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Backup Documents 09/23/2025 Item #16D 7 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 D ? TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 9.23.25 BCC MTG THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. Carolyn Noble Community and Human CN 9.17.25 Services 2. County Attorney Office— County Attorney Office 3. BCC Office $Breard drCountyc6,n+y Goniniissibrrers 4. Minutes and Records Clerk of Court's Office148 cc! A PRIMARY CONTACT INFORMATION f Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is neede in the event one of the addressees above,may need to contact staff for additional or missing information. Name of Primary Staff Carolyn Noble Phone Number 239-450-5186 Contact/ Depai tutent Agenda Date Item was 9.23.25 Agenda Item Number 16.D.7 Approved by the BCC Type of Document 1 DPP LOA, 1 GME LOA 1 GTE IGT Number of Original 4 original documents Attached QUESTIONNAIRE AND 1 DPP IGT Documents Attached QUESTIONNAIRE PO number or account number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature STAMP OK CN 2. Does the document need to be sent to another agency for additional signatures? If yes, N/A provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be Yes signed by the Chairman,with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the N/A document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's YES signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip N/A should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved by the BCC on above date and all changes made during N/A is not the meeting have been incorporated in the attached document. The County an option for Attorney's Office has reviewed the changes,if applicable. this line. 9. Initials of attorney verifying that the attached document is the version approved by the N/A is not BCC,all changes directed by the BCC have been made,and the document is ready for the an option for Chairman's signature. this line. 16D7 is Directed Payment Program Letter of Agreement THIS LETTER OF AGREEMENT (LOA) is made and entered into in duplicate on the 23(J day of 2025, by and between Collier County LPPF(the"IGT Provider")on behalf of Regio�heState of Florida, Agency for Health Care Administration (the "Agency„), for good and valuable consideration, the receipt and sufficiency of which are acknowledged. { DEFINITIONS "Intergovernmental Transfers (IGTs)" means transfers of funds from a non-Medicaid governmental entity (e.g., counties, hospital taxing districts, providers operated by state or local government)to the Medicaid agency. IGTs must be compliant with 42 CFR Part 433 Subpart B. "Medicaid" means the medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., and regulations thereunder, as administered in Florida by the Agency. "Directed Payment Program (DPP)," pursuant to the General Appropriation Act, Laws of Florida 2025-198, is the program that provides direct supplemental payments to eligible public and private entities that provide inpatient and outpatient services to Medicaid managed care recipients. A. GENERAL PROVISIONS 1. Per Senate Bill 2500, the General Appropriations Act of State Fiscal Year 2025-2026, passed by the 2025 Florida Legislature, the Collier County LPPFGT Provider and the Agency agree that the IGT Provider will remit IGT funds to the Agency in an amount not to exceed the total of $23,084,530.00 . The IGT Provider and the Agency have agreed that these IGT funds will only be used for the DPP program. 2. The IGT Provider will return the signed LOA to the Agency. 3. The IGT Provider will pay IGT funds to the Agency in an amount not to exceed the total of$23,084,530.00. The IGT Provider will transfer payments to the Agency in the following manner: a. Per Florida Statute 409.908, annual payments for the months of July 2025 through June 2026 are due to the Agency no later than October 31, 2025, unless an alternative plan is specifically approved by the agency. b. The Agency will bill the Collier County LPPF when payment is due. 4. The Collier County LPPF and the Agency agrees that the Agency will maintain necessary records and supporting documentation applicable to health services covered by this LOA in accordance with public records laws and established retention schedules. a. AUDITS AND RECORDS is i. The IGT Provider agrees to maintain books, records, and documents (including electronic storage media) pertinent to performance under this LOA in accordance Collier County LPPF_Region 8_DPP LOA_SFY 2025-26 (TAO 16D7 with generally accepted accounting procedures and practices, which sufficiently and properly reflect all revenues and expenditures of funds provided. ii. The IGT Provider agrees to ensure that these records shall be subject at all reasonable times to inspection, review, or audit by state personnel and other is personnel duly authorized by the Agency, as well as by federal personnel. iii. The IGT Provider agrees to comply with public record laws as outlined in section 119.0701, Florida Statutes. b. RETENTION OF RECORDS i. The IGT Provider agrees to retain all financial records, supporting documents, statistical records, and any other documents (including electronic storage media) pertinent to performance under this LOA for a period of six (6) years after termination of this LOA, or if an audit has been initiated and audit findings