Memorandum of Agreement Between
Louisiana Department of Health
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THIS MEMORANDUM OF AGREEMENT, hereinafter referred to as “Agreement”, is entered into as of the Click here to enter text. day of Click here to enter text. 2017, by and between the Louisiana Department of Health, 628 N. 4th Street, Baton Rouge, Louisiana 70802, hereinafter referred to as "LDH", and the host site(s) indicated below hereinafter referred to as "Host":
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The parties to this Agreement agree as follows:
The purpose of this Agreement is to ensure residents of Louisiana have an opportunity to apply for Medicaid benefits at provider locations through the Onsite Medicaid Worker Program and to assist the state in providing matching funds to comply with 42 C.F.R. 435.904 and 42 C.F.R. 433.66.
The Host shall reimburse the direct costs associated with the Medicaid Analyst(s) operating out of one or more of their sites on a quarterly retrospective basis, payable directly to LDH. At a minimum, direct costs could include:
- Salary of the on-site Eligibility Worker
- Related benefits for the on-site Eligibility Worker
- Prorated share of:
o Outreach activities
o Outstation Support Staff and related benefits
Total funds to be transferred under this Agreement shall not exceed $20,000.00 per Analyst, per twelve-month period. Direct costs will be calculated for actual costs incurred and will be invoiced to the host site per the following schedule:
Description of Invoice / Invoice DateDirect costs incurred from January 1st – March 31st / On or before April 15th
Direct costs incurred from April 1st – June 30th / On or before July 15th
Direct costs incurred from July 1st – September 30th / On or before October 15th
Direct costs incurred from October 1st – December 31st / On or before January 15th
The host shall reimburse based on the invoiced amount as detailed by LDH within fifteen (15) calendar days from the date of the invoice. Funds should be sent via EFT or may be remitted to the following address:
Louisiana Department of Health
Attention: Accounts Receivable Department - Outstationing
Post Office Box 3797
Baton Rouge, LA 70821-3797
This Agreement is contingent upon the availability of federal funding and shall be terminated immediately should such funding cease to be available. LDH will determine the availability of federal funding. Outstation staff are subject to the confidentiality of information rules specified in CFR 435.904 and to all other State or Federal laws concerning conflict of interest.
By signing this Agreement, the Host acknowledges that the eligibility worker(s) assigned to the Hosts location(s) are LDH employees and that LDH retains all authority and control over their activities and duties pursuant to this Agreement,
IN WITNESS WHEREOF, LDH AND HOST, by their authorized agents, in consideration of the mutual promises, covenants and conditions exchanged between them, have executed this Agreement to be effective as of the Click here to enter text. day of Click here to enter text. 2017 and shall remain effective for a minimum of one (1) year. The Host may terminate this agreement with thirty (30) days written notice to LDH.
Organization / Authorized Representative / Signature / DateLouisiana Department of Health “LDH” / Pam Diez
BHSF Chief Financial Officer
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MOA v9 Rev 3/17 Page 2 of 2