R2006-103 07-10-06 RESOLUTION NO. R2006-103
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PEARLAND,
TEXAS, AUTHORIZING THE CITY MANAGER OR HIS DESIGNEE TO
ENTER INTO A MUTUAL AID AGREEMENT WITH THE TEXAS
DEPARTMENT OF HEALTH SERVICES.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PEARLAND, TEXAS:
Section 1. That certain Mutual Aid Agreement by and between the City of
Pearland, and the Texas Department of Health Services, a copy of which is attached
hereto as Exhibit "A" and made a part hereof for all purposes, is hereby authorized and
approved.
Section 2. That the City Manager or his designee is hereby authorized to execute
and the City Secretary to attest a Mutual Aid Agreement with the Texas Department of
Health Services.
PASSED, APPROVED and ADOPTED this the 10th day of July, A.D., 2006.
)071.1 4-214-4°
TOM REID
MAYOR
ATTEST:
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Ye NG %ir-T � G, ;-M
Y S,PRETAR
APPROVED AS TO FORM:
041A—:—)`f ell---
DARRIN M. COKER
CITY ATTORNEY
DEPARTMENT OF STATE HEALTH SERVICES
vow EXHIBIT
EDUARDO J.SANCHEZ,M.D.,M.P.H. 'a . 1100 W.49th Street•Austin,Texas 78756
COMMISSIONER 1-888-963-7111 •http://www.dshs.state.tx.us
Memorandum of Agreement For Mutual Aid of Emergency Medical Services
for Public Assistance to Provide Mutual Aid in a Pending or Actual
Disaster Between:
The Department of State Health Services
And
DSHS Licensed EMS Providers
I. PURPOSE
State Missions
The purpose of this Memorandum of Agreement(MOA) is to establish a
mechanism whereby staffed ambulances may be deployed throughout the
state to provide mutual aid in a pending or actual disaster, as a"state
mission." NOTE: It is the intent of DSHS that ambulance firms only
commit their resources to state missions to the extent that their local service
area will NOT experience a significant degradation of service nor will the
provider exceed any of their other contractual obligations during-a disaster
situation and/or normal course of business for the purposes of this MOA
(e.g. contracts to evacuate nursing homes, 911 contracts, etc)
State Facility Evacuation
The purpose of this Memorandum of Agreement(MOA)is to establish a
mechanism whereby staffed ambulances will be placed on a list of
ambulance resources and will be required to respond to State Facilities for
the mission of evacuating the state schools and/or hospital as authorized by
the State Operations Center and/or the Department of State Health Services.
NOTE: It is the intent of DSHS that ambulance firms only commit their
resources to the evacuation of state facilities to the extent that their local
service area will NOT experience a degradation of service nor exceed any of
their other contractual obligations during a disaster situation and/or normal
course of business for the purposes of this MOA(e.g. contracts to evacuate
nursing homes, 911 contracts, etc)
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II. DESCRIPTION
The Department of State Health Services (DSHS) intends to complete Memorandum of
Agreements for Mutual Aid of Emergency Medical Services for Public Assistance with
DSHS licensed Emergency Medical Services (EMS) Providers in order to have
available a sufficient number of ambulances to respond to provide mutual aid in a
pending disaster or actual disaster.
III. ACTIVATION
State Missions
This agreement may be activated only by notification by the Assistant
Commissioner for Regulatory Services or his/her designee to any needed
DSHS Licensed EMS Providers. Activation,pursuant to this MOA, may
occur at any time; day or night including weekends and/or holidays only
after an official written and signed notification of deployment letter has been
sent via fax or email to the DSHS Licensed EMS Provider with the official
deployment packet of documents/forms to be utilized during the mission. If
the DSHS Licensed EMS Providers self-deploys, without proper notification
from DSHS, they will not be eligible for reimbursement through this
Memorandum of Agreement. Upon acceptance of deployment activation,
the DSHS Licensed EMS Provider must have properly staffed ambulances
en route to the designated mission within eight(8)hours from the time they
receive the notification of deployment letter from DSHS. For
reimbursement purposes, the mission will start when the DSHS Licensed
EMS Provider leaves its home area and will conclude at the time it is
demobilized from duties by DSHS.
