YH15-0006-02-MARICOPA COUNTY INMATE HOSPITALIZATION-PARTIALLY EXECUTED.PDF

AHCCCS Janice K. Brewer, Governor
Arizona Health Care Cost Containment System Thomas J. Betlach, Director
INTERGOVERNMENTAL AGREEMENT
FOR AHCCCS INMATE HOSPITALIZATION
YH15-0006-02
This Intergovernmental Agreement ("Agreement") is entered into by and between Maricopa County
on behalf of Correctional Health Services, a political subdivision of the State of Arizona ("COUNTY") ,
and the Arizona Health Care Cost Containment System ("AHCCCS"), and shall be effective upon
execution by both parties and terminated pursuant to the terms set forth in this agreement.
RECITALS
WHEREAS, AHCCCS is duly authorized to execute and administer Agreements under A.R.S. §§ 36-2903
et seq., 36-2932 et seq. and 11-952; and
WHEREAS, the COUNTY is duly authorized to enter into this Agreement under A.R.S. § 11-952; and
WHEREAS, the COUNTY and AHCCCS are authorized by A.R.S. § 11-951 et seq. to enter into
Intergovernmental Agreements for cooperative action pertaining to reimbursement or advancements
of funds for services performed; and
WHEREAS, the COUNTY and AHCCCS wish to enter into this Agreement in order to establish procedures
to permit AHCCCS to pay for Medical services that qualify for Federal Financial Participation (FFP)
provided to Inmates of the County jail detention facilities or other penal facilities.
NOW, THEREFORE, the COUNTY and AHCCCS (collectively, the "Parties"), pursuant to the above and in
consideration of the matters hereinafter set forth, do mutually agree as follows:
801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov
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AGREEMENT
1. DEFINITIONS Unless otherwise defined in this Agreement, all terms shall have the same meaning as set
forth in Title 36 of the Arizona Revised Statutes.
1.1. AAC: Arizona Administrative Code
1.2. ADES: Arizona Department of Economic Security
1.3. AGREEMENT: This document, together with any and all attachments, appendices, exhibits,
schedules and future amendments as agreed to by the Parties.
1.4. AHCCCS: Arizona Healthcare Cost Containment System
1.5. AHCCCS PROVIDER MANUAL: The Fee-for-Service Provider Manual promulgated by AHCCCS.
The AHCCCS Provider Manual is available online at:
http://www.azahcccs.gov/commercial/ProviderBilling/manuals/FFSProviderManual.aspx
1.6. APPLICANT: A person who submits, or whose authorized representative submits a written,
completed, signed, and dated eligibility application for AHCCCS benefits.
1.7. ARS: Arizona revised Statutes
1.8. CFR: United States Code of Federal regulations, the official compilation of Federal rules and
requirements.
1.9. CLEAN CLAIM: Clean claim means one that can be processed without obtaining additional
information from the provider of the service.
1.10. CORRECTIONAL HEALTH ELIGIBILITY COORDINATOR: A person designated by the County to
coordinate and initiate the eligibility process for hospitalized inmates.
1.11. CMS: Centers for Medicare and Medicaid Services, a Federal agency within the U.S.
Department of Health and H uman Services.
1.12. CMS-37: A report providing the State estimate of the quarterly award from the Federal
government.
1.13. DAY: A calendar day, unless specified otherwise.
1.14. DOCUMENTATION: Copies of evidence that support an Applicant's eligibility determination.
Documentation includes, but is not limited to, any of the following: birth certificates, death
certificates, court orders, insurance policies, pay stubs, award letters, medical bills, expenses,
letters and responses from collateral sources, Applicant's authorization to share the eligibility
information and the COUNTY's or AHCCCS' entries in case records.
1.15. EMERGENCY MEDICAL SERVICES: Services provided to treat a medical condition manifesting
itself by acute symptoms of sufficient severity, including severe pain that the absence of
immediate medical attention could reasonably be expected to result in any of the following:
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1.15.1. labor and delivery;
1.15.2. placing the patient's health in serious jeopardy
1.15.3. serious impairment to bodily functions; or
1.15.4. serious dysfunction of any bodily organ or part.
1.16. EXPARTE INMATE ELIGIBILITY DETERMINATION: A determination of Inmate eligibility made
by AHCCCS after the person is released from a jail, detention facility or other penal facility and is
no longer an Inmate at the time of the eligibility determination.
