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Docusign Envelope lD: CEBC6B3C-DFA1-4B6C-AFE8-6A4A634400B6 <br />ExntnrrB-4-A <br />Tnrno P.q.Rrv Hn.Lr,rn BnNnrrr ExcnnNcn <br />RuMsunsuMENT RATES <br />Rates. Subject to the terms of the Agreement, reimbursement rates for Covered Services <br />billed under Facility's federal tax ID number for the Third-Party Benefit Plans listed below <br />shall be the lesser of billed charges or the following, and will be less any applicable Cost <br />Sharing Amounts. <br />A. CHPW-Affiliated "Cascade Care" Public Option Plans: <br />Network Name: CHPW Cascade Care Affiliate Network <br