SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

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(a) The Health Service is a Medicaid Covered Service when provided in person by Provider; (b) The Medicaid Covered Service is Medically Necessary; (c) The Medicaid Covered Service is a service recognized as an essential health benefit under section 1302(b) of the federal Patient Protection and Affordable Care Act in effect on January 1, 2015, RCW 48.43.005 and 48.43.715; (d) The Medicaid Covered Service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the Medicaid Covered Service meets the standards required by state and federal laws governing the privacy and security of protected health information; and 5.32.4 In accordance with subsection 5.32.3 above, Wellpoint will reimburse Provider for a Medicaid Covered Service provided to a Medicaid Member through telemedicine as provided by Washington law, the same amount of compensation Wellpoint would pay Provider under this Agreement, if the Medicaid Covered Service was provided in person by Provider. 5.32.5 An originating site for a telemedicine Health Service subject to subsection 5.32.3 above includes a: (a) Hospital; (b) Rural Health Clinic; (c) Federally Qualified Health Center; (d) Physician's or other provider's office; (a) Licensed or Certified Behavioral Health Agency; (f) Skilled Nursing Facility; (g) Home or any location determined by the individual receiving the service including, but not limited to, a pharmacy licensed under Chapter 18.64 RCW or a school -based health center as defined in RCW 43.70.825. If the site chosen by the individual receiving service is in a state other than the state of Washington, a provider's ability to conduct a telemedicine encounter in that state is determined by the licensure status of the provider and the provider licensure laws of the other state; or (h) Renal dialysis center, except an independent renal dialysis center. 5.32.6 Provider shall ensure that access to telemedicine Health Services is inclusive for Medicaid Members who may have disabilities or limited English proficiency and for whom the use of telemedicine technology may be more challenging, in accordance with Regulatory Requirements. ARTICLE VI TERMINATION 6.1 Termination of Medicaid Participation Attachment. Either party may terminate this Attachment without cause by giving at least one hundred eighty (180) days prior written notice of termination to the other party. 6.2 Termination of Government Contract. If a Government Contract between the applicable State Agency and Wellpoint terminates, expires or ends for any reason or is modified to eliminate a Medicaid Program, this Attachment shall have no further force or effect with respect to the applicable Medicaid Program. In the event of termination of the Government Contract between Wellpoint and State Agency, Provider shall immediately make available to State Agency, or its designated representative, in a usable form, any or all records, whether medical or financial, related to Provider's activities undertaken pursuant to this Agreement. The provision of such records shall be at no expense to Wellpoint or State Agency. 6.3 Effect of Termination. Following termination of this Attachment, the remainder of the Agreement shall continue in full force and effect, if applicable. In addition, upon termination of this Attachment but subject to the Washington Enterprise Provider Agreement Medicaid Attachment 27 1183932156 ® 2024 July— Wellpoint Washington, Inc. 05/0512025