1.17. FEDERAL EMERGENCY SERVICES PROGRAM (FESP): A Federal emergency services program
covered under AAC R9-22-217, to treat an emergency medical condition for an Applicant who is
determined eligible under A.R.S § 36-2903.03(D).
1.18. FFP: Federal Financial Participation refers to the Federal matching rate that the Federal
government makes to the Title XIX program portion of AHCCCS, which are the monies that
AHCCCS can claim from CMS for the Federal share of AHCCCS Program service and
administration costs.
1.19. IBNR: Incurred But Not Reported claims refers to claims with dates of service within the
effective dates of this Agreement but which have not been invoiced or recorded in the AHCCCS
claims system.
1.20. IMD: Institution for Mental Disease as defined in 42 CFR 435.1010.
1.21. INMATE: A person, either adult or juvenile, who is living in a County jail, detention facility, or
other penal facility, or in a Medical Institution where but for an illness or an injury, the person
would be living in a County jail or detention facility or other penal facility, and who may be
eligible for FFP payment as determined by AHCCCS.
1.22. INPATIENT: As it relates to an inmate, is a patient who has been admitted to a Medical
Institution as an inpatient as defined in 42 CFR 435.1010. An Inpatient is a patient who has
been admitted to a Medical Institution as an inpatient in a non-secure ward on
recommendation of a physician or dentist and who:
1.22.1. Receives room, board and professional services in the institution for a 24 hour period
or longer; or
1.22.2. Is expected by the institution to receive room, board and professional services in the
institution for a twenty-four (24) hour period or longer even though it later develops
that the patient dies, is discharged or is transferred to another facility and does not
actually stay in the institution for twenty-four (24) hours.
1.23. MEDICAL INSTITUTION: Any facility, including IMDs providing FFP qualifying services, that is
engaged in the delivery of health care services and is authorized to do so by the state in which
those services are delivered. Medical Institution means an institution that:
1.23.1. Is organized to provide medical care, including medical, surgical, psychiatric, nursing
and convalescent care;
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1.23.2. Has the necessary professional personnel, equipment, and facilities to manage the
medical, nursing, and other health needs of patients on a continuing basis in
accordance with accepted standards;
1.23.3. Is authorized under State law to provide medical care;
1.23.4. Is staffed by professional personnel who are responsible to the institution for
professional medical and nursing services. The services must include adequate and
continual medical care and supervision by a physician; registered nurse or licensed
practical nurse supervision and services and nurses' aid services, sufficient to meet
nursing care needs; and a physician's guidance on the professional aspects of
operating the institution; and
1.23.5. Services are rendered on a non-secure ward.
1.24. MEDICAL SERVICES: Services provided by a medical provider in the community, including
Medical Institution. Medical Services includes, but is not limited to, medical, surgical,
psychiatric, diagnostic, and specialty physician services.
1.25. MEMBER: An Inmate who qualifies for Title XIX coverage.
1.26. PROVIDER: Any individual or entity that is engaged in the delivery of health care services and
that is authorized to do so by the state in which those services are delivered.
1.27. RECIPIENT: A person who has been determined eligible to receive AHCCCS benefits.
1.28. REVIEW: An analysis of all factors affecting a family's or person's eligibility.
1.29. STATE: The State of Arizona.
1.30. STATE MATCH: The percentage of payment for health services usually paid by the State; but
under this contract paid to the State by County to qualify for FFP.
1.31. SUBCONTRACT: Any contract or agreement between the COUNTY and a third party to provide,
or be accountable for providing a service.
1.32. TITLE XIX: That section of the Social Security Act that authorizes the Medicaid Program.
2. PURPOSE OF THIS AGREEMENT
The purpose of this Agreement is for the COUNTY and AHCCCS to jointly develop, and mutually agree
upon, an eligibility application and determination process that complies with both Federal and State
laws, regulations, rules and appropriate CMS approval and to adjudicate and pay claims for covered
services provided to Members in accordance with Federal and State laws, regulations, and rules. This
Agreement is entered into pursuant to A.R.S. § 36-2903 to provide AHCCCS with the appropriate State
Match in order to pay for Medical Services that qualify for FFP provided to Inmates who qualify for Title
XIX while they are an inpatient in a non-secure ward of a Medical Institution. It also provides AHCCCS
with the funds to pay for administrative costs associated with this Agreement.
