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AG 16-068IRETURN TO: Jeffrey Watson EXT: 2650 CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: CD /COMMUNITY SERVICES 2. ORIGINATING STAFF PERSON: _JEFFREY WATSON EXT: 2650 3. DATE REQ. BY: 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT ❑ REAL ESTATE DOCUMENT ❑ ORDINANCE ❑ CONTRACT AMENDMENT (AG #): OTHER _MOU WITH ST. FRANCIS HOSPITAL REGARDING 340B PROGRAM AND INDIGENT SUPPORT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ MAINTENANCE AGREEMENT ❑ HUMAN SERVICES / CDBG ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS) ❑ RESOLUTION ❑ INTERLOCAL 5. PROJECT NAME: ST. FRANCIS HOSPITAL MOU REGARDING 340B PROGRAM 6. NAME OF CONTRACTOR: N/A A-. *my\V \g j 4 t ADDRESS: '315157 '? M. S. , ¶QdQtit WIN.i W °Inn TELEPHONE 253 - (O () - 46106' E -MAIL: FAX: SIGNATURE NAME: I TIAST (q�01 � TITLE CAI) T - 7. EXHIBITS AND ATTACHMENTS: ❑ SCOPE, WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS /CERTIFICATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT /AMENDMENTS 8. TERM: COMMENCEMENT DATE: COMPLETION DATE: 9. TOTAL COMPENSATION $ N/A (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑ YES ❑ NO IF YES, $ ❑ PURCHASING: PLEASE CHARGE TO: 10. DOCUMENT /CONTRACT REVIEW ROJECT MANAGER DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) ❑ LAW 11. COUNCIL APPROVAL (IF APPLICABLE) 12. CONTRACT SIGNATURE ROUTING ❑ SENT TO VENDOR/CONTRACTOR ❑ ATTACH: SIGNATURE AUTHORITY, ❑ LAW DEPARTMENT ❑ CHIEF OF STAFF ❑ SIGNATORY (MAYOR OR DIRECTOR) ❑ CITY CLERK ❑ ASSIGNED AG# ❑ SIGNED COPY RETURNED COMMENTS: PAID BY: ❑ CONTRACTOR ❑ CITY Li/_WD •T APP' •VE COMMITTEE APPROVAL DATE: mac_ 3I( !! COUNCIL APPROVAL DATE: 4 DATE SENT: DATE REC'D: INSURANCE CERTIFICATE, LICENSES, EXHIBITS MUTT AL / DATE SIGNED ((lo .0112�(1t1 AG# ilo-01 B DATE SENT: 05 -410 -1(0 lq 11/9 COUNCIL MEETING DATE: April 19, 2016 CITY OF FEDERAL WAY CITY COUNCIL AGENDA BILL ITEM #: 5h SUBJECT: MEMORANDUM OF UNDERSTANDING (MOU) BETWEEN THE CITY OF FEDERAL WAY AND ST. FRANCIS HOSPITAL POLICY QUESTION: Should City Council approve a Memorandum of Understanding (MOU) between the City of Federal Way and St. Francis Hospital regarding the provision of services to the indigent in connection with the Hospital's participation in the Federal 340B discount drug program, and the authorize the Mayor to execute the MOU and related certification? COMMITTEE: PRHSPSC MEETING DATE: 04/12/2016 CATEGORY: Ggl Consent City Council Business ❑ Ordinance ❑ Resolution ❑ Public Hearing ❑ Other STAFF REPORT BY: Jeffrey Watson DEPT: CD Attachments: Memorandum of Understanding (MOU) between the City of Federal Way and St. Francis Hospital, and Certification of Contract St. Francis Hospital desires to participate in the drug discount program established under Section 340B of the Public Health Services Act (the "340B Program "). In order to participate in the 340B Program, St. Francis Hospital must enter into a contract with a unit of state or local government, pursuant to which St. Francis Hospital commits to provide healthcare services to low- income individuals who are not entitled to benefits under Title XVIII of the Social Security Act, nor eligible for assistance under any State plan pursuant to Title XIX of the Social Security Act. Additionally, the City and the Hospital must complete a certification form stipulating that the required contract is in place. Options Considered: 1. Approve the MOU between the City of Federal Way and St. Francis Hospital and authorize the Mayor to execute the MOU and related certification. 2. Do not approve the MOU and provide direction to staff. MAYOR'S RECOMMEND: TION: Option 1 MAYOR APPROVAL: DIRECTOR APPROVAL: CHIEF OF STAFF: ommittee Initial /Date Counc Initial/ nitial/Date COMMITTEE RECOMMENDATION: 1 move to forward the MOU to the April 19, 2016 Council B>xsrness agenda for approval. 'S'S�,.