Fillable Printable 091615 Esiga Template
Fillable Printable 091615 Esiga Template
091615 Esiga Template
801 East Jefferson, Phoenix, AZ 85034 •PO Box 25520, Phoenix, AZ 85002 •
602-417-4000 •
www.azahcccs.gov
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INTERGOVERNMENTAL AGREEMENT
FOR AHCCCS ENROLLMENT SUSPENSE
YH16-0028-__
This Intergovernmental Agreement (“Agreement”) is entered into by and between ________ County,
apolitical 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
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
The COUNTY is duly authorized to enter into this Agreement under A.R.S. § 11-952; and
The COUNTY is responsible for the oversight, management and the provision of healthcare services to
detainees in the custody of the Sheriff’s Department and utilizes outside healthcare vendors for the
provision of healthcare services; and
WHEREAS,The medical services program in the ________ County Detention Center is administered by
________ County Sheriff’s Office who is a Covered Entity for purposes of compliance with the Health
Insurance Portability and Accountability Act (HIPAA); and
WHEREAS,________ County and its healthcare vendor, (______________________),
has been designated by the County as a health care component consistent with 45 CFR
164.105(a)(2)(iii)(D).
Individuals are not eligible to receive AHCCCS benefits while incarcerated; and
Suspension, rather than termination, of AHCCCS benefits during any period of incarceration is
economically efficient. Additionally, for individuals released from custody, suspension of benefits
facilitates continuity of care and minimizes the number of uninsured because reinstatement of benefits
is much more timely; and
The COUNTY and AHCCCS wish to enter into this Agreement in order to establish procedures to
accommodate AHCCCS eligibility suspension at the time of incarceration, reinstatement of an
individual’s enrollment upon his/her release from incarceration, and transmission of match results to
the COUNTY for COUNTY’S use in discharge planning for inmates about to be released.
SCOPE OF WORK
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1.DEFINITIONS
1.1.Authorized Use:Access given to AHCCCS by COUNTY to Booking Information, that AHCCCS
would not be entitled to otherwise have, for the sole purposesof 1) suspending medical
eligibility of incarcerated individuals in the ________ County Detention Center and 2) returning
individuals to their pre-incarceration status upon release from the ________ County Detention
Center.
1.2.Booking Information:Certain information provided by COUNTY concerning individuals
incarcerated in the ________ County Detention Center. This information may include
individuals’ booking name, alias name(s), booking number, booking date, date of birth, gender,
race, and release date, whether the individual was released to another agency.
1.3.Incarcerated:For purposes of this Agreement an individual detained at the ________ County
Detention Center will not be considered incarcerated until both of the following have taken
place: an initial court appearance has occurred AND a minimum of 24 (twenty-four) hours have
elapsed since the time of the individual’s detention. Additionally, those individuals serving a
sentence on weekends will not be included on the file.
1.4.Invalid format:Query result from AHCCCS indicating that some section of the query was
incomplete or invalid.
1.5.Match:Query result from AHCCCS indicating that data entered matches data in the system. A
match requires verification by AHCCCS.
1.6.Member:An individual who is eligible for Title XIX benefits who is enrolled with AHCCCS, an
AHCCCS Contractor, or a Regional Behavioral Health Authority (RBHA) for medical or behavioral
health services.
1.7.No Match:Query result from AHCCCS indicating that the individual’s information did not match
any data in the AHCCCS system.
1.8.No-pay Status:For the purposes of this Agreement AHCCCS will not reimburse claims
submitted or pay capitation for individuals while incarcerated.
1.9.Partial Match:Query result from AHCCCS indicating that some data in query matched data in
AHCCCS system. Requires verification by AHCCCS.
1.10.Rejected:Query results from AHCCCS indicating that query was not successful.
1.11.Title XIX Benefits:Medicaid benefits provided under Title XIX of the Social Security Act.
2.PURPOSE OF THIS AGREEMENT
The purpose of this Agreement is for the COUNTY and AHCCCS to jointly develop and implement a
system to match AHCCCS member data with COUNTY’s inmate population data to facilitate the
identification of incarcerated individuals so that those individuals’ Title XIX benefits may be suspended
or placed on a no-pay status and so that those individuals will be immediately returned to their pre-
incarceration status upon their release from custody.
Any and all data provided under this Agreement shall be used for the sole purposes of said Agreement,
and not used for any other purpose.
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3.TERM
3.1.This Agreement is effective ________________ and shall remain in effect, with no end date,
until terminated pursuant to the terms set forth in this Agreement.
4.SCOPE
4.1.COUNTY Responsibilities:
4.1.1.Prior to 5:00 p.m. each day, including weekends and holidays, electronically transmit, in
a format agreed to by the Parties, booking and release data for the preceding twenty
four (24) hour period. Data that is transmitted shall include, but is not limited to, the
detainee’s booking number, name, date of birth, gender, time of booking or release, and
if detainee was released to another facility and name of facility. Social security numbers
shall not be transmitted.In the event there are no bookings or releases, the COUNTY
will transmit the file indicating “no records.”