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3. TERM
3.1. This Agreement is effective October 1, 2014 upon execution by both parties and shall remain in
effect for a term of one (1) year with annual automatic renewals until terminated pursuant to
the terms and conditions of this Agreement.
4. SCOPE
4.1. Eligibility Requirements and Application Process:
When required to determine a non-citizen's eligibility for FFS only, the disability determination
will be made by ADES, Disability Determination Services Administration (DDSA), pursuant to an
agreement between AHCCCS and ADES, for an additional cost to the COUNTY as set forth in
Attachment A to this Agreement.
4.2. Claims Processing And Payment:
4.2.1. AHCCCS Administration and the COUNTY will jointly develop and mutually agree to a
claims processing and payment process that complies with both Federal and State laws,
regulations, and rules; and is not in conflict with the provisions of this contract.
4.2.2. AHCCCS will process and pay clean claims in accordance with AHCCCS policies and
procedures.
4.3. Mutual Data Exchange:
Subject to the confidentiality rules specified in AAC R9-22-512, 42 CFR Part 431, Subpart F, and
45 CFR, Parts 160 and 164, AHCCCS and COUNTY will timely provide to each other any
information that may be required for program administration. Upon the request of either
party, AHCCCS and the COUNTY will meet to address any issues regarding the transmission of
information, identify corrective actions required, and monitor the effectiveness of the
corrective actions. The COUNTY and AHCCCS will cooperate with all parties in the corrective
actions. The COUNTY and AHCCCS will cooperate with all parties in the determination of an
Applicant's eligibility for the Program, including supplying any needed information. AHCCCS and
the COUNTY shall provide the information to each other in a timely manner.
4.4. AHCCCS Rights and Obligations:
4.4.1. Eligibility Decision:
4.4.1.1. AHCCCS / ADES shall determine the eligibility of Inmates who apply for Title
XIX while an Inpatient in an acute hospital and not in a separate county or
contracted hospital unit that houses only county/state inmates. An eligibility
determination for non-citizens who do not qualify for full Medical Services
will be completed when the services qualify under A.R.S § 36-2903.03 (D) as
an emergency service and when required, the COUNTY agrees to pay the cost
of any DDSA determination in the amount set forth in Attachment A this
Agreement. The eligibility determination may also include an Exparte Inmate
Eligibility Determination when appropriate. The COUNTY is not financially
liable for an Exparte Eligibility Determination.
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4.4.1.2. AHCCCS/ADES shall contact the COUNTY, as appropriate and consistent with
applicable privacy laws, to obtain additional information required to
complete an Applicant's application and to determine the person's ongoing
eligibility.
4.4.1.3. AHCCCS/ADES shall issue a decision notice to the Applicant and a copy to the
COUNTY in accordance with the confidentiality rules of Title XIX.
4.4.2. Payment for Services in Agreement:
Payments made to AHCCCS by the COUNTY pursuant to this Agreement are conditioned
upon the availability of the COUNTY funds authorized for expenditure in the manner and
for the purpose(s) stated herein. AHCCCS is not liable for any purchases of subcontracts
entered into by the COUNTY in anticipation of such funding. AHCCCS is not responsible
for any payments to a Medical Institution or Provider for claims submitted under this
Agreement if the COUNTY has not provided the State Match for such payments.
Notwithstanding the provisions of the terms and conditions "Amendments" section of
this Agreement (2.0), AHCCCS and the COUNTY agree that changes in the claims
processing and payment procedures that do not have a monetary effect may be made
from time to time by mutual written agreement of the Assistant Director of AHCCCS and
the COUNTY. Such changes shall become effective and binding without execution of an
amendment to this Agreement.
4.4.3. AHCCCS Payment Recoupment from Medical Institutions and Providers:
4.4.3.1. AHCCCS shall require Medical Institutions and Providers submitting claims to
reimburse AHCCCS upon demand or AHCCCS shall deduct from future
payments to the Medical Institutions or Providers any amount:
4.4.3.1.1. Received by a Medical Institution or Provider from AHCCCS for
Agreement services that have been inaccurately reported or
paid or are found to be for an excluded service; or
4.4.3.1.2. Paid by AHCCCS for which a Medical Institution's or Provider's
books, records, and other documents are not sufficient to clearly
confirm that those amounts were used by the Medical
Institution or Provider to perform billed services; or
4.4.3.1.3. Identified as a questioned cost as the result of a financial
management review or audit.