� ,---- Committee Chair) Committee ember Committee mber PROPOSED COUNCIL MOTION: "I move approval of the MOU between the City of Federal Way and St. Francis Hospital and authorize the Mayor to execute the MOU and related certification." (BELOW TO BE COMPLETED BY CITY CLERKS OFFICE) ..RUNCIL ik) APPROVE ❑ DENIED ❑ TABLED/DEFERRED/NO ACTION ❑ MOVED TO SECOND READING (ordinances only) REVISED— 1/2015 COUNCIL BILL # 1ST reading Enactment reading ORDINANCE # RESOLUTION # MEMORANDUM OF UNDERSTANDING BETWEEN ST. FRANCIS HOSPITAL AND THE CITY OF FEDERAL WAY, WASHINGTON THIS MEMORANDUM OF UNDERSTANDING ( "MOU ") is made this jq day of April, 2016, by and between the undersigned representatives of the CITY OF FEDERAL WAY, a Washington Municipal Corporation ( "City "), and ST. FRANCIS HOSPITAL, 34515 9th Avenue South, Federal Way, Washington. RECITALS: WHEREAS, St. Francis Hospital is a Washington not - for - profit hospital that provides a disproportionate share of healthcare services to the Medicare population in addition to supporting many programs that benefit the indigent, uninsured, or underinsured population in the State of Washington; and WHEREAS, St. Francis Hospital desires to participate in the drug discount program established under Section 340B of the Public Health Services Act (the "340B Program "); and WHEREAS, in order to participate in the 340B Program, St. Francis Hospital must enter into a contract with a unit of state or local government, pursuant to which St. Francis Hospital commits to provide healthcare services to low - income individuals who are not entitled to benefits under Title XVIII of the Social Security Act, nor eligible for assistance under any State plan pursuant to Title XIX of the Social Security Act; and WHEREAS, the City of Federal Way and St. Francis Hospital agree that it is in the best interest of Federal Way citizens if St. Francis Hospital continues to provide healthcare services to the Medicare population, the indigent, the uninsured and the underinsured; and WHEREAS, St. Francis Hospital desires to make a formal commitment to the City of Federal Way and its citizens that it will continue to provide these healthcare services; and WHEREAS, the City of Federal Way agrees to accept such commitment on behalf of the Citizens of Federal Way. NOW, THEREFORE, in consideration of the mutual agreements and covenants contained herein and for other good and valuable consideration, the receipt and sufficiency of which hereby are acknowledged, it is mutually agreed and covenanted, by and between the parties to this Agreement, as follows: 1. Commitment of St. Francis Hospital to Provide Indigent Care. Until this MOU is terminated pursuant to Section 4 below, the City and St. Francis Hospital agree that St. Francis Hospital will continue its historic commitment to the provision of healthcare to indigent, uninsured, and underinsured residents in the City. In 2015, this commitment totaled approximately $7 Million in lost charges. Pursuant to this commitment, it is the intention of St. Francis Hospital that indigent care provided during the term of this MOU will range Page 1 of 4 between $5 Million and $7 Million. In any event, St. Francis Hospital will assume that all patients will receive necessary care, as required by law, regardless of ability to pay. 2. Acceptance and Acknowledgement of City of Federal Way. a) The City accepts the commitment of St. Francis Hospital set forth above; b) The City has executed a certification form, attached hereto, which acknowledges that the healthcare services provided by St. Francis Hospital are being provided to low - income individuals who are neither entitled to benefits under Title XVIII of the Social Security Act, nor eligible for assistance under any State plan pursuant to Title XIX of the Social Security Act; and c) The City authorizes St. Francis Hospital to submit the attached certification in support of St. Francis Hospital's application to enroll in the 340B program. 3. Representations of St. Francis Hospital. St. Francis Hospital represents that as of the date of this MOU: a) St. Francis Hospital constitutes a corporation duly organized and validly existing in good standing under the laws of the State of Washington with the corporate power and authority to enter into and perform its obligations under this MOU; b) St. Francis Hospital is a tax - exempt corporation under Section501(c)(3) of the Internal Revenue Code of the United States, as amended and under applicable laws of the State of Washington; and c) The healthcare services St. Francis Hospital provides hereunder are being provided to individuals who are not entitled to benefits under Title XVIII or eligible for assistance under any State plan pursuant to Title XIX of the Social Security Act. 4. Term and Termination. The term of this MOU shall commence on the date written above and shall continue until terminated by either party upon not less than sixty (60) days prior written notice to the other. St. Francis Hospital agrees to notify the City immediately if it ceases to provide the healthcare services committed to under this MOU. This MOU will terminate immediately if St. Francis Hospital ceases to provide the healthcare services committed to under this MOU. The City of Federal Way and St. Francis Hospital reserve the right to immediately terminate this MOU if St. Francis Hospital ceases to be eligible for the 340B Program. 