have not been resolved at the end of six (6) years, the records shall be retained until resolution of the audit findings. ii. Persons duly authorized by the Agency and federal auditors shall have full access to and the right to examine any of said records and documents. iii. The rights of access in this section must not be limited to the required retention period but should last as long as the records are retained. c. MONITORING i. The IGT Provider agrees to permit persons duly authorized by the Agency to inspect any records, papers, and documents of the IGT Provider which are relevant to this LOA. d. ASSIGNMENT AND SUBCONTRACTS i. The IGT Provider agrees to neither assign the responsibility of this LOA to another party nor subcontract for any of the work contemplated under this LOA without prior written approval of the Agency. No such approval by the Agency of any assignment or subcontract shall be deemed in any event or in any manner to provide for the incurrence of any obligation of the Agency in addition to the total dollar amount agreed upon in this LOA. All such assignments or subcontracts shall be subject to the conditions of this LOA and to any conditions of approval that the Agency shall deem necessary. 5. This LOA may only be amended upon written agreement signed by both parties. The IGT Provider and the Agency agree that any modifications to this LOA shall be in the same form, namely, the exchange of signed copies of a revised LOA. 6. The IGT Provider confirms that there are no pre-arranged agreements (contractual or otherwise) between the respective counties, taxing districts, and/or the providers to redirect any portion of these aforementioned supplemental payments in order to satisfy non-Medicaid, non-uninsured, and non-underinsured activities. Collier County LPN'_Region 8_DPP LOA_SFY 2025-26 GAO 16D7 7. The IGT Provider agrees that the following provision shall be included in any agreements between the IGT Provider and local providers where IGT funding is provided pursuant to this LOA. Funding provided in this agreement shall be prioritized so that designated IGT funding shall first be used to fund the Medicaid program and used secondarily for other purposes. 8. This LOA covers the period of July 1, 2025, through June 30, 2026, and shall be terminated September 30, 2026, which includes the state's certified forward period. 9. This LOA may be executed in multiple counterparts, each of which shall constitute an original, and each of which shall be fully binding on any party signing at least one counterpart. DPP Local Intergovernmental Transfers Program 1 Amount State Fiscal Year 2025-2026 Estimated IGTs $23,084,530.00 Total Funding Not to Exceed $23,084,530.00 IN WITNESS WHEREOF, the parties have caused this page Letter of Agreement to be executed by their undersigned officials as duly authorized. COLLIER COUNTY LPPF STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION SIGNED SIGNED BY: BY: NAME: NAME: Stephanie Scanlon TITLE: C TITLE: Chief of Medicaid Program ( Prig e( Finance DATE: 09 /2.JJJ��j?JJ 12.0 DATE: Collier County LPPF_Region& DPP LOA_5FY 2025-26 16D7 Graduate Medical Education Letter of Agreement THIS LETTER OF AGREEMENT (LOA) is made and entered into in duplicate on the G'y day of 2025, by and between Collier LPPF (the"IGT Provider") on behalf of Naples Community Hospital, and theState of Florida, Agency for Health Care Administration (the "Agency"), for good and valuable consideration, the receipt and sufficiency of which are acknowledged. DEFINITIONS "Graduate Medical Education (GME)" is the term used for the Graduate Medical Education Startup Bonus Program, established to provide resources for the education and training of physicians in specialties that are in a statewide supply-and-demand deficit, as listed in the General Appropriations Act, Laws of Florida 2025-231. "Intergovernmental Transfers (IGTs)" means transfers of funds from a non-Medicaid governmental entity(e.g., counties, municipalities, hospital taxing districts, providers operated by state or local government)to the Medicaid agency. IGTs must be considered a bona fide donation pursuant to 42 CFR § 433.54. "Medicaid" means the medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., and regulations thereunder, as administered in Florida by the Agency. A. GENERAL PROVISIONS 1. Per Senate Bill 2500, the General Appropriations Act of State Fiscal Year 2025-2026, passed by the 2025 Florida Legislature, the IGT Provider and the Agency agree that the IGT Provider will remit IGT funds to the Agency in an amount not to exceed the total of $2,373,918.09. The IGT Provider and the Agency have agreed that these IGT funds will only be used in accordance with § 409.909, Florida Statutes (2021). 2. The IGT Provider will return the signed LOA to the Agency no later than October 1, 2025. 