4.4.3.2. For purposes of this Agreement only, the COUNTY is responsible to reimburse
AHCCCS for payments for services rendered that are not eligible for Federal
financial participation (FFP) if AHCCCS is unable to recoup payments from the
Medical Institutions or Providers. The COUNTY is not responsible for services
where AHCCCS failure to recoup payments from Medical Institutions and
Providers is due to AHCCCS' negligence or inattention.
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4.4.3.3. If an Inmate is not AHCCCS eligible, and if the COUNTY is legally required to
pay the medical expenses for the Inmate, the COUNTY shall pay Medical
Institutions or Providers for services rendered if AHCCCS has recouped funds.
This section does not obligate the COUNTY to pay a Medical Institution or
Provider in excess of the terms of a contract between the COUNTY and a
Medical Institution or Provider, or, where there is no contract, the actual cost
of care.
4.4.4. Monitoring:
AHCCCS shall monitor services covered by this Agreement that are provided by any
Medical Institution, Provider, or any Provider subcontractor to ensure compliance with
the AHCCCS Provider Manual.
4.4.5. Visitation, Inspection and Copying:
After the date of this Agreement, all related COUNTY contracts with Medical
Institutions, Providers and Providers' subcontractors shall require that the Medical
Institution's, Provider's or a subcontractor's facilities, services, books, accounts, reports,
files, and other records directly related to this Agreement shall be subject at all
reasonable times to visitation, inspection, and copying by AHCCCS and any other
appropriate agent of State or Federal government for five (5) years after completion of
this Agreement. Such records shall be available at the Medical Institution's, Provider's,
or a subcontractor's offices or shall be produced at the AHCCCS main office or any other
office designated by AHCCCS.
4.5. COUNTY's Rights and Obligations
4.5.1. Application for Title XIX:
4.5.1.1. The COUNTY shall appoint a Correctional Health Eligibility Coordinator to
assist Inmates who potentially qualify for Title XIX coverage while an Inpatient
in an acute hospital, with the AHCCCS application process. Before assisting an
individual with the application process, COUNTY shall obtain the Inmates'
authorization to apply for AHCCCS in accordance with AAC R9-22-1406.
4.5.1.2. The Correctional Health Eligibility Coordinator shall obtain the Applicant's
authorization for AHCCCS to release eligibility information to the COUNTY and
the COUNTY shall maintain the confidentiality of the Applicant's records in
accordance with AAC R9-22-152.
4.5.1.3. The Correctional Health Eligibility Coordinator shall attempt to obtain the
required Documentation to establish eligibility for the budget month and to
assist the AHCCCS Administration or the ADES in obtaining any information
required for the Inmate's ongoing eligibility.
4.5.1.4. When authorized by an Inmate to assist with the application, the Correctional
Health Eligibility Coordinator shall take the application and obtain the
Applicant's signature in the month of the hospital stay. The completed
application, all verification and Documentation will be submitted to AHCCCS
during the first week of the month following the month of application. For
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cases in which additional time is needed to collect appropriate verification
and/or Documentation, the Correctional Health Eligibility Coordinator will
submit the application as soon as the Documentation is complete, but no
later than the 15th of the month following the month of application. The
month of application is the month in which the inpatient service is received
and the appropriate party signs the application.
4.5.1.5. The Correctional Health Eligibility Coordinator will not submit an application
on inmates that are treated in the secure ward of the hospital. If the inmates
were treated in both the secure and non-secure ward of the hospital the
Correctional Health Eligibility Coordinator will identify those secure days on
the application to ensure the edibility segment identifies them as non-eligible.
4.5.2. Advance payment for Medical Services and Administrative Costs by the COUNTY:
4.5.2.1. Quarterly estimates of the State Match payments for program services will be
determined based on the prior year's dollar value of claims and any additional
information provided by the COUNTY. For the initial year of the Agreement,
the COUNTY must provide an estimate of the number of paper claims,
electronic claims and applications to be processed as well as an estimate of
the dollar value of claims to be paid. The quarterly estimates will be
documented on Attachment B of this Agreement. Based on these estimates,
the COUNTY shall make an advance payment to AHCCCS of the estimated
amount on or before the last business day of the first month of each quarter.
