FLSA State Share Payments

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

Attachment 1

NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS

MANAGED CARE ORGANIZATION

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

I hereby attest that funding for all Medicaid home care services provided or arranged for by _____________________________ (MCO Name) in accordance with the Department´s April 2017 Dear Colleague Letter on FLSA implementation, will be paid to network providers in whole or in part provided that any unspent funds shall be returned to the Department of Health. I further attest that we have employed a reasonable methodology for the allocation of funding to the appropriate network providers.

Name of MCO _______________________________________________________

National Provider Identifier____________________________ Date _____________

Signature __________________________________________________________

Name (Please Print) __________________________________________________

Title (Please Print) ___________________________________________________

Please note that only the following individuals may sign the attestation form:

Proprietary Sponsorship – Operator/ Owner /Chief Executive Officer

Voluntary Sponsorship – Officer (President, Vice President, Secretary or Treasurer), Chief Executive Officer, Chief Financial Officer or Chairperson of the Governing Board

Public Sponsorship – Public Official Responsible for the Operation of the MCO

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.