4.2.AHCCCS Responsibilities:
4.2.1.After 5:00 p.m. each day, including weekends and holidays, utilizing the information
provided by COUNTY, query its member database to identify individuals appearing in
both data sources (“matches”).
4.2.2.Suspend if incarcerated or reinstate if released Member Title XIX benefit eligibility based
on the Member’s incarceration status at the time of the query.
4.2.3.Update eligibility information daily, including weekends and holidays.
4.2.4.On the same day each query is performed, provide a copy of that day’s query results to
the ________ County Jail Health Services identifying the query results for each
individual listed: a match, no match, partial match, rejected or invalid format of the
data.
4.2.5.On the same day each query is performed, post results of query, including eligibility
renewal date/termination, on the AHCCCS secure ftp site for ________ County Jail
Health Services retrieval for the purposes of discharge planning. There is no public
access to this site.
5.SYSTEM CAPABILITY REQUIREMENTS
Additional information and/or technical documents will be provided to COUNTY to ensure system
capabilities and explain data exchange requirements.
6.FINANCING
Each party will bear its own cost for the performance of its responsibilities as set forth in this
Agreement.
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7.NOTICES
Any notices or correspondence related to this Agreement shall be sent to the parties or their designees
respectively as follows:
7.1.AHCCCS
Procurement and Contracts:
Mark Held, Senior Procurement Specialist
701 East Jefferson St., MD 5700
Phoenix, AZ 85034
Phone: (602) 417-4094
Mark.H[email protected]
7.2.Programmatic Correspondence:
Penny Ellis, Acting Assistant Director, Division of Member Services
801 E. Jefferson St., MD2600
Phoenix, AZ 85034
Phone: (602) 417-4512
E-Mail: Penn[email protected]v
7.3.Technical Contact:
Dawn O’Dell, Automation Manager, Division of Member Services
801 E. Jefferson St., MD2600
Phoenix, AZ 85034
Phone: (602) 417-4644
E-Mail: Dawn.O'[email protected]v
7.4.COUNTY:
Insert County Contacts:
TERMS AND CONDITIONS
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1.0ADA
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.
2.0Amendments
2.1Any amendment to this agreement must be in writing and signed by both parties.
2.2Amendments 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.
2.3All requests for additional services shall be in writing and signed by both parties.
2.4An 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.
3.0Arbitration 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.
4.0Assignment 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.
5.0Compliance 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.
6.0Disposal of Property
Upon the termination of this agreement, all property involved shall revert back to the owner.
Termination will not relieve any party from liabilities or costs already incurred under this
Agreement, not affect ownership of property pursuant to this agreement.
7.0E-Verify Requirement
In accordance with ARS § 41-4401, all parties warrant compliance with all Federalimmigration laws
and regulations relating to employees and warrants its compliance with A.R.S. § 23-214, Subsection
A.
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8.0Execution in Counterparts / Electronic Documents
8.1This 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.
8.2Facsimile signatures, electronic signatures and signatures transmitted by email after having
been scanned shall be accepted as originals for the purposes of this Agreement.
9.0Federal 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.
10.0Health 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.
11.0Insurance
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.
12.0Liability
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.
13.0Non-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.
14.0No 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.
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15.0No 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.
16.0Non-Discrimination
In accordance with ARS § 41-1461 et. seq., the parties shall provide equal employment
opportunities for all persons, regardless of race, color, creed, religion, sex, age, national origin,
disability or political affiliation. The parties agree to comply with the Americans with Disabilities Act.
17.0Records 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.
18.0Severability
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.
19.0Termination
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.
20.0Cancellation for Conflict of Interest.
This IGA is subject to cancellation for conflict of interest pursuant to ARS § 38-511, the pertinent
provisions of which are incorporated into this IGA by reference.
SIGNATURE PAGE
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IN WITNESS THEREOF,the parties have executed this Agreement:
COUNTY:
Arizona Health Care Cost Containment System
(AHCCCS):
Signature: ______________________________
Signature: _____________________________
Printed Name:
Printed Name:Meggan Harley, CPPO, MSW
Title: Chairman, Board of Supervisors
Title: Procurement and Contracts Manager
Date: _________________________________
Date: ________ ______________
In accordance with A.R.S. § 11-952, this Agreement has
been reviewed by the undersigned who has determined
that this Agreement is in the appropriate form and is
within the power and authority granted to COUNTY.
County Attorney
In accordance with A.R.S. § 11-952, this Agreement is
in the proper form and is within the power and
authority granted to AHCCCS under A.R.S. §§36-2903
et seq. and 36-2932 et seq.
Legal Counsel for AHCCCS