AHCCCS may request additional State Match funds for program services to be
advanced more frequently than quarterly to address an increase in the
volume of claims or dollar value of claims to be processed.
4.5.2.2. The State Match for the administrative costs of this Agreement per
application or claim is estimated to be as shown in Attachment A. Any
changes to the estimated State Match for the administrative costs may only
be assessed by written agreement of the Parties.
4.5.2.3. AHCCCS will calculate a quarterly invoice for the State Match of the
administrative fees of this Agreement based on the actual costs, number of
electronic claims, paper claims and applications processed for the quarter.
The quarterly invoice will be emailed to the COUNTY by the last business day
of the month following the end of the quarter. The quarterly administrative
fees owed to AHCCCS will be deducted from the amount the COUNTY has on
deposit. If sufficient funds are not on deposit, the COUNTY will pay AHCCCS
for the remainder of the administrative fees so that AHCCCS will receive the
monies due within thirty (30) days of the invoice date.
4.5.2.4. AHCCCS shall deposit the quarterly advance payments made by the COUNTY
into a separate account (the State Match Fund). All funds in the State Match
Fund are the property of the COUNTY until withdrawn by AHCCCS to pay the
State Match on a claim or administrative fees. AHCCCS will inform the
COUNTY of the State Match Fund balance as of the end of each quarter in a
report received with the quarterly administrative fees invoice. This report
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will be emailed by the last business day of the month following the end of the
quarter. Notwithstanding the previous sentence, AHCCCS will immediately
inform the COUNTY if, at any time, the State Match Fund contains less than
twenty five percent (25%) of the quarterly estimate of the State Match
advance payments for program services documented on Attachment B of this
Agreement. In the event the State Match Fund falls below twenty five
percent (25%) of the quarter estimate of the State Match advance payments
for program services documented on Attachment B of this Agreement,
COUNTY shall pay into the State Match Fund sufficient money to increase
the Fund to the quarterly estimate of the State Match documented in
Attachment B. Any amount in the State Match Fund that is not expended at
the end of a quarter shall be applied to the advance payment for the
subsequent quarter, and AHCCCS shall reduce the estimate for the
subsequent quarter by such amount. If at any time this Agreement is
terminated by either party, any money remaining in the State Match Fund
shall be returned to the COUNTY after the claim submission deadline, as of
the date of termination.
4.5.2.5. The COUNTY shall bear the administrative cost of any appeal process
requested by the COUNTY of deferred or disallowed claims.
4.5.3. AHCCCS Recoupment from the COUNTY: In the event CMS modifies its methodology for
allocating FFP, the COUNTY shall be responsible for the Federal portion of deferred or
disallowed claims and any interest charged thereon pursuant to 42 CFR 433.38, subject
to the payment limitations in listed in this agreement in Section 4.4.3.2.
5. GENERAL FINANCIAL RESPONSIBILITIES
5.1. Quarterly Program Expenditure estimates:
The COUNTY shall submit to AHCCCS a quarterly estimate of expenditures to be used for the
development of the CMS-37. The estimates shall be submitted to AHCCCS thirty (30) days after
the end of each quarter unless otherwise determined by Federal requirements.
5.2. AHCCCS Reporting:
5.2.1. Quarterly Expenditures Report. AHCCCS will submit to the COUNTY reports that
show actual quarterly program expenditures made pursuant to this Agreement.
Each report shall detail the amount expended of State Match funds provided by the
COUNTY and the matching FFP funds, and the administrative fees AHCCCS charged
to the COUNTY. The expenditure reports shall be submitted by the last business day
of the month following the end of each quarter.
5.2.2. Claims Paid Report. AHCCCS will provide a report to the COUNTY reporting the
claims paid by AHCCCS. The report will be produced weekly, monthly or quarterly if
necessary depending on the frequency of claims paid.
5.3. AHCCCS Annual Reconciliation with the COUNTY:
5.3.1. In the Quarterly Expenditure Report dated June 30 th of each State fiscal year,
AHCCCS will provide to the COUNTY the actual amounts claimed and paid on an
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annual basis under this Agreement. This report shall also show any and all amounts
paid in advance using estimate reports.
5.3.2. AHCCCS will reconcile the actual amounts paid against the COUNTY's AHCCCS
estimates and advanced payments for the twelve month period of the state fiscal
year. This reconciliation shall be completed within ninety (90) days of the end of the
state fiscal year.
