HomeMy WebLinkAboutRES 15-109RESOLUTION NO. 15-109
BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF BEAUMONT:
THAT the City Manager be and he is hereby authorized to execute the Certification of
Governmental Entity Participation for Hospital Affiliates, substantially in the form
attached hereto as Exhibit "A," in accordance with the requirements of establishing a
Municipal Health Care Provider Participation Program.
PASSED BY THE CITY COUNCIL of the City of Beaumont this the 9th day of
June, 2015.
® � 1
M r Becky Ames -
HEALTH AND IIUMANSERVICES COMMISSION
TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM
1115 DEMONSTRATION WAIVER PROGRAM
CERTIFICA'T'ION OF GOVERNMENTAL ENTITY PARTICIPATION
FOR HOSPITAL AFFILIATES
Version 2012-I (09/05/2012)
EXHIBIT 'W1
DOCUMENT HISTORY LOG
i FSTATnUjS'
DOCUMENT
REVISION2
EFFECTIVE
DATE
VESOMPTION'
Baseline
"/a
initial version of the Certification of Govemmental Entity
Participation
Revision
1.1
0910512012
Added cover page,.
Revision
1.2
09/0512012
Added Document History Log.
Revision
1.3
0910612012
Various formatting changes.
Revision
1,4
0910W2012
Added version number (Vemlon 2012-1) and date of
and date of
issuance to cover page and page footer,
Revision
1.5
0910512012
_f,4
Humane
Deleted "Texas' from 'Health and Human Services
Services
4name.
Commission* to reflect agency's statutory i
Revision
1.6
09!0512012
Revised paragraph 4.% to replace and'at the end of
I n
subparagraph Ji following the semicolon with ',or.*
'Baseline' indicates initial dowment issuances, 'Revision' indicates changes to the Baseline version, and
`Cancellation' indicates withdrawn versions.
2 Numbering conventions, Revisions are numbered according to the version of the document and the sequential
'1.2* refers to the first version of the document and the second revision.
Brief description of the changes to the document made in the revision.
Health & Hunan Serviecs Cmarnission I 115 Dernonsiration Waiver PwWwn
Go.vemmattal Entity Gwifw:ation for 110spital Payments Version 2032-1(0410512012)
HEALTH AND HUMAN SERVICES COMMISSI()N
TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT
PROGRAM 1115 DEMONSTRATION WAIVER PROGRAM
CERTIFICATION OF GO VERWENTAL MVr1rYPAN TICIPA TION FOR
HOSPITAL A FFILIA TES
On behalfof
organized under the laws of the State of Texas (hereinafter referred to as "the
Governmental Entity), 1, affirm and certify the
following. -
1. LegalAuthorkadom
a, The Governmental Entity is legally authorized to levy and oollect ad valorem
taxes, generate public revenue, or receive and expend appropriated public funds
("Public Funds");
b. I'he Govemmental Entity is legally authorized to enter into, and has entered into
Affiliation Agreements with one or more private hospitals ("the Affiliated -
Hospitals") for, among other purposes, providing indigentcare in the community
served by the Coverninental Entity.
Z Public Adoption anifAceesy.
a. The governing body of the Governmental Entity adopted the conditions
described in this certification by recorded vote taken in apublic meeting held in
compliance with the Texas Open Meetings Act, Cfiapter 551, Government Code;
b. Copies of all Affiliation Agreements will be made available.,as provided under
the Texas Public Information Act, Chapter 5.52, Government I Code, and will be
provided to HRSC on request.
Health & Human Seryim Commission t 11 5 Demonstmian Waiver Propum
GavMrMW Emily condmation for "Ovital Payments I version 2012-1 (09105/2012)
3. Funding oflntergovernmental Transfers and Supplemental Payments.
a. The Governmental Entity has or has agreed to transfer Public Funds to the
Health and Human Services Commission ("HHSC") via intergovernmental
transfer ("IGT"} for use as the non-federal share of supplemental waiver
payments (the "Supplemental Payments") to the Affiliated Hospitals in
accordance with 1 Tex. Admin_ Code §355.8201, Waiver Payinents to
Hospitals (the "Waiver Program");
b. All transfers of Public Funds by the Governmental Entity to HHSC to support
the Supplemental Payments to the Affiliated Hospitals under the Waiver
Program comply with:
i. The applicable regulations that govern provider -related donations
codified at section 1903(w) of the Social Security Act (42 U.S.C.