State Facility Evacuation
This agreement will be activated only by notification by the Assistant
Commissioner for Regulatory Services or his/her designee to DSHS
Licensed EMS Providers who agreed to respond to state facility mission(s).
Activation, pursuant to this MOA,may occur at any time; day or night
including weekends and/or holidays. Activation of deployment will occur
when DSHS.sends an official written and signed notification of deployment
letter via fax or email to the DSHS Licensed EMS Provider along with the
official deployment packet of documents/forms to be utilized during the
mission. DSHS Licensed EMS Providers should not self-deploy to a state
mission. If the DSHS Licensed EMS Providers self-deploy, they will not be
eligible for reimbursement through this Memorandum of Agreement. When
activated, the DSHS Licensed EMS Provider must have properly staffed
ambulances en route to the designated area within three(3)hours from the
time they receive the notification of deployment letter from DSHS. For
reimbursement purposes the mission will start when the DSHS Licensed
EMS Provider leaves its home area and will conclude at the time it is
demobilized from duties.
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IV. RESPONSIBILITIES
State Missions
The DSHS Licensed EMS Provider will be required to comply with the following
during when providing mutual aid in a pending or actual disaster:
1. The DSHS Licensed EMS Provider must have at least twelve(12)months of
experience providing local and/or long distance emergency medical services to
live human beings in the State of Texas.
2. The DSHS Licensed EMS Provider must maintain a business office within the
boundaries of the State of Texas.
3. The DSHS Licensed EMS Provider must adhere and abide by all federal, state
and local laws and must adhere and abide by the Texas Health& Safety Code,
Chapter 773, Emergency Medical Services and the Texas Administrative Code,
Title 25: Health Services, Chapter 157: Emergency Medical Care during the
time of its deployment to provide mutual aid in a pending or actual disaster and
must adhere and abide by all laws and rules at all times.
4. The DSHS Licensed EMS Provider will only respond when notified by the
Assistant Commissioner for Regulatory Services or his/her designee. If the
DSHS Licensed EMS Provider deploys without proper notification(self-deploy)
the Memorandum of Agreement will not be in effect, and the provider will not
be reimbursed.
5. The DSHS Licensed EMS Provider must keep detailed records (utilizing the
DSHS packet of documents/forms) of the services requested and fulfilled, and
provide those records as requested to include,but not limited to:
• Patient Care Records;
• Patient demographics, including patient(s) insurance information;
• A Time Log Record form of activities.
6. The DSHS Licensed EMS Provider must keep all receipts of its expenditures
during deployment.
7. The DSHS Licensed EMS Provider will be required to be self-sufficient for an
undetermined amount of time and should be aware that its staff could be
living in field conditions. The following items are suggested,but not limited to:
• Cell phone and charger;
• Cash and credit cards to purchase fuel and food;
• Extra clothes;
• Extra expendable medical supplies;
• Food and water; and
• Sleeping bags.
8. The DSHS Licensed EMS Provider must ensure that all personnel responding
have proof of their individual DSHS EMS certifications and a form of picture
identification with them at all times.
9. If the DSHS Licensed EMS Provider commits to provide a BLS unit, they must
staff it with a minimum of 2 Texas EMT-Basics.
10. If the DSHS Licensed EMS Provider commits to provide an ALS unit, they must
staff it with a minimum of 1 Texas certified EMT-Basic and 1 Texas certified
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EMT-Intermediate.
11. If the DSHS Licensed EMS Provider commits to provide a MICU unit, they
must staff it with a minimum of 1 Texas certified EMT-Basic and 1 Texas
certified EMT-Paramedic.
12. The DSHS Licensed EMS Provider must bill primary sources of reimbursement,
such as Medicaid, Medicare,private insurances or third party providers before
sending an invoice to DSHS. The DSHS Licensed EMS Provider must submit
proof of denial and proof of payment for each patient that is transported.