5.3.3. If any monies are due the COUNTY, these will be applied to the next quarterly
payment.
5.4. Insufficient Appropriation
If at any time during the term of the Agreement, the COUNTY determines that the money the
COUNTY budgeted to meet its obligations under this Agreement is insufficient, the COUNTY
shall notify AHCCCS in writing and shall include in the notice recommendations as to the
resolution of the shortage.
5.5. Unused Funds
After the close of each State of Arizona fiscal year and the administrative adjustment period,
upon request of the COUNTY, any funds remaining in the State Match Fund, shall be returned to
the COUNTY. It is understood that if any valid INBR claim appears after funds are returned to
the COUNTY, the COUNTY is still responsible for payment within the terms of this Agreement.
5.6. COUNTY Annual Budget Submissions
The COUNTY shall provide AHCCCS with projected funding requirements for this Agreement by
July 31 of each new fiscal year to allow AHCCCS to request the appropriate amount of Federal
authority.
5.7. COUNTY Budget Revisions
Any revisions to expenditure projections shall be expeditiously forwarded to AHCCCS as soon as
the need for revision becomes known to the COUNTY in order for AHCCCS to adjust the Federal
cash projections to CMS.
6. NOTICES
Any notices or correspondence related to this Agreement shall be sent to the parties or their designees
respectively as follows:
6.1. AHCCCS
Procurement and Contracts:
Mark Held, Senior Procurement Specialist
701 East Jefferson St., MD 5700
Phoenix, AZ 85034
(602) 417-4094
Mark.Held@azahcccs.gov
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Eligibility Determination:
Melanie Norton, Assistant Director, Division of Member Services
801 E. Jefferson St., MD2600
Phoenix, AZ 85034
E-Mail: Melanie. Norton@azahcccs.gov
Finance/Funding Requirements:
Karen D. MacLean
Assistant Finance Administrator
AHCCCS
701 E Jefferson MD 5400
Phoenix, AZ 85034
(602) 417-4293
Karen.MacLeanPazahcccs.gov
Claims Processing and Payment:
Tricia Krotenberg
Third Party Accounts Manager-DFSM/Claims
(602) 417-4149
Patricia.Krotenberg@azahcccs.gov
6.2. COUNTY:
Lisa Gardner
Finance Manager
Maricopa County Correctional Health Services
234 N. Central, Fifth Floor, Ste. 5000
Phoenix, Arizona 85004
(602) 506-1070
L Gardner@mail.maricopa.gov
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TERMS AND CONDITIONS
1.0 ADA
The Parties must comply with all applicable provisions of the Americans with Disabilities Act (Public
Law 101-336, 42 U.S.C. 12101-12213) and all applicable federal regulations under the Act, including
28 CFR Parts 35 and 36.
2.0 Amendments
2.1 Any amendment to this Agreement must be in writing and signed by both parties.
2.2 Amendments signed by each of the parties and attached hereto are hereby adopted by
reference as a part of this Agreement, from the effective date of the amendment, as if fully
set out herein.
2.3 All requests for additional services shall be in writing and signed by both parties.
2.4 An amendment shall not be necessary when completing a change of contact person, change
of key personnel, change of address, change of signatory or other non- material changes to
this Agreement.
3.0 Arbitration and Disputes
In accordance with ARS § 12-1518, the parties to agree to resolve all disputes arising out of or
relating to this agreement through arbitration, after exhausting applicable administrative review
except as may be required by other applicable statutes. The laws of the State shall govern any
interpretation of this Agreement and the venue shall be in Maricopa County, Arizona.
4.0 Assignment and Delegation
This Agreement may not be assigned by any party without the prior written consent of the other
parties. If consent to an assignment is obtained, this Agreement is binding on the successors and
assigns of the parties to this Agreement.
5.0 Compliance with Laws, Rules and Regulations
AHCCCS, the COUNTY and their subcontractors must comply with all applicable Federal and State
laws, rules, regulations, standards and Executive Orders, without limitation to those designated
within this Agreement. The laws and regulations, of the State of Arizona govern the rights of the
Parties, the performance of this Agreement, and any disputes arising from the Agreement. Any
action relating to this Agreement must be brought by arbitration to the extent required by A.R.S. §
12-1518 or in an appropriate court. Any arbitration award will be enforced in an appropriate court.
