structure ultimately results in enhanced funding returned to the hospitals for the Medicaid shortfall and for physician training. The information currently available suggests the maximum assessment collected this year will be $25,415,167 from participating hospitals. The collected assessment will be transmitted to AHCA and will not exceed the actual amount of assessment dollars received by the County, less administrative costs. **** These amounts will not be valid until notified by consultant – may not be until January Hospital name Assessment Amount NCH Baker Hospital $ 15,494,544 Physicians Regional $ 9,269,508 Encompass Health Rehabilitation $ 502,891 Willough at Naples $ 148,224 $ 25,415,167 Regarding budget administration, FY26 budget amendments in the amount of $25,479,948.09 are necessary to amend the tentative FY26 budget within the Local Provider Participation Fund (1130). The budget amendment will include the FY25 assessments received from participating hospitals, as well as recognizing additional carryforward. The associated budget amendments will permit IGTs in an amount not to exceed $25,458,448.09 to be paid to ACHA as well as additional budget for administrative expenses associated with overseeing the program. GROWTH MANAGEMENT IMPACT: There is no Growth Management impact. LEGAL CONSIDERATIONS: This item is approved as to form and legality and requires a majority vote for Board action. - CLD RECOMMENDATIONS: To authorize the County Manager to sign (a) the Directed Provider Payment Letter of Page 2393 of 3896 9/23/2025 Item # 16.D.7 ID# 2025-2941 Agreement in the amount of $23,084,530.00, (b) the Graduate Medical Education Program Letter of Agreement for an estimated amount of $2,373,918.09 with the Agency for Health Care Administration for an estimated total not to exceed $25,458,448.09, (c) the required Provider Questionnaires, and (d) authorize the necessary Budget Amendments. Local Provider Fund (1130). PREPARED BY: Carolyn Noble, Grants Coordinator, CHS ATTACHMENTS: 1. LPPF BA 1130 FY26 2. DPP LOA 25-26 CAO Stamped 3. GME LOA 25-26 CAO Stamped 4. DPP IGT Questionnaire CAO Stamped 5. GME IGT Provider Questionnaire 9.16.25 CAO Stamped Page 2394 of 3896 Page 2395 of 3896 Page 2396 of 3896 Page 2397 of 3896 Page 2398 of 3896 Page 2399 of 3896 Page 2400 of 3896 Page 2401 of 3896 Page 2402 of 3896 Page 2403 of 3896 Page 2404 of 3896 Page 2405 of 3896 lntergovernmental Transfers Questionnaire IGT Provider Name: Health Care Provider Name: IGT Amount: State Fiscal Year Ending. Collier County N/A $2,373,918.09 6t30t2026 1. What type of governmental entity is your organization considered? (county, city, hospital taxing district, or other) County lf other ease tn 2. Does your organization have a relationship with the provider for which you contribute lGTs as named in the preamble of the enclosed Letter of Agreement (LOA)? No lf yes, please describe your relationship, including servlces provided to/by the provider to/by the organization and any other financial transactions between the provider and the organization. 3. Please describe the source of the IGT funding for your organization, including whether the source is from a tax, a provider donation, or other funds. Provide the amount of funding from each source. Source Amount Special Assessment for FY2026 $2,373,918.09 $ lf other a. Verify whether the funds are public funds as defined by 42 CFR S 433.51 , and exclude any federal funds. Yes lf no eex Yes 4. Does your organization have taxing authority? CAO Page 2406 of 3896 5. lf the source of IGT funding is from taxes, please answer the following questions: a. ls the tax a state or district tax? lf other b. What entities are taxed? Licensed non-public hospitals in Collier County c. What is the tax structure e.tax e of revenue assessme etc. d. What is the amount or of the tax? e. Does at least 85% of the burden of the tax revenue fall on health care providers as defined in 42 CFR $433.55? (Provide the total tax revenue and the health care provider tax burden) lf so, please answer the following questions: Amount Total Tax Burden $25,415,167 Healthcare Provider Tax Burden $25,415,167 '100.00% i) ls the tax broad based? A broad based tax can be defined as a tax that is imposed on at least all health care items or services in the class or providers of such items or services furnished by all non-Federal, non-public providers in the State, and is imposed uniformly, pursuant to 42 cFR S 433.68. Yes intf Special assessment Net Patient Revenue (inpatient hospital services): 1.74%. Net Patient Revenue (outpatient hospital services): 2.81 % CAO Countv Page 2407 of 3896 ii) ls the tax uniform across all entities being taxed? Based on 42 CFR S 433.68, a health care- related tax will be considered to be imposed uniformly even if it excludes Medicaid or Medicare payments (in whole or in part), or both; or in the case of health care-related tax based on revenue or receipts with respect to a class of items or services, if it excludes either Medicaid or Medicare revenue with respect to a class of items or services, or both. The exclusion of Medicaid revenue must be applied uniformly to all providers being taxed. Yes iii) ls the tax generally redistributive and a waiver of the broad-based or uniform tax requirement was granted in accordance with 42 CFR $433.68(e)? No lf no SE ain iv) Does the tax program comply with the hold harmless provisions included in 42 CFR $ 433.68(0? Yes lf no v) Does every tax paying entity receive a supplemental payment equal to or exceeding its tax cost? 6. Please answer the following regarding provider funds received from the healthcare entity and/or other health care entities. a. Are provider voluntary payments or in-kind services received by the organization as defined in 42 cFR S 433.52? No b. How much of the organization's revenue is received from provider-related donations (Provide the total revenue and the provider-related donation amounts)? Amount Total Revenue $ Provider Related Donations $ c. Do individual provider donations exceed $5,000 per year or $50,000 per year for a health care organizational entity? No tf n lain laintf No waiver was requested. county is not involved in the distribution of funds following federal match. The county is not in a position to speak to the ultimate distribution to hospitals from the managed care nizations. CAO Page 2408 of 3896 lf yes, please list the provider and payment amount. Amount d. Does any portion of the provider donation constitute as a "bona fide donation" pursuant to 42 CFR S 433.54? 42 CFR S 433.54 requires donations will not be returned to the individual provider, the provider class, or related entity under a hold harmless provision. No e. ls there an agreement between the IGT provider and the health care entity? lf so, please specify whether the agreement is written and provide the details. 7. Were funds utilized for the IGT specifically appropriated by the organization's board? lf yes, provide the board minutes and date of the appropriation certify that the statements and information contained in this submittal are true, accurate, and complete. Signature of Officer or Administrator Title Date $ $ $ No qqo Page 2409 of 3896