§ 1396b(w)), and Title 42; Code of Federal, Regulations, Part 433,
subpart B, sections 433.52 and 433.54;
ii. HHSC administrative rules codified at i Tex. Admin Code §355.8201,
Waiver Payments to°Hospitals.
4. Assurances and Represemations.
a. The Governmental Entity does not and will not at any time receive any part of
the supplemental payments that are made by HHSC to the Affiliated Hospitals
under the Waiver Program;
b. The Governmental Entity has not entered into a contingent fee arrangement
related to the Governmental Entity's participation in the Waiver Program;
c. The Governmental Entity has not entered and will not enter into any agreement
to condition either the amount of the Public Funds transferred by the
Governmental Entity or the amount of Supplemental Payments an Affiliated
Hospital receives on the amount of indigent care the Affiliated Hospital has
provided or. will provide;
d. The Governmental Entity has not entered and will not enter into any agreement
to condition the amount of any Affiliated Hospital's indigent -care obligation on
either the amount of Public Funds transferred by the Governmental' Entity to
HHSC or the amount of Supplemental Payment an Affiliated Hospital maybe
eligible to receive;
e. With regard to any escrow, trust or other financial mechanism (an "Account")
utilized in connection with an indigent care Affiliation Agreement or an IGT
issued for a payment period that occurs after the effective date of this
Certification, the following representations are true and correct:
Health & Human Serviees Commission 1115 Demonstmsioa Waiver Program
Governmental Wity Certification for Hospital Payments Version 2012-1(09105/20I2)
i. The amount of any Account is not conditioned or contingent on the
amount of indigent care services that an Affiliated Hospital provided or
will provide;
ii- The Governmental Entity has disclosed the existence of any Amount to
14HSC; and
iii. Any such Account will not be used to effect a -quid pro quo for the
provision of indigent care services by.or on behalf of the Affiliated
Hospitals,
f, The Governmental Entity has not received and will not receive refunds of
payments the Governmental Entity made ormakes to an Affiliated Hospital for
any purOse in consideration for an IGT of Public Forttis by the Governmental
Entity to HHSC to support the Supplemental Payments;
g. The Governmental Entity has not received and will not receive any cash or in-
kind transfers from an Affiliated Hospital or any other entity acting on behalf of
an Affiliated Hospital or group of Affiliated Hospitals other than transfers and
transactions that:
i. Following the date this Certification was executed, are unrelated to the
administration ofthe Waiver Program or the delivery of indigent care.
services under an Affiliation Agreement;
ii. Constitute fair market value for goods` or services rendered or provided
by the Govenimental Entity to an Affiliated Hospital; or
iii. Represent independent, bona fide transactions negotiated at arms -length
and in the ordinary course of business between the Affiliated Hospital
and the Governmental Entity;
b. The Governmental Entity has not:
i. Following the date this Certification was executed, assigned or agreed to
assign a contractual or statutory obligation of the G- ovenimental Entity
to an Affiliated Hospital or any other entity acting on behalf of an
Affiliated Hospital or group of Affiliated Hospitals; or
I Authorized or consented to the assumption of a statutory or contractual
obligation of the Governmental Entity by an Affiliated Hospital or any
other entity acting on behalf of an Affiliated Hospital or group of
Affiliated Hospitals,
I. Eval,14(lon.
H641h & Human Services Commission 11 I5 Demonanition Waiver PmVam
GDVCn=adW wity catirX&I'M cm H*spiw p4yments version 2012-1 (09105INI2)
a. Consistent with its constitutional, statutory, and fiduciary obligations, the
Governmental Entity may evaluate a private hospital's historical experience in
providing indigent care in the community or performance under an Affiliation
Agreement including the impact and amount of indigent care provided by the
hospital, for the following purposes:
L To detennine whether the Governmental Entity will enter into an
Affiliation Agreement with a private hospital;
ii. To detennine whether and to what degree the Governmental Entity will
supply an IGT, provided such decision does not include consideration of
matters prohibited under paragraph 4 of this Certification;
iii. To determine whether an Affiliated Hospital's participation benefited
the community and whether its continued participation in the indigent
care program is likely to continue to berief it the community; or
iv. To provide accountability to local taxpayers;
b. The Governmental entity's evaluation tinder this paragraph 5 may;
i. Be documented in a manner sufficient to confirm achievement of the
Governmental Entity's mission and provide art appropriate and
constitutional basis on which to transfer the Public Fonds to HH'SC; and
ii. Not include consideration of matters prohibited under paragraph 4 of
this Certification ,
On behalf of the Governmental Entity, I hereby certify that I have read and understood the above
statements; that the statements are true, correct, and complete; and that I am authorized to bind
the Governmental Entity and to certify to the above.
