CN-680000-ME216-A1.pdf

AHCA CONTRACT NO. MED216

AMENDMENT NO. 1

AHCA Contract No. MED216, Amendment No. 1, Page 1 of 1 April 2020

THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency," and FLORIDA MEDICAL SCHOOLS QUALITY NETWORK, INC., hereinafter referred to as the "Vendor," is hereby amended as follows:

1. Attachment VI, IRS Form 990 and Total Executive Compensation Reporting

Requirements, is hereby incorporated into this Contract.

All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.

This Amendment and all its attachments are hereby made a part of this Contract.

IN WITNESS WHEREOF, the Parties hereto have caused this two (2) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

FLORIDA MEDICAL SCHOOLS QUALITY

NETWORK, INC.

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

SIGNED

BY:

SIGNED

BY:

NAME: NAME:

TITLE: TITLE:

DATE: DATE:

List of Attachments included as part of this Amendment:

Specify Type Number Description Attachment VI IRS Form 990 and Total Executive

Compensation Reporting Requirements

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DocuSign Envelope ID: 23A3B8A9-5205-4883-AA99-ACCA4F9EF6E4

5/31/2022

Kelli Kessack

Executive director, FMSQN

Thomas Wallace

5/31/2022

Deputy Secretary of Medicaid

ATTACHMENT VI

IRS FORM 990 AND TOTAL EXECUTIVE COMPENSATION

REPORTING REQUIREMENTS

AHCA Contract No. MED216, Attachment No. VI, Page 1 of 1

The Vendor shall submit to the Agency an annual report, including the most recent IRS Form 990, detailing the total compensation for each member of the Vendor’s executive leadership teams.

Total compensation shall include salary, bonuses, cashed-in leave, cash equivalents, severance pay, retirement benefits, deferred compensation, real-property gifts, and any other payout. In addition, Vendor must inform the Agency of any changes in total executive compensation between the annual reports within sixty (60) days of any change taking effect. All compensation reports must indicate what percent of compensation comes directly from the State and/or Federal allocations to the Vendor.

The annual report must be submitted to the Agency’s Contract Manager and emailed to CATS.Help@ahca.myflorida.com within one hundred and eighty (180) calendar days after the end of the Vendor’s tax year. This requirement shall survive the Contract end date until the final annual report is submitted to the Agency, and the Agency has provided written acceptance of the final annual report. If the Vendor fails to submit the annual report, the Agency will impose liquidated damages, as specified below in Table 1, Performance Standards and Liquidated Damages.

TABLE 1

PERFORMANCE STANDARD AND LIQUIDATED DAMAGE

Performance Standard Requirement Liquidated Damages to be Imposed

Executive Order Number 20-44 Annual Report

The Vendor shall submit an annual report that meets the requirements of this Attachment VI of the Contract.

$100.00 per day for each day past the due date until the annual report is submitted to the Agency.

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DocuSign Envelope ID: 23A3B8A9-5205-4883-AA99-ACCA4F9EF6E4 mailto:CATS.Help@ahca.myflorida.com

MED216 Attachment VI_IRS Form 990 and Annual Reporting Requirements