6.0 E-Verify Requirement
In accordance with ARS § 41-4401, all parties warrant compliance with all Federal immigration laws
and regulations relating to employees and warrants its compliance with AAC Section A.R.S. § 23-
214, Subsection A.
7.0 Execution in Counterparts / Electronic Documents
7.1 This Agreement may be executed in one or more counterparts, each of which shall be
deemed to be an original but all of which together shall constitute one and the same
document.
7.2 Facsimile signatures, electronic signatures and signatures transmitted by email after having
been scanned shall be accepted as originals for the purposes of this Agreement.
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8.0 Federal Immigration and Nationality Act
The parties shall ensure compliance with the Federal Immigration and Nationality Act (FINA) and all
other Federal immigration laws and regulations related to the immigration status of its employees
to include but not limited to sub-contractors. All services under this Agreement shall be performed
within the borders of the United States.
9.0 Fraud and Abuse
9.1 It shall be the responsibility of AHCCCS and the COUNTY to report all cases of suspected
fraud and abuse by subcontractors, members or employees. AHCCCS and the COUNTY shall
provide written notification of all such incidents to the Contracting Officer.
9.2 As stated in A.R.S. § 13-2310, incorporated herein by reference, any person who knowingly
obtains any benefit by means of false or fraudulent pretenses, representations, promises or
material omissions is guilty of a class 2 felony.
9.3 AHCCCS and the COUNTY are required to research potential overpayments identified by a
fraud and abuse investigation or audit conducted by AHCCCS or the COUNTY. After
conducting a cost benefit analysis to determine if such action is warranted, the Parties
should attempt to recover any overpayments identified due to erroneous, false or
fraudulent billings.
10.0 Health Insurance Portability and Accountability Act (HIPAA) of 1996
The parties certify that each is familiar with the requirements of HIPAA, as amended by the Health
Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009, and
accompanying regulations and will comply with all applicable HIPAA requirements in the course of
this Agreement. The parties warrant that each will cooperate in the course of performance of the
Agreement so that the parties will be in compliance with HIPAA, including cooperation and
coordination with the Arizona Strategic Enterprise Technology (ASET), Statewide Information
Security and Privacy Office (SISPO) Chief Privacy Officer and HIPAA Coordinator and other
compliance officials required by HIPAA and its regulations. COUNTY will sign any documents that
are reasonably necessary to keep AHCCCS in compliance with HIPAA, including, but not limited to,
business associate agreements.
11.0 Insurance
The parties acknowledge that they are self-insured pursuant to statutory authority. The parties
agree that the general liability coverage afforded by the self-insurance programs is sufficient to
meet the purposes of this Agreement.
12.0 Liability
The parties shall each be responsible for any and all liability for their own negligence arising from
the Agreement and each shall bear all costs for their own defense of any litigation to the extent
allowed by law.
13.0 Non-Conforming Performance
Either party's failure to insist on strict performance of any term or condition of the Agreement shall
not be deemed a waiver of that term or condition even if the party accepting or acquiescing in the
nonconforming performance knows of the nature of the performance and fails to object to it.
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14.0 No Joint Venture
Nothing in this Agreement is intended to create a joint venture between the Parties and it will not
be so construed. Neither AHCCCS' nor COUNTY's employees will be considered officers, agents or
employees of the other or be entitled to receive any employment-related fringe benefits from the
other.
15.0 No Third Party Beneficiaries
Nothing in the provisions of this IGA is intended to create duties or obligations to or rights in third
parties not Parties to this IGA or effect the legal liability of either Party to the IGA.
16.0 Records and Audit
Under A.R.S. § 35-214 and A.R.S. § 35-215, The parties agree to retain and shall contractually
require each subcontractor to retain all data and other records ("records") relating to the
acquisition and performance of the Agreement for a period of five (5) years after the completion of
the Agreement. All records shall be subject to inspection and audit by the State and where
applicable the Federal Government at reasonable times. Upon request, the parties will produce a
legible copy of any or all such records.
17.0 Severability
If any provision of this Agreement or the application thereof to any circumstance shall be invalid or
unenforceable to any extent, it is the intention of the parties that the remainder of the Agreement
and the application of such provision to other circumstances shall not be affected thereby and shall
be enforced to the greatest extent permitted by law.
18.0 Termination
Either party may terminate this Agreement upon thirty (30) working days written notice to the
other party. Termination will be without further obligation or penalty and will be effective upon
receipt, unless specified otherwise.