5. Notice. All notices required or permitted to be given under this MOU shall be deemed given when delivered by hand or sent by registered or certified mail, return receipt requested, addressed as follows: Send to: City of Federal Way Attention: Mayor's Office 33325 8t' Ave S Federal Way, WA 98003 Page 2 of 4 Send to: CHI Franciscan Health Attention: Mike Fitzgerald 1145 Broadway, Suite 1200 Tacoma, WA 98402 6. Governing Law. This MOU shall be governed by and construed in accordance with the laws of the State of Washington (excepting any conflict of laws provisions which would serve to defeat application of Washington substantive law). [Signature page follows] Page 3 of 4 IN WITNESS WHEREOF, St. Francis Hospital and the City have executed this Agreement as of the day and year first written above by their duly authorized representatives. CITY OF FEDERAL WAY DATE: OA ST. FRANCIS HOSPITAL By: Printed Name: 4N/6 ,/TZf e Title: CFO DATE: ,9/„q6,7go/ STATE OF WASHINGTON COUNTY OF / ) On this day personally appeared before me /Wen/7664'V, to me known to be the e� — of 3r / actiUC'/S g that executed the foregoing instrument, and acknowledged the said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that he /she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. ) ss. ATTEST: ity erk, Stephanie Courtne" APPROVED AS TO FORM: In( City Attorney, Amy Jo Pearsall GIVEN my hand and official seal this o day of ,,� �, •. `` ': Notary's signature ? .'��4 Notary's printed name �= �TARY =° = a► • f. = Notary Public in and for the State of Washington. PuB.ic SAWS' My commission expires •.,t1.14,'1e... .......... c, • 44 MO. ''S1•,,181..... 1/L ,20/ /9 aeanz6 Page 4 of 4 Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau OMB No. 0915 -0327; Expiration Date: 10/31/2015 OFFICE OF PHARMACY AFFAIRS (OPA) CERTIFICATION OF CONTRACT BETWEEN PRIVATE, NON - PROFIT HOSPITAL AND STATE /LOCAL GOVERNMENT TO PROVIDE HEALTH CARE SERVICES TO LOW INCOME INDIVIDUALS To demonstrate that the hospital meets the statutory definition of covered entity under section 340B(a)(4)(L)(i) as a private non - profit hospital which has a contract with a State or local government to provide health care services to low income individuals, this certification must be completed and signed by both parties. ST. FRANCIS HOSPITAL Name of Hospital 34515 NINTH AVE S, FEDERAL WAY WA 98003 City, State, Zip Pursuant to the requirement of Section 340B of the Public Health Service Act (42 U.S.C. 256b), I certify that a valid contract (DSH500141) is currently in place between the private, non - profit hospital named above, and the State or Local Government Entity named below, to provide health care services to low income individuals who are not entitled to benefits under Title XVIII of the Social Security Act or eligible for assistance under the State plan of Title XIX of the Social Security Act. In addition, the authorizing official certifies that when this contract is no longer valid, appropriate notice will be provided to the Office of Pharmacy Affairs. The undersigned represents and confirms that he/she is fully authorized to legally bind the covered entity an certifies that the contents of any statement made or reflected in this document are truthful and agqurat Signature of Hospital th ' r iz ing Official MIKE FITZGERALD its CFO Name and Title of Authorizing Official (e.g., CEO, CFO, COO) (please print or type) Wai %a/ Date 253 - 680 -4005 Phone Numbex o cal mikefitzgerald @.chifranciscan.org E -Mail Address Government nment Official Name of State or Local Government Official (please print or type) 1110/012.1 C.11-1 � F %¢AL 14Aj WA Title and Unit o Government 333Z ekge. "524-1,44 48 Address 253 - 8=35-2442 J1/$1.PistriEt&. err' offepEPALWAtC Phone Number Ext. E -Mail Address This registration form must be completed and submitted according to the established deadlines that are published on the OPA website (www.hrsa.gov /opa).