State Facility Evacuation
The DSHS Licensed EMS Provider will be required to comply with the following to
provide mutual aid in a pending or actual disaster for state facility mission(s):
1. The DSHS Licensed EMS Provider must respond to the request of DSHS to
evacuate state facilities. By checking the state facility box in the Acceptance of
Agreement section below, it will be obligated to timely respond and deploy
upon receipt of a DSHS notification of deployment letter.
2. The DSHS Licensed EMS Provider must deploy and be en route to the state
facility within three (3)hours from the time they receive the notification of
deployment letter from DSHS.
3. The DSHS Licensed EMS Provider must have at least twelve(12)months of
experience providing local and/or long distance emergency medical services to
live human beings in the State of Texas.
4. The DSHS Licensed EMS Provider must maintain a business office within the
boundaries of the State of Texas.
5. The DSHS Licensed EMS Provider must adhere and abide by all federal, state
and local laws and must adhere and abide by the Texas Health& Safety Code,
Chapter 773 Emergency Medical Services Act and the Texas Administrative
Code, Title 25: Health Services, Chapter 157: Emergency Medical Care during.
the time of a state or federal State of Emergency, mass casualty event or disaster
and must adhere and abide by all laws and rules at all times.
6. The DSHS Licensed EMS Provider will only respond when notified by the
Assistant Commissioner for Regulatory Services or his/her designee. If the
DSHS Licensed EMS Providers self-deploys,without proper notification from
DSHS, they will not be eligible for reimbursement through this Memorandum of
Agreement.
7. The DSHS Licensed EMS Provider must keep detailed records (utilizing the
DSHS packet of documents/forms) of the services requested and received, and
provide those records as requested to include,but not limited to:
• Patient Care Records;
• Patient demographics, including patient(s) insurance information;
• A Time Log Record form of activities.
8. The DSHS Licensed EMS Provider must keep all receipts of its expenditures.
9. The DSHS Licensed EMS Provider will be required to be self-sufficient for an
undetermined amount of time and should be aware that it could be living in
field conditions. The following items are suggested,but not limited to:
• Cell phone and charger;
• Cash and credit cards to purchase fuel and food;
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• Extra clothes;
• Extra expendable medical supplies;
• Food and water; and
• Sleeping bags.
10. The DSHS Licensed EMS Provider must ensure that all personnel responding
have proof of their individual DSHS EMS certifications and a form of picture
identification with them at all times.
11. If the DSHS Licensed EMS Provider commits to provide a BLS unit, they must
staff it with a minimum of 2 Texas certified EMT-Basics.
12. If the DSHS Licensed EMS Provider commits to provide an ALS unit, they must
staff it with a minimum of 1 Texas certified EMT-Basic and 1 Texas certified
EMT-Intermediate.
13. If the DSHS Licensed EMS Provider commits to provide a MICU unit, they
must staff it with a minimum of 1 Texas certified EMT-Basic and 1 Texas
certified EMT-Paramedic.
14. The DSHS Licensed EMS Provider must bill primary sources of reimbursement,
such as Medicaid, Medicare,private insurances or third party providers before
sending an invoice to DSHS. The DSHS Licensed EMS Provider must submit
proof of denial and proof of payment for each patient that is transported.
V. PUBLIC INFORMATION COORDINATION
The EMS providers and DSHS will ensure that local jurisdictions (e.g., regional
medical operations centers (ROMCs); emergency operations centers (EOCs); regional
advisory councils (RACs) are apprised that the provider has voluntarily assigned assets
to State Missions and/or State Facility Evacuations.
VI. FUNDING
• The DSHS Licensed EMS Provider costs related to the implementation of this
agreement will be the responsibility of the DSHS Licensed EMS Provider.
• In the event that the terms of this agreement are activated in response to provide mutual
aid in a pending or actual disaster, the DSHS Licensed EMS Provider may invoice
DSHS as follows:
• Private-Not-For-Profit Providers without paid staff(Volunteer Providers):
• DSHS will reimburse a base rate of$47.92 per hour for response-ready
hours for non-reimbursable(meaning all primary sources of payment,
such as Medicaid, Medicare,private insurances or third party providers
have been attempted to be billed) costs for a Basic Life Support(BLS)
ambulance. NO labor costs will be paid, since volunteer providers do
not pay for staffing.
