II^HCS
CALIFORNIA DEPARTMENT OF
HEALTH CARE SERVICES
MichelleBaass |Director
PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION PROGRAM
INTERGOVERNMENTAL TRANSFER CERTIFICATION FORM
STATE CALENDAR YEAR 2026
I,the undersigned,hereby declareand certifyon behalfof
CITY OF NEWPORT BEACH (the"PublicEntity")as follows:
1. As a publicadministrator,a publicofficer,or other publicindividual,Iam duly authorized to make this certification.
2. The PublicEntity elects tomake thisintergovernmentaltransfer(IGT)to the Department of HealthCare Service(DHCS) as a voluntarycontribution to the non-federalshare(NFS)of Medi-Calexpendituresforpurposes of Assembly Bill 1705 (2019) pursuant to Sections 14105.94, 14105.945, 14129, 14129.3, and 14164 of the Welfare and Institutions(W&l) Code. Allfunds transferredpursuant to thiscertificationqualifyforfederalfinancialparticipation(FFP)pursuant to Section 1903(w) of the SocialSecurityAct and Title42 of the Code of Federal Regulations,Section433 Subpart B,and are not derivedfrom impermissible sources such as recycledMedicaid payments, federalmoney excluded from use as the NFS, impermissiblehealthcare-relatedtaxes,or non-bona fideprovider- related donations.
3. Voluntary contributionsattributableto the period of January 1,2024,through December 31,2026, willbe made viarecurringtransfersas indicated on the invoicesprovided to the PublicEntityby DHCS. The voluntarycontributionsmade by the PublicEntitymay alsoincludeadjustmentsrelatedto the calendaryear (CY) 2024 and CY 2025 ratingperiod'sNFS reconciliationas described in paragraph 7 below. Please note,the totalIGT amount at the bottom of this IGT certificationwillcontinueto be itemizedon your invoicewhich issent to you along with thisIGT certificationform 45-days inadvance of the IGT contribution due date.The PublicEntityacknowledges thatany transfersmade pursuant to thiscertificationduring thistime periodare consideredan elective IGT made pursuant to W&l Code sections14105.945 and 14164, to be used by DHCS, subjectto paragraph four herein,exclusivelyas the source forthe NFS of ground emergency medical transportpublicprovidersupplemental payments in both CaliforniaDepartment of Health Care Services
Capitated Rates Development Division
1501 CapitolAvenue, P.O.Box 997413
Sacramento,CA |95899-7413
MS 4413 Iwww.dhcs.ca.gov
State of California ,4
Gavin Newsom, Governor ^
CaliforniaHealthand Human ServicesAgency
Attachment A
PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION PROGRAM
INTERGOVERNMENTAL TRANSFER CERTIFICATION FORM
STATE CALENDAR YEAR 2026
Medi-Cal fee forservice(FFS)payments and the portionof the risk-based capitationrateto Medi-Cal managed care healthplansassociated with reimbursement made in accordance with Section 14105.945, subdivision (h)(1) (hereafter,the AB 1705 PublicProvider(PP)Ground Emergency Medical Transportation(GEMT) Program, or the (PP-GEMT Program),and DHCS costs associatedwith administeringthe PP-GEMT Program.
4. DHCS may accept thisvoluntarycontributionto the extent it is able to obtain FFP forthe PP-GEMT Program as permittedby federallaw.In the event DHCS is unable to obtainFFP forthe PP-GEMT Program, or the fullpayments cannot otherwisebe made to and retainedby eligiblepublicproviders,and, therefore,all or a portionof the transferredamount cannot be used as the NFS of payments, DHCS willnotifythe PublicEntityviae-mailand returnthe applicableportionof the unused IGT amount.
5. The PublicEntityacknowledges thatstatelaw inW&l Code section 14105.945, subdivision(h)(2)authorizesDHCS, upon obtainingany necessary approvals,to assessa ten percent (10%) fee on each transferof publicfunds to the stateto pay forhealthcarecoverage and to reimburse DHCS itscosts associated with administeringthe PP-GEMT Program.The PublicEntityacknowledges thatwhile DHCS isnot assessingthisfee currentlypending federalapproval,DHCS has not waived itsrightto assessthe administrativefee under statelaw upon obtaining any necessaryfederalapprovals.
6. The PublicEntityacknowledges thatthe IGT isto be used by DHCS forthe filing of a claim with the federalgovernment forfederalfunds and understands that any misrepresentationregardingthe IGT may violatefederal and state law.