Page 14 of 17

SIGNATURE PAGE
IN WITNESS THEREOF, the parties have executed this Agreement:
COUNTY: Arizona Health Care Cost Containment System
(AHCCCS):
Signature: Signature:
Printed Name: Denny Barney Printed Name: Megan Harley, CPPO, MSW
Title: Chairman, Board of Supervisors Title: Procurement and Contracts Manager
PIPPOl+
Date: Date:
In accordance with A.R.S. § 11-952, this Agreement has In accordance with A.R.S. § 11-952, this Agreement is
been reviewed by the undersigned who has determined in the proper form and is within the power and
that this Agreement is in the appropriate form and is authority granted to AHCCCS under A.R.S. §§ 36-2903
within the power and authority granted to COUNTY. et seq. and 36-2932 et seq.
COUNTY Attorney Legal Counsfrfor AHCCCS
Page 15 of 17

ATTACHMENT A
AHCCCS
Administrative Annual Cost Estimates for
Maricopa County Medicaid Eligible Inmates FFS Project IGA SFY15
State Federal
Claims Electronic Paper Total Fund Share Share
94% 6% 100% 50% 50%
Estimated total number of claims:
Physician & Emergency Transport/Hospital 800 50 850
DFSM Cost per Claim 2 $ 0.68 0.80
OIG Cost per Claim 2 $ 0.14 0.14
ISD Cost per Claim 2 $ 3.16 3.21
Concurrent Review Average Cost
Estimated cost per case 3 $ 96.25
Estimated number of HSAG reviews 4 2
Claims Processing costs:
DFSM $547.59 $40.04 $587.64 $293.82 $293.82
OIG $110.11 $6.88 $116.99 $58.50 $58.50
ISD $2,529.32 $160.75 $2,690.06 $1,345.03 $1,345.03
Total Claims Processing Costs $3,187.02 $207.67 $3,394.69 $1,697.35 $1,697.35
Direct DFSM Labor for Maricopa Co Medicaid Claims Processing
Direct ISD Labor for Maricopa Co Medicaid Claims Processing 6 $7,000.00 $3,500.00 $3,500.00
Concurrent Review Estimated costs:
Cost for 2 reviews $192.50 $96.25 $96.25
Administrative Costs (see detail)
DBF Paper Processing Personnel costs 7 $9,447.00 $4,723.50 $4,723.50
Postage @ $.0824/claim $70.04 $35.02 $35.02
Data Center Charges @ $.37/claim 9 $314.51 $157.26 $157.26
Indirect at 10% $944.70 $472.35 $472.35
Total DBF Administrative Costs $10,776.25 $5,388.13 $5,388.13
Total Claims Processing Costs $21,363.44 $10,681.72 $10,681.72
DMS Eligibility Costs
Application Processing Costs - DMS 10 $8 330 00 $4,165.00 $4,165.00
Estimated Total Annual Costs for Program $29,693.44 $14,846.72 $14,846.72
Cost per Claim 11 $34.70 $17.35 $17.35
'Actual number of claims may be higher. Number includes, original, recoupment and adjustment claims.
2 Cost based on actual SF711 (before Childless Adult Freeze) expenditures and actual number ofclaims processed
'Average rate per contract. Actual costs will be a strict pass-through based on price negotiated ° Postage based on average cost per claim times number of claims.
on new contract. Data Center charges calculated based on average SF713 costs
Actual number may be higher or lower depending on Maricopa County Medicaid Inmate requirements. 10 DMS Eligibility charges calculated at $98/determination.
6 Based on estimates of DFSM stafftime required to process the claims. Estimated 85 annual applications/determinations.
6 Estimate based on 40 hours at a rate of$175 per hour. Will only be billed for actual hours incurred. 11 Cost per claim does not include a cost for concurrent reviews
Based on estimates of DBF stafftime required to monitor funding activity and process payments.
Page 16 of 17

ATTACHMENT B
AHCCCS
Quarterly Estimate of State Match Advance Payments for Program Services
Maricopa County Medicaid Eligible FFS Project IGA SFY15
SFY11 (Before Childless Adult Freeze) Annual Dollar Value of Claims Paid $ 486,000.00
Average Federal Financial Participation Rate 75.43%
Estimate of State Match Payments for Program Services for Current Year $ 119,434.50
Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS $ 30,000.00
Page 17 of 17