b
Stealth & Human Services Commission 1115 nstration Waiver Program
Goventmentai Entity Certification for Hosspitai Payments Version 2012-I (09*512012)
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM
1115 DEMONSTRATION WAIVER PROGRAM
CERTIFICATION OF GOVERNMENTAL ENTITY PARTICIPATION
FOR HOSPITAL AFFILIATES
Version 2012-1(09/05/2012)
DOCUMENT HISTORY LOG
STATUS
DOCUMENT
EFFECTIVE
DESCRIPTION
REVISION
DATE
Baseline
n/a
Initial version of the Certification of Governmental Entity
Participation
Revision
1.1
09/05/2012
Added cover page.
Revision
1.2
09/05/2012
Added Document History Log.
Revision
1.3
09/05/2012
Various formatting changes.
Revision
1.4
09/05/2012
Added version number (Version 2012-1) and date of
issuance to cover page and page footer.
Revision
1.5
09/05/2012
Deleted "Texas" from "Health and Human Services
Commission" to reflect agency's statutory name.
Revision
1.6
09/05/2012
Revised paragraph 4.g. to replace "and" at the end of
subparagraph ii following the semicolon with "or."
"Baseline" indicates initial document issuances, "Revision" indicates changes to the Baseline version, and
"Cancellation" indicates withdrawn versions.
2 Numbering conventions: Revisions are numbered according to the version of the document and the sequential
revision—e.g., 1.2" refers to the first version of the document and the second revision.
3 Brief description of the changes to the document made in the revision.
Health & Human Services Commission H 15 Demonstration Waiver Program
Governmental Entity Certification for Hospital Payments Version 2012-1 (09/05/2012)
HEALTH AND HUMAN SERVICES COMMISSION
TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT
PROGRAM 1115 DEMONSTRATION WAIVER PROGRAM
CERTIFICATION OF GOVERNMENTAL ENTITYPARTICIPATION FOR
HOSPITAL AFFILIATES
On behalf of the City of Beaumont , a home -rule municipality
organized under the laws of the State of, rexas (hereinafter referred to as "the
Governmental Entity"), I, Kyle Hayes , affirm and certify the
following:
L Legal Authorization
a. The Governmental Entity is legally authorized to levy and collect ad valorem
taxes, generate public revenue, or receive and expend appropriated public funds
("Public Funds");
b. The Governmental Entity is legally authorized to enter into and has entered into
Affiliation Agreements with one or more private hospitals ("the Affiliated
Hospitals") for, among other purposes, providing indigent care in the community
served by the Governmental Entity.
2. Public Adoption and Access.
a. The governing body of the Governmental Entity adopted the conditions
described in this certification by recorded vote taken in a public meeting held in
compliance with the Texas Open Meetings Act, Chapter 551, Government Code;
b. Copies of all Affiliation Agreements will be made available as provided under
the Texas Public information Act, Chapter 552, Government Code, and will be
provided to HHSC on request.
I leaM & Human Senims Commivtiinn 1 i 1 i Demonstration Waiver Program
Governmental Entity Certification for Hospital Payments Version 2012-1 (0910512012)
3. Funding of Intergovernmental Transfers and Supplemental Payments.
a. The Governmental Entity has or has agreed to transfer Public Funds to the
Health and Human Services Commission ("HHSC") via intergovernmental
transfer ("IGT") for use as the non-federal share of supplemental waiver
payments (the "Supplemental Payments") to the Affiliated Hospitals in
accordance with 1 Tex. Admin. Code §355.8201,'Waiver Payments to
Hospitals (the "Waiver Program");
b. All transfers of Public Funds by the Governmental Entity to HHSC to support
the Supplemental Payments to the Affiliated Hospitals under the Waiver
Program comply with:
i. The applicable regulations that govern provider -related donations
codified at section 1903(w) of the Social Security Act (42 U.S.C.
§1396b(w)), and Title 42, Code of Federal Regulations, Part 433,
subpart B, sections 433.52 and 433.54;
ii. HHSC administrative rules codified at 1 Tex. Admin Code §355.8201,
Waiver Payments to Hospitals.
