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D. By November 30 of each year:Provider agrees to submit,electronically via email,the Excel version of <br /> the cost report accompanied by a signed PDF copy of the annual GEMT participation agreement and <br /> cost report for the prior fiscal year ending June 30,to: HCAGEMTAdmin@hca.wa.gov. <br /> E. Provider agrees to accept as payment in full the reimbursement received for services subject to <br /> supplemental reimbursement pursuant to this agreement.Under no circumstances will the total <br /> amount of reimbursement received exceed one hundred percent of actual care costs.As such,if the <br /> provider does not have any uncompensated care costs,the provider will not receive a supplemental <br /> payment under this program. <br /> F. Provider agrees that when it is determined that they received federal funds in excess of their <br /> determined cost per transport,the state shall recover the excess in accordance with state and federal <br /> regulations within 30 calendar days.The Washington State Health Care Authority(HCA) is not <br /> responsible for the compliance costs of the GEMT providers. <br /> G. Provider agrees to reimburse HCA an administrative fee for all costs associated with the <br /> implementation and administration of the GEMT Program.The fee is based on the number of <br /> transports provided during the service period (July 1 through June 30)and cannot be included as a <br /> reported expense on the provider's annual cost report. <br /> The undersigned hereby warrants that: <br /> • They have the requisite authority to enter into this agreement on behalf of <br /> The City of Everett (provider) and thereby bind the above named <br /> provider to the terms and conditions of the same,and <br /> • The information provided in support of this agreement is true and correct and that the undersigned <br /> understands that HCA is relying on the truthfulness and accuracy of the information presented. <br /> Provi.erAuthorized Representative's Signature <br /> Cassie Franklin APPROVED AS TO FARM <br /> Print Name <br /> JAMES D.ILES,City Attorney <br /> Mayor <br /> Title <br /> 2930 Wetmore Ave, Suite 10 <br /> Street Address <br /> Everett, WA 98201 <br /> City,State and Zip <br /> January 24, 2018 <br /> Date <br /> AP ROVED AS 0 FOR AT STe <br /> 4144.14114 <br /> JAMES D,ILES,City Attorney City Clerk <br />