FLSA State Share Payments

  • Attestation is also available in Portable Document Format (PDF)

Attachment 5

NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS

CONSUMER DIRECTED FISCAL INTERMEDIARY

Attestation of Compliance with Fair Labor Standards Act (FLSA) Funding

I hereby attest that funding for all Medicaid consumer directed personal assistance services provided by my organization in accordance with the Department´s April 2017 Dear Colleague Letter on FLSA implementation, will be passed through to the consumer directed worker, in its entirety. I further certify that I will maintain all records necessary to verify compliance with this directive (including this attestation and related information) for a period of no less than ten years from the end of the applicable calendar year; and that such records will be subject to audit by the Department and/or its agents for possible retroactive recoupment of Medicaid payments for services that are determined to be in less than full compliance.

In addition, I will provide the managed care organization, if applicable, and/or the Department (when applicable) with all information to verify my compliance with the terms of this directive (including this attestation) and that such information shall be made available to the Department upon request.

Please check the appropriate box:



Name of FI ____________________________________________________________________________________

MMIS No. (Medicaid ID)________________________ Date ______________________________________________

Signature ______________________________________________________________________________________

Name (Please Print) ______________________________________________________________________________

Title (Please Print) ________________________________________________________________________________

The following individuals may sign this attestation:

Proprietary Sponsorship – Operator/ Owner

Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or any Member of the Board of Directors


Please note that the Department reserves the right to request additional information in the future to ensure compliance with terms of the April 2017 Dear Colleague Letter on FLSA implementation.