• DSHS will reimburse a base rate of$54.92 per hour for response-ready
hours for non-reimbursable(meaning all primary sources of payment,
such as Medicaid, Medicare,private insurances or third party providers
have been attempted to be billed) costs for an Advanced Life Support
(ALS) ambulance. NO labor costs will be paid, since volunteer
providers do not pay for staffing.
• DSHS will reimburse a base rate of$57.92 per hour for response-ready
hours for non-reimbursable(meaning all primary sources of payment,
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such as Medicaid, Medicare,private insurances or third party providers
have been attempted to be billed) costs for a Mobile Intensive Care Unit
(MICU) ambulance. NO labor costs will be paid, since volunteer
providers do not pay for staffing.
• Private-Not-For-Profit Providers with paid staff:
• DSHS will reimburse a base rate of$47.92 per hour for response-ready
hours plus actual labor costs plus fringe benefits for non-reimbursable
(meaning all primary sources of payment, such as Medicaid, Medicare,
private insurances or third party providers have been attempted to be
billed) costs for a Basic Life Support (BLS) ambulance.
• DSHS will reimburse a base rate of$54.92 per hour for response-ready
hours plus actual labor costs plus fringe benefits for non-reimbursable
(meaning all primary sources of payment, such as Medicaid, Medicare,
private insurances or third party providers have been attempted to be
billed) costs for an Advanced Life Support(ALS) ambulance.
• DSHS will reimburse a base rate of$57.92 per hour for response-ready
hours plus actual labor costs plus fringe benefits for non-reimbursable
(meaning all primary sources of payment, such as Medicaid, Medicare,
private insurances or third party providers have been attempted to be
billed) costs for a Mobile Intensive Care Unit(MICU) ambulance.
• Private-For-Profit Providers:
• DSHS will reimburse a base rate of$47.92 per hour for response-ready
hours plus actual labor costs plus fringe benefits for non-reimbursable
(meaning all primary sources of payment, such as Medicaid, Medicare,
private insurances or third party providers have been attempted to be
billed) costs for a Basic Life Support(BLS) ambulance.
• DSHS will reimburse a base rate of$54.92 per hour for response-ready
hours plus actual labor costs plus fringe benefits for non-reimbursable
(meaning all primary sources of payment, such as Medicaid,Medicare,
private insurances or third party providers have been attempted to be
billed) costs for an Advanced Life Support(ALS) ambulance.
• DSHS will reimburse a base rate of$57.92 per hour for response-ready
hours plus actual labor costs plus fringe benefits for non-reimbursable
(meaning all primary sources of payment, such as Medicaid, Medicare,
private insurances or third party providers have been attempted to be
billed) costs for a Mobile Intensive Care Unit(MICU) ambulance.
• Municipalities or Governmental Providers:
• DSHS will reimburse a base rate of$47.92 per hour for response-ready
hours plus actual overtime labor costs plus fringe benefits for non-
reimbursable(meaning all primary sources of payment, such as
Medicaid, Medicare,private insurances or third party providers have
been attempted to be billed) costs for a Basic Life Support(BLS)
ambulance.
• DSHS will reimburse a base rate of$54.92 per hour for response-ready
hours plus actual overtime labor costs plus fringe benefits for non-
reimbursable (meaning all primary sources of payment, such as
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Medicaid, Medicare,private insurances or third party providers have
been attempted to be billed) costs for an Advanced Life Support(ALS)
ambulance.
• DSHS will reimburse a base rate of$57.92 per hour for response-ready
hours plus actual overtime labor costs plus fringe benefits for non-
reimbursable(meaning all primary sources of payment, such as
Medicaid, Medicare,private insurances have been attempted to be billed)
costs for a Mobile Intensive Care Unit(MICU) ambulance.