7. The amount voluntarilytransferredto DHCS isbased on the estimated Medi-Cal FFS and Medi-Cal managed care NFS of ground emergency medical transport payments, as referencedinparagraph threeherein.Since the amount to be voluntarilytransferredto DHCS willbe based on an estimate,the PublicEntity acknowledges thata reconciliationof the voluntaryNFS contributions to the actualNFS expenditureswilloccur.To the degree necessaryto fund the NFS for the PP-GEMT Program, amounts due to or owed by PublicEntityas a resultof the reconciliationmay be offsetagainst,or added to,futuretransfersas applicable CaliforniaDepartment of Health Care Services
CapitatedRates Development Division
1501 CapitolAvenue, P.O. Box 997413
Sacramento,CA) 95899-7413
MS 4413 Iwvvw.dhcs.ca.gov
State of California j
Gavin Newsom, Governor
CaliforniaHealthand Human ServicesAgency
PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION PROGRAM
INTERGOVERNMENTAL TRANSFER CERTIFICATION FORM
STATE CALENDAR YEAR 2026
and as determined by DHCS. DHCS may accept a voluntarycontribution to the extent itisable to obtain FFP forPP-GEMT payments as permitted by federallaw.
The PublicEntityacknowledges thatallrecordsof funds transferredare subjectto review and auditupon DHCS' request.The PublicEntitywill maintain documentation supporting the allowablefunding source of the IGTs.
Upon noticefrom the federalgovernment of a disallowanceor deferral related to thisIGT,the PublicEntityresponsibleforthisIGT shallbe the entityresponsible forthe federalportion of that expenditure.
I hereby declare under penalty of perjuryunder the law of the United States that the foregoing istrue and correctto the best of my knowledge. 1 further understand that the known filingof a falseor fraudulentclaim,or making falsestatements in support of a claim,may violatethe FederalFalseClaims Act or other applicablestatuteand federallaw and may be punishablethereunder.
8. 9.
Executed on this day of ,20_at California.
SignatureofAuthorizedPerson:
Seimone JurjisName of Authorized Person:
CityManagerTitle of Authorized Person:
CITY OF NEWPORT BEACH
Name of PublicEntity:
1679579296
NPi of PublicEntity:
126,858.98Amount of IGT:$.
APPROVED AS TO FORM:
CITY ATTORNEY'S OFFICE
Dats;
State of California j
Gavin Newsom. Governor *
CaliforniaDepartment of Health Care Services
CapitatedRates Development Division
1501 CapitolAvenue, P.O.Box 997413
Sacramento,CA |95899-7413
MS 4413 Iwww.dhcs.ca.gov CaliforniaHealth and Human ServicesAgency fe^HCSCALIFORNIA DEPARTMENT OF
HEALTH CARE SERVICES
Michelle Baass |Director
PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION (PP-GEMT) PROGRAM
MANAGED CARE AND FEE FOR SERVICE - INVOICE
1/16/2026|EntityInformation: Due Date:
Entity Name:
CityOf Newport Beach Payment Details
Year: 2026 Contribution #: 1
NPI:
1679579296 Total Amount Due: $126,858.98
Program/Payee Information: Banking Information:
Vendor Name:
CaliforniaDepartment of Health Care Services
Bank Name:
US Bank
Please await Wire Request Memo for payment instructions PP-GEMT Program Email:
[email protected]
Payment Me^ods Accepted:
jACH or Wire Transfer J
Payment Instructions:
Attention: Please review,sign,and submit the Intergovernmental Transfer (IGT)Certificationform by January 2, 2026, to [email protected]. IGT Certificationforms are requiredto be submitted priorto each collectiondue date.Once the IGT Certification form is received,DHCS willsend a Wire Request Memo providingpayment detailsand instructions.Please do not send your IGT payment untilyou have received the Wire Request Memo as payment detailsare subject to change.
IGT Non-Federal Share (NFS) Breakdown By DHCS DeliverySystem Managed Care (MC)
MCNFS#1 $ 113,403.72
Fee For Service (FFSi
FFSNFS#! $ 13,455.26
Total* IGT Transfer Amount: $ 126,858.98
*Any differencesare due to rounding.
CY 2026 Invoicing Schedule
12/2^025
1/2/2026
Invoice Packets Sent
CY 2026 Invoice #1 IGT Certifications Due
Payment Due 1/16/2026
3/3/2026Invoice Packets Sent
CY 2026 Invoice #2 4/3/2026IGT Certifications Due
4/17/2026Payment Due
CY 2024 FFS Recon #1 Date of Service Jan-100 2024
CY 2025 MC Recon #1 Date of Service TBD
6/2/2026Invoice Packets Sent
7/3/2026CY 2026 Invoice #3 IGT Certifications Due
7/17/2026Payment Due
9/1/2026Invoice Packets Sent
CY 2026 Invoice U4 10/2/2026IGT Certifications Due
10/16/2026Payment Due
Date of Service Jul-Dec 2024CY 2024 FFS Recon «2
CY 2025 MC Recon « Date of Service TBD