3. The IGT Provider will pay IGT funds to the Agency in an amount not to exceed the total of$2,373,918.09. The IGT Provider will transfer payments to the Agency in the following manner: a. Per Florida Statute 409.908, annual payments for the months of July 2025 through June 2026 are due to the Agency no later than October 31, 2026, unless an alternative plan is specifically approved by the agency. i'. b. The Agency will bill the IGT Provider when payment is due. 4. The IGT Provider and the Agency agree that the Agency will maintain necessary records and supporting documentation applicable to the GME program covered by this LOA in accordance with public records laws and established retention schedules. Collier LPPF_Naples Community Hospital_GME LOA_SFY 2025-2026 CA( 16D7 a. AUDITS AND RECORDS i. The IGT Provider agrees to maintain books, records, and documents (including electronic storage media) pertinent to performance under this LOA in accordance with generally accepted accounting procedures and practices, which sufficiently and properly reflect all revenues and expenditures of funds provided. ii. The IGT Provider agrees to assure that these records shall be subject at all reasonable times to inspection, review, or audit by state personnel and other personnel duly authorized by the Agency, as well as by federal personnel. iii. The IGT Provider agrees to comply with public record laws as outlined in section 119.0701, Florida Statutes. b. RETENTION OF RECORDS i. The IGT Provider agrees to retain all financial records, supporting documents, statistical records, and any other documents (including electronic storage media) pertinent to performance under this LOA for a period of six (6) years after termination of this LOA, or if an audit has been initiated and audit findings have riot been resolved at the end of six (6) years, the records shall beretained until resolution of the audit findings. il. Persons duly authorized by the Agency and federal auditors shall have full access to and the right to examine any of said records and documents. iii. The rights of access in this section must not be limited to the required retention period but shall last as long as the records are retained. c. MONITORING i. The IGT Provider agrees to permit persons duly authorized by the Agency to inspect any records, papers, and documents of the IGT Provider which are relevant to this LOA. d. ASSIGNMENT AND SUBCONTRACTS i. The IGT Provider agrees to neither assign the responsibility of this LOA to another party nor subcontract for any of the work contemplated under this LOA without prior written approval of the Agency. No such approval by the Agency of any assignment or subcontract shall be deemed in any event or in any manner to provide for the incurrence of any obligation of the Agency in addition to the total dollar amount agreed upon in this LOA. All such assignments or subcontracts shall be subject to the conditions of this LOA and to any conditions of approval that the Agency shall deem necessary. 5. This LOA may only be amended upon written agreement signed by both parties. The IGT Provider and the Agency agree that any modifications to this LOA shall bein the same form, namely the exchange of signed copies of a revised LOA. Collier LPPF_Naples Community Hospital_GME LOA_SFY 2025-2026 CA So 16D7 1. The IGT Provider confirms that there are no pre-arranged agreements (contractual or otherwise) between the respective counties, taxing districts, and/or the providers to redirect any portion of these aforementioned charity care supplemental payments in order to satisfy non-Medicaid, non-uninsured, and non-underinsured activities. 2. The IGT Provider agrees that the following provision shall be included in any agreements between the IGT Provider and local providers where IGT funding is provided pursuant to this LOA. 'Funding provided in this agreement shall be prioritized so that designated IGT funding shall first be used to fund the Medicaid program and used secondarily for other purposes." 3. This LOA covers the period of July 1, 2025, through June 30, 2026, and shall be terminated September 30, 2026, which includes the state's certified forward period. 4. This LOA may be executed in multiple counterparts, each of which shall constitute an original, and each of which shall be fully binding on any party signing at least one counterpart. is Collier LPPF-- Naples Community Hospital_GME LOA_SFY 2025-2026 is i'. CM) 16D7 GME Local Intergovernmental Transfers Program/Amount State Fiscal Year 2025-2026 Estimated IGTs $2,373,918,09 Total Funding • $2,373,9180.9 If IN WITNESS WHEREOF, the parties have caused this page Letter of Agreement to be executed by their undersigned officials as duly authorized. COLLIER LPPF STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION SIGNED SIGNED BY: BY: NAME: y 1 ?a-H.r -- ie NAME: Stephanie Scanlon TITLE: LA TITLE: Chief of Medicaid Program eo (J11 t/)ct r— Finance DATE: / Z312,a2 DATE: ` is I{, is is is Collier LPPF_Naples Community Hospital_GME LOA_SFY 2025-2026 is 16D7 2 t .y. Intergovernmental Transfers Questionnaire IGT Provider Name: Collier County Health Care Provider Name: N/A IGT Amount: $ 2,373,918.09 State Fiscal Year Ending: 6/30/2026 1. What type of governmental entity is your organization considered?(county,city, hospital taxing district, or other) County If other, please explain 2. Does your organization have a relationship with the provider for which you contribute IGTs as named in the preamble of the enclosed Letter of Agreement(LOA)? No If yes, please describe your relationship, including services 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 If other, please explain a. Verify whether the funds are public funds as defined by 42 CFR§433.51, and exclude any federal funds. Yes If no, please explain 4. Does your organization have taxing authority? Yes LAO 16D7 5. If the source of IGT funding is from taxes, please answer the following questions: a. Is the tax a state,county,city,or hospital district tax? County If other, please explain b. What entities are taxed? Licensed non-public hospitals in Collier County. c. What is the tax structure(i.e. property tax, percentage of revenue,assessment,etc.)