• DSHS has based these rates through experience from the 2005 Hurricane season and the
reimbursement process. A chart describing the breakdown of the rates according to
quantity, line item description,unit of measure and cost of measure is shown in
Appendix A of this document.
• The DSHS Licensed EMS Provider shall timely submit paperwork,
documentation,receipts and an invoice to DSHS after the DSHS Licensed EMS
Provider has been demobilized.
• DSHS will submit a method for submitting the required information after the
mutual aid provided during a pending or actual disaster.
• Based on previous mutual aid during pending and/or actual disasters, DSHS will
require EMS providers to attempt to bill primary sources of reimbursement to
include,but not limited to Medicaid, Medicare, private insurances and third
party providers. The DSHS Licensed EMS Provider must submit proof of
denial and proof of payment to DSHS when they submit an invoice to DSHS.
VII. EFFECTIVE DATE,AMENDMENT AND TERMINATION
This Memorandum of Agreement For Mutual Aid of Emergency Medical Services for
Public Assistance to Provide Mutual Aid in a Pending or Actual Disaster becomes
effective on the date of final signature by DSHS and will remain in effect until
superseded, suspended or terminated by written mutual agreement. Either party
wishing to terminate this agreement shall submit a written notification no less than sixty
(60) days prior to the desired termination date.
VIII. ACCEPTANCE OF AGREEMENT
(Firm Administrator or Firm Owner) commits
(Ambulance Service) to the following Department of State
Health Services Memorandum of Agreement For Mutual Aid of Emergency Medical Services for
Public Assistance to Provide Mutual Aid in a Pending or Actual Disaster.
State Mission #of units Level of units
State Facility Evacuation(Mandatory when called by DSHS)
#of units Level of units
State Facility Evacuation(Mandatory as above) and any subsequent State
Mission(s) #of units Level of units
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Respondent:
Respondent Business Name
Respondent Business Address
Respondent Business Phone Number Fax Number
Respondent Business Email Address
Respondent Business Contact Name and Title
Respondent Business Contact Phone Number(Land or Cell)
Respondent Business Service Area(counties and RAC)
Number of Units available for deployment
Contact Name Signed Printed Name Title Date
2°d Contact Name(if applicable)Signed Printed Name Title Date
Department of State Health Services (DSHS):
Texas State EMS Director or designee Date
Director,Client Services Contract Unit Date
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APPENDIX A
DSHS has based reimbursement rates as follows:
Line Item Unit of Unit of Hourly
Quantity .Description Measure Cost Rate
COSTS FOR BLS UNIT
1 Ambulance per hour $35.00 $35.00
Per Diem -Based on
$35.00 per day per
employee for 2
1 employees per hour $2.92 $2.92
Medical Supplies
Cost- Based on
$240.00 per day per
1 ambulance per hour $10.00 $10.00
$47.92
COSTS FOR ALS UNIT
1 Ambulance per hour $40.00 $40.00
Per Diem -Based on
$35.00 per day per
employee for 2
1 employees per hour $2.92 $2.92
Medical Supplies
Cost- Based on
$288.00 per day per
1 ambulance per hour $12.00 $12.00
$54.92
COSTS FOR MICU UNIT
1 Ambulance per hour $40.00 $40.00
Per Diem -Based on
$35.00 per day per
employee for 2
1 employees per hour $2.92 $2.92
Medical Supplies
Cost-Based on
$360.00 per day per
1 ambulance per hour $15.00 $15.00
$57.92
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Respondent:
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Respondent Btainess Name
Respondent Business Address
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Respo`nd�entiB�usiness Phone Number pp ��, Fax Number
Respondent Bucmes nail ddress
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Responde„ytBust~ness Contact Name anil Title
Respondent Business Contact Phone Number(Land or Cell)
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Respondent Busin s Mee{ rides and RAC)
I _
Number of Units available for deployment
Contact Name Signed Printed Name Title bate
Contact Name(if applicable)Signed, Printed Nsme tide Date
Department of State Health Services (DSHS):
Texas State J MS Direetox or designee Date
Director,Client Services Contract Unit bate
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