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HomeMy WebLinkAboutAG 23-182 - SOLID GROUND, STATEWIDE HEALTH BENEFIT ADVISORS (SHIBA) PROGRAMf l l RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM ORIGINATING DEPT./DIV: City of Federal Way - Federal Way Community Center 2. ORIGINATING STAFF PERSON: Ashdya Guptar EXT: 5950 3. DATE REQ. BY: 4/17/23 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT ❑ REAL ESTATE DOCUMENT ❑ ORDINANCE ❑ CONTRACT AMENDMENT (AG#): 9M OTHER MOU 5. PROJECT NAME: Agreement Between SHIBA & CoFW FWCC ❑ HUMAN SERVICES / CDBG ❑ SECURITY DOCUMENT (E.0 BOND RELATED DOCUMENTS) ❑ RESOLUTION ❑ INTERLOCAL 6. NAME OF CONTRACTOR: Solid Ground, Statewide Health Benefit Advisors (SHIBA) Program ADDRESS: 1501 N 45th St, Seattle WA 98103 TELEPHONE 206-694-6785 E-MAIL: jeng@solid-ground.org FAX?06-694-6777 SIGNATURE NAME: Jennifer G haaanl TITLE volunteer Services Manager 7. EXHIBITS AND ATTACHMENTS: ICJ SCOPE, WORK OR SERVICES ❑ COMPENSATION :R INSURANCE REQUIREMENTS/CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: 5ni23 COMPLETION DATE: 5/1/25 9. TOTAL COMPENSATION $ (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑ YES N NO 1F YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ®YES ONO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ CITY RETAINAGE: RETAINAGE AMOUNT: ❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED ❑ PURCHASING: PLEASE CHARGE TO: 10. DOCUMENT/CONTRACT REVIEW 4 PROJECT MANAGER ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) IN LAW 11. COUNCIL APPROVAL (IF APPLICABLE) 12. CONTRACT SIGNATURE ROUTING INITIAL / DATE REVIEWED DS 4/11/23 M/i1 12oz� JE 4/18123 INITIAL / DATE APPROVED COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE: ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: _ ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS ❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR I MONTH PRIOR TO EXPIRATION DATE (Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.) €�1 AW DEPARTMENT ❑ SIGNATORY (MAYOR OR DIRECTOR) ❑ CITY CLERK ❑ ASSIGNED AG# COMMENTS: INITIAL/ DATE SIGNED Z • z1 AG# 23-182 2'21117 • • • • - • go=' An Agreement Between Solid Ground, Statewide Health Benefits Advisors (SHIBA) program Partner Organization: City of Federal Way - Federal Way Community Center Street Address: 876 S 333rd St City State, Zip: Federal Way, WA, 98003 Contact Person: David Schmidt Phone: 253-835-6925 Email: david.schmidt@cityoffederalway.com Web Site: https:Hitallhappenshere.org/ This Memorandum of Understanding (MOU) is a letter of agreement between your agency and SHIBA/Solid Ground which defines the basic provisions that will guide our working relationship. SHIBA volunteers provide free and unbiased information on Medicare. Volunteers offer information people can use to make decisions based on their own unique needs, values, and circumstances. SHIBA volunteers can provide information about: o Original Medicare o Prescription drugs o Low-income programs to help pay for Medicare o Medigap (Medicare Supplement) plans o Medicare Advantage plans o Medicare fraud and abuse SHIBA Volunteers Training and Certification.- SHIBA Volunteers are trained and certified by the Office of the Insurance Commissioner (OIC). To become a certified SHIBA volunteer, and remain active, individuals must meet the following minimum requirements: 1 • Attend Solid Ground's Volunteer Orientation which includes an anti -racism orientation. • Attend a confidentiality training on an annual basis. • Attend an 8-hour Medicare Basic Training. • Pass an exam to become a certified SHIBA volunteer. • Attend monthly trainings hosted by OIC to stay up to date with the changes in Medicare. The volunteer must attend 8 out of the 9 trainings per year • Pass a background check processed by OIC. • Agrees to only provide free unbiased, and confidential healthcare information and advice. • SHIBA volunteers do not sell or pick out insurance plans for clients. • SHIBA volunteers cannot have an active insurance sales license during their time as a SHIBA volunteer. • SHIBA volunteers agree to follow site location health and safety guidelines including masking, physical distancing, and/or vaccination verification. • SHIBA volunteers agree to follow site/agency code of conduct guidelines. SHIBA PARTNER ORGANIZATION RESPONSIBILITIES: • Provide a private meeting space to maintain confidentiality of counseling sessions. Amenities that are not required but preferred, are access to computer, a telephone, printing ability, and access to the internet for SHIBA volunteers and the people they serve. Check all that apply: Required: Access to private meeting space Optional: Access to a computer Access to a phone Ability to print Access to Internet • Schedule appointments and reminder calls for participants with the volunteer assigned to the site during the hours agreed. • Display and share SHIBA promotional and informational materials (e.g., posters, flyers, brochures) on the premises to inform people of services available to them through the program. 