? Special assessment d. What is the amount or percent of the tax? Net Patient Revenue(inpatient hospital services): 1.74%. Net Patient Revenue(outpatient hospital services):2.81% 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) If so, please answer the following questions: Amount Total Tax Burden $ 25,415,167 Healthcare Provider Tax Burden $ 25,415,167 100.00% i) Is 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§433.68. Yes If no, please explain CAO 16D7 ii) Is the tax uniform across all entities being taxed?Based on 42 CFR§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 If no, please explain iii) Is 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 If no, please explain No waiver was requested. iv) Does the tax program comply with the hold harmless provisions included in 42 CFR§ 433.68(f)? Yes If no, please explain v) Does every tax paying entity receive a supplemental payment equal to or exceeding its tax cost? If yes,please explain The 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 organizations. 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§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 CA( 16D7 If yes, please list the provider and payment amount. Provider Name Funding Source Amount d. Does any portion of the provider donation constitute as a"bona fide donation"pursuant to 42 CFR §433.54?42 CFR§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. Is there an agreement between the IGT provider and the health care entity? If so, please specify whether the agreement is written and provide the details. No 7. Were funds utilized for the IGT specifically appropriated by the organization's board? If yes, provide the board minutes and date of the appropriation. I 4j' t.q n certify that the statements and information contained in this submiij I are true, accurate,and complete. Signature of cer or Administrator ` ec:ttatil Mangy er Title 061/2 /20ZS-- Date 16D7 �FpttN caRFgo �4�OF FLO? Intergovernmental Transfers Questionnaire IGT Provider Name: Collier County Health Care Provider Name: N/A IGT Amount: $ 23,084,530.00 State Fiscal Year Ending: 6/30/2026 1. What type of governmental entity is your organization considered? (county, city, hospital taxing district, or other) County If other, please explain 2. Does your organization have a relationship with the provider for which you contribute IGTs as named in the preamble of the enclosed Letter of Agreement(LOA)? No If yes, please describe your relationship, including services 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 $ 25,415,167.00 LPPF rollover balance $ 598,813.00 If other, please explain a. Verify whether the funds are public funds as defined by 42 CFR §433.51, and exclude any federal funds. Yes If no, please explain 4. Does your organization have taxing authority? Yes CAO 1 6 D 7 5. If the source of IGT funding is from taxes, please answer the following questions: a. Is the tax a state, county,city, or hospital district tax? County If other, please explain b. What entities are taxed? Licensed non-public hospitals in Collier County. II c. What is the tax structure(i.e. property tax, percentage of revenue, assessment, etc.)? Special assessment d. What is the amount or percent of the tax? Net Patient Revenue(inpatient hospital services): 1.74%. Net Patient Revenue (outpatient hospital services):2.81% 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) If so, please answer the following questions: Amount Total Tax Burden $ 25,415,167 Healthcare Provider Tax Burden $ 25,415,167 100.00% i) Is 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§433.68. Yes If no, please explain 16D7 ii) Is the tax uniform across all entities being taxed? Based on 42 CFR §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 If no, please explain iii) Is 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 If no, please explain No waiver was requested. iv) Does the tax program comply with the hold harmless provisions included in 42 CFR§ 433.68(f)? Yes If no, please explain v) Does every tax paying entity receive a supplemental payment equal to or exceeding its tax cost? If yes, please explain The 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 organizations. 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§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 . i• 16D7 If yes, please list the provider and payment amount, Provider Name Funding Source Amount d. Does any portion of the provider donation constitute as a "bona fide donation"pursuant to 42 CFR §433.54?42 CFR§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. Is there an agreement between the IGT provider and the health care entity? If so, please specify whether the agreement is written and provide the details. No 7. Were funds utilized for the IGT specifically appropriated by the organization's board? If yes, provide the board minutes and date of the appropriation. I ATY) � � � \ certify that the statements and information contained in this submit I are true, accurate, and complete. Si ature of icer or Administrator Title CI/2- Date is