4. Assurances and Representations.
a. The Governmental Entity does not and will not at any time receive any part of
the supplemental payments that are made by HHSC to the Affiliated Hospitals
under the Waiver Program;
b. The Governmental Entity has not entered into a contingent fee arrangement
related to the Governmental Entity's participation in the Waiver Program;
c. The Governmental Entity has not entered and will not enter into any agreement
to condition either the amount of the Public Funds transferred by the
Governmental Entity or the amount of Supplemental Payments an Affiliated
Hospital receives on the amount of indigent care the Affiliated Hospital has
provided or will provide;
d. The Governmental Entity has not entered and will not enter into any agreement
to condition the amount of any Affiliated Hospital's indigent care obligation on
either the amount of Public Funds transferred by the Governmental Entity to
HHSC or the amount of Supplemental Payment an Affiliated Hospital may be
eligible to receive;
e. With regard to any escrow, trust or other financial mechanism (an "Account")
utilized in connection with an indigent care Affiliation Agreement or an IGT
issued for a payment period that occurs after the effective date of this
Certification, the following representations are true and correct:
4
Health & Human Services Commission 1115 Demonstration Waiver Program
Governmental Entity Certification for Hospital Payments Version 2012-1 (09/05/2012)
i. The amount of any Account is not conditioned or contingent on the
amount of indigent care services that an Affiliated Hospital provided or
will provide;
ii. The Governmental Entity has disclosed the existence of any Account to
HHSC; and
iii. Any such Account will not be used to effect a quid pro quo for the
provision of indigent care services by or on behalf of the Affiliated
Hospitals;
f. The Governmental Entity has not received and will not receive refunds of
payments the Governmental Entity made or makes to an Affiliated Hospital for
any purpose in consideration for an IGT of Public Funds by the Governmental
Entity to HHSC to support the Supplemental Payments;
g. The Governmental Entity has not received and will not receive any cash or in -
kind transfers from an Affiliated Hospital or any other entity acting on behalf of
an Affiliated Hospital or group of Affiliated Hospitals other than transfers and
transactions that:
i. Following the date this Certification was executed, are unrelated to the
administration of the Waiver Program or the delivery of indigent care
services under an Affiliation Agreement;
ii. Constitute fair market value for goods or services rendered or provided
by the Governmental Entity to an Affiliated Hospital; or
iii. Represent independent, bona fide transactions negotiated at arms -length
and in the ordinary course of business between the Affiliated Hospital
and the Governmental Entity;
h. The Governmental Entity has not:
i. Following the date this Certification was executed, assigned or agreed to
assign a contractual or statutory obligation of the Governmental Entity
to an Affiliated Hospital or any other entity acting on behalf of an
Affiliated Hospital or group of Affiliated Hospitals; or
ii. Authorized or consented to the assumption of a statutory or contractual
obligation of the Governmental Entity by an Affiliated Hospital or any
other entity acting on behalf of an Affiliated Hospital or group of
Affiliated Hospitals.
S. Evaluation.
Health & Human Services Commission 1115 Demonstration Waiver Program
Governmental Entity Certification for Hospital Payments Version 2012-1 (09/05/2012)
a. Consistent with its constitutional, statutory, and fiduciary obligations, the
Governmental Entity may evaluate a private hospital's historical experience in
providing indigent care in the community or performance under an Affiliation
Agreement including the impact and amount of indigent care provided by the
hospital, for the following purposes:
i. To determine whether the Governmental Entity will enter into an
Affiliation Agreement with a private hospital;
ii. To determine whether and to what degree the Governmental Entity will
supply an IGT, provided such decision does not include consideration of
matters prohibited under paragraph 4 of this Certification;
iii. To determine whether an Affiliated Hospital's participation benefited
the community and whether its continued participation in the indigent
care program is likely to continue to benefit the community; or
iv. To provide accountability to local taxpayers;
b. The Governmental Entity's evaluation under this paragraph 5 may:
i. Be documented in a manner sufficient to confirm achievement of the
Governmental Entity's mission and provide an appropriate and
constitutional basis on which to transfer the Public Funds to HHSC; and
ii. Not include consideration of matters prohibited under paragraph 4 of
this Certification;
On behalf of the Governmental Entity, I hereby certify that I have read and understood the above
statements; that the statements are true, correct, and complete; and that I am authorized to bind
the Governmental Entity and to certify to the above.
Signature Date
,l /L �`G7 Offictat Se4
/ �f (Ifapplicable}
Name and T le
J
6
Health & Human Services Commission 1115 Demonstration Waiver Program
Governmental Entity Certification for Hospital Payments Version 2012-1 (09/05/2012)