2 ■ Receive approval from SHIBA Program Coordinator before posting any SHIBA related promotional, informational materials including event or program blurbs shared with the public that were written or produced by any agency or organization other than the Office of the Insurance Commissioner or Solid Ground. ■ Provide SHIBA program coordinator with information pertaining to volunteer accomplishments and the impact they have on your agency, participants, and community if requested. Ensure that volunteers receive adequate supervision and a safe environment for their volunteer assignment. Comply with any appropriate WA State and King County health and safety regulations. • Keep the SHIBA coordinator informed of COVID-19 protocols such as volunteer vaccine requirements. • Read and understand the supplemental volunteer insurance policy. Please note coverage limits. https:Hsl4621.pcdn.co/wp-content/uploads/2015/12/RSVP- VollnsuranceBrochure.pdf • Notify the SHIBA Program Coordinator in the event of an accident involving a SHIBA volunteer. • Partner agrees to indemnify and hold the Solid Ground Washington harmless from and against any and all claims, expenses, and actions based on negligence of the Partner, including claims, demands, and suits alleging property damage or bodily injury (see additional insurance requirements section below). • Agree to not discriminate against SHIBA volunteers or participants on the basis on race, color, national origin (including limited English proficiency), sexual orientation, age, political affiliation, religion, or on the basis of disability. • Maintain the SHIBA program as accessible to persons with disabilities (including mobility, hearing, vision, mental, and cognitive impairments or addictions and diseases) and/or limited English language proficiency and provide reasonable accommodation to allow person with disabilities to participate in programs and activities. • Reach out to the volunteers referred by SHIBA within 10 business days of referral. The partner organization will make final decisions regarding their placement. Office of Insurance Commissioner (OIC) performs National background checks. SOLID GROUND /SHIBA RESPONSIBILITIES: • Coordinate training and support of SHIBA volunteers with OIC. • Inform SHIBA volunteers of their responsibilities as a volunteer. • Refer interested SHIBA volunteers for placement at your organization as well as work to find a replacement volunteer if the need arises. • Recognize SHIBA volunteers for their volunteer service. • Provide supplemental accident, personal liability, and auto liability insurance beyond any other coverage available to the volunteer. • Provide access to SHIBA promotional and informational materials. 3 • Solid Ground Washington agrees to indemnify and hold Partner harmless from and against any and all claims, expenses, and actions based on negligence of Solid Ground Washington, including claims, demands, and suits alleging property damage or bodily injury. ALL PARTIES RESPONSIBILITIES: • Communicate and work together on an ongoing basis to serve the needs of SHIBA program participants and volunteers by updating each other on changes to the partner programs and meeting with staff at least once a year to access, discuss, and update participant, volunteer, and site needs. • Train volunteers on their respective missions and scopes of their organization, including orienting volunteers to the program site. • Work cooperatively and in partnership to resolve differences or misunderstandings. • Agree to keep SHIBA participant and volunteer's sensitive information confidential. This includes maintaining a private space for SHIBA Medicare counseling sessions away from the public during the length of the counseling appointment. • Agree to not store or disclose SHIBA participants or volunteers' personal protected information (PPI). You can find definitions of what information is included in PPI here: SHIBA's confidentiality requirements (wa.gov). • Understand that confidentiality is protected by Federal law (42CF R Part II and Uniform Health Care Information Act). Violations may result in suspension and/or termination of partnership. More on confidentiality can be viewed here SHIBA's confidentiality requirements (wa.gov) m Comply with the nondiscrimination provisions of the Americans with disabilities act and title VI of the civil rights act of 1964. INSURANCE REQUIREMENTS Insurance: Partner Organization needs to hold: 1. General Liability Insurance Policy. Provide a General Liability Insurance Policy, including liability, in adequate quantity to protect against legal liability arising out of MOU activity but no less than $250,000 per occurrence. 2. The insurance required must be issued by an insurance company/ies authorized to do business within the state of Washington. Cl Additional Insurance: Partner Organization must name Solid Ground as additional insured on their insurance policy and as it relates to this MOU. All policies must be primary to any other valid and collectable insurance. SHIBA Partner Organization must instruct the insurers to give Solid Ground thirty (30) calendar days advance notice of any insurance cancellation. Other Insurance: If Partner Organization is part of an insurance pool, proof of insurance coverage meeting the insurance requirements listed above can in accepted in lieu of the additional insurance requirement. SHIBA partner organizations must provide Solid Ground thirty (30) calendar days advance notice of any insurance cancellations. Please email to: The SHIBA program coordinator, Sam Stones, at Sams@solid-ground.or or mail to: Solid Ground Attn: SHIBA Coordinator 1501 N 45th St Seattle, WA 98103 This MOU will remain in effect for 2 years. It may be amended, in writing, at any time with concurrence of both parties. It may also be ended by either party with 30 days written notice. Your agency representative who will serve as liaison with SHIBA/Solid Ground and who will be responsible for volunteer supervision is: Name: David Schmidt Title: Senior Services Coordinator E-mail: david.schmidt@cityoffederalway.com Phone: 253-835-6925 ******************************************************************* Signature: le 'V Zj Title of Partn rganization R pr tative: Date: J��4WVLI__ Volunteer Services Manaeer. Solid Ground _ Signature & Title of SHIBA Program Representative Date 5 312/23, 9:32 AM Corporations and Charities System ,i7 irss fyffit.*nd Charities Filing System BUSINESS INFORMATION Business Name: SOLID GROUND WASHINGTON UBI Number: 600147 686 Business Type: WA NONPROFIT CORPORATION Business Status: ACTIVE Principal Office Street Address: 1501 N 45TH ST, SEATTLE, WA, 98103-6708, UNITED STATES Principal Office Mailing Address: 1501 N 45TH ST, SEATTLE, WA, 98103-6708, UNITED STATES Expiration Date: 07/31/2023 Jurisdiction: UNITED STATES, WASHINGTON Formation/ Registration Date: 07/25/1974 hftps:Hccfs.sos.wa.gov/#/BusinessSearch/Businesslnformation 1/3 3/2/23, 9:32 AM Corporations and Charities System PERPETUAL SOCIAL SERVICES zi 23-7421892 0 0 ❑■ i0 REGISTERED AGENT INFORMATION SHALIMAR GONZALES Period of Duration: Inactive Date: Nature of Business: Charitable Corporation: Nonprofit EIN: Most Recent Gross Revenue is less than $500,000: Has Members: Public Benefit Designation: Host Home: Registered Agent Name: https://ccfs.sos.wa.gov/#/BusinessSearch/Businessinformation 2/3 312/23. 9:32 AM Corporations and Charities System 1501 N 45TH ST, SEATTLE, WA, 98103-6708, UNITED STATES 1501 N 45TH ST, SEATTLE, WA, 98103-6708, UNITED STATES GOVERNORS Title Governors Type GOVERNOR INDIVIDUAL GOVERNOR INDIVIDUAL Back Entity Name First Name SHALIMAR SHELLY Fili ng History I I ame Hi story Street Address: Mailing Address: Last Name GONZALES HOLMES PARRISH Print I Return to Business Search hops://ccfs.sos.wa.dov/#/BusinessSearch/Businessinformation 3/3 3/2/23, 9:28 AM Washington State Department of Revenue Washington State Department of Revenue < Business Lookup License Information: Entity name: SOLID GROUND WASHINGTON Business name: SOLID GROUND Entity type: Nonprofit Corporation UBI #: 600-147-686 Business ID: 001 Location ID: 0001 Location: Active Location address: 1501 N 45TH ST SEATTLE WA 98103-6708 Mailing address: 1501 N 45TH ST SEATTLE WA 98103 0 New search Back to results hftps://secure.dor.wa.gov/gteunauth/_/#13 1 /3 3/2/23, 9:28 AM Excise tax and reseller permit status: Secretary of State status: Endorsements Endorsements held at this la License # Federal Way Nonprofit Business Washington State Department of Revenue Click here Click here Count Details Status Expiration date First issuance date Active Oct-31-2023 Nov-04-2022 Governing People May include governing people not registered with Secretary of State Governing people GONZALES, SHALIMAR HOLMES PARRISH, SHELLY Registered Trade Names Registered trade names Status First issued SOLID GROUND Active 0ct-09-2006 View Additional Locations https://secure.dor.wa.gov/gteunauth/_/#1 3 2/3 3/2/23, 9:28 AM Washington State Department of Revenue The Business Lookup information is updated nightly. Search date and time: 3/2/2023 9:28:41 AM Contact us How are we doing? Take our survey! Don't see what you expected? Check if your browser is supported https://secure.dor.wa.gov/gteunauth/_/#1 3 3/3 Insurance Authority P.O. Box 88030 Tukwila, WA 98138 Plione: 206-575-6046 Fax: 206-575-7426 4/18/2023 ROM 14591 www.wciapool.org Solid Ground SHIBA Attn: Sam Stones, Coordinator 1501 N 45th St Seattle, WA 98103 Re: City of Federal Way Volunteer Services Evidence of Coverage The City of Federal Way is a member of the Washington Cities Insurance Authority (WCIA), which is a self -insured pool of over 160 public entities in the State of Washington. WCIA has at least $4 million per occurrence limit of liability coverage in its self -insured layer that may be applicable in the event an incident occurs that is deemed to be attributed to the negligence of the member. Liability coverage includes general liability, automobile liability, stop- gap coverage, errors or omissions liability, employee benefits liability and employment practices liability coverage. WCIA provides contractual liability coverage to the City of Federal Way. The contractual liability coverage provides that WCIA shall pay on behalf of the City of Federal Way all sums which the member shall be obligated to pay by reason of liability assumed under contract by the member. WCIA was created by an interlocal agreement among public entities and liability is self -funded by the membership. As there is no insurance policy involved and WCIA is not an insurance company, your organization cannot be named as an additional insured. Sincerely, Rob Roscoe Deputy Director cc: Ryan Call