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HCA Contract No.: K1407 ....-,,,,,_., Wa shington State uth ority -., CONTRACT Amendment No.: 02 Hea lth Care AMENDMENT THIS AMENDMENT TO THE CONTRACT is between the Washington State Health Care Authority and the party whose name appears below, and is effective as of the date set forth below . CONTRACTOR NAME CONTRACTOR doing business as (DBA) Kittitas County Health Department CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS IDENTIFIER 507 N. Nan um Street, Suite 102 (UBI) Ellensburg, WA 98926 /9:J--tJo'J.0 73 WHEREAS, HCA and Contractor previously entered into a Contract to support Medicaid related outreach and linkage activities performed by Local Health Jurisdictions (LHJ) to Washington State residents who live within its jurisdiction, and; WHEREAS, HCA and Contractor wish to amend the Contract to identify the HCA Contract Manager in Section 2.4 -Contract Manager Contact Information; update the administrative fee requirements in Section 6.0 -Administrative Fee; and update the overpayment requirements in Section 7 Timely Filing and Overpayment Requirements as follows: NOW THEREFORE, the parties agree the Contract is amended as follows : 1. Section 2.4 Contract Manager Contact Information. The Contract Manager for HCA, is amended to read as follows: Name: Title: Address : Email: Phone : Jon Bragger Program Manager PO Box45506 Olympia, WA 98501 jon.brogger@hca.wa.gov (360) 725-1647 2. Statement of Work Section 6 Administrative Fee. This section is replaced in its entirety to read as follows: HCA charges MAC contractors an administrative fee to offset HCA's costs for the administration of the MAC program. The rate is based on the costs associated with the staff effort spent on MAC related work for an entire State Fiscal Year (SFY) and is billed as a line item on the quarterly claim form A-19-1A submitted by the MAC contractor. This cost is divided by the dollar amount of administrative claims submitted by the participating contractors in the MAC program for the same SFY. The calculated rate is used on the claims for the subsequent SFY. At the end of the period, the rate used will be validated using the actual claimed expenditures for that period and any variances will be settled with the contractor during the second quarter of the new SFY. HCA Contract No. K1407-02 Page 1 of 2