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Washington State PROFESSIONAL SERVICES <br />Health Care Athority CONTRACT for HCA Contract Number: K3069 <br />MEDICAID ADMINISTRATIVE <br />CLAIMING <br />THIS CONTRACT is made by and between Washington State Health Care Authority, (HCA) and Kittitas <br />County Health Dept., (Contractor). <br />CONTRACTOR NAME <br />HCA DIVISION/SECTION <br />MPOI/CS <br />CONTRACTOR DOING BUSINESS AS (DBA) <br />Kittitas County Health Dept. <br />PRINTED NAME AND TITLE <br />Health Care Authority <br />Jon Brogger <br />CONTRACTOR ADDRESS I Street <br />City <br />State <br />Zip Code <br />507 N. Nanum Street, Suite 102 <br />Ellensburg <br />WA <br />98926 <br />CONTRACTOR CONTACT <br />CONTRACTOR TELEPHONE <br />CONTRACTOR E-MAIL ADDRESS <br />Liz Whitaker <br />1 (509) 962 7068 <br />liz.whitaker@co.kittitas.wa.us <br />Is Contractor a Subrecipient under this Contract? <br />CFDA NUMBER(S): FFATA Form Required <br />®YES ❑NO <br />93.778; <br />®YES [-]NO <br />HCA PROGRAM <br />Medicaid Administrative Claiming (MAC) <br />HCA DIVISION/SECTION <br />MPOI/CS <br />HCA CONTACT NAME AND TITLE <br />HCA CONTACT ADDRESS <br />PRINTED NAME AND TITLE <br />Health Care Authority <br />Jon Brogger <br />626 8th Avenue SE <br />Medical Assistance Program Specialist <br />PO Box 45506 <br />Olympia, WA 98504-5506 <br />HCA CONTACT TELEPHONE <br />HCA CONTACT E-MAIL ADDRESS <br />(360) 725-1647 <br />jon.brogger@hca.wa.gov <br />CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT AMOUNT <br />January 1, 2019 December 31, 2020 1 No Maximum <br />PURPOSE OF CONTRACT. <br />The purpose of this Contract is to support Medicaid related outreach and linkage activities performed by Local Health <br />Jurisdictions (LHJ) to Washington State residents who live within its jurisdiction. These activities assist residents who <br />have no or inadequate medical coverage, and includes explaining the benefits of the Medicaid program, assisting them <br />in the Medicaid application and renewal processes, and linking them to Medicaid covered services. This Agreement <br />provides a process for partially reimbursing the Contractor for allowable and reasonable expenses associated with the <br />time its staff spend performing Medicaid Administrative Claiming (MAC) activities. <br />The parties signing below warrant that they have read and understand this Contract, and have authority to <br />execute this Contract. This Contract will be binding on HCA only upon signature by HCA. <br />CONTRACTOR SIGNATURE <br />PRINTED NAME AND TITLE <br />DATE SIGNED <br />HCA SIGNATURE <br />PRINTED NAME AND TITLE <br />DATE SIGNED <br />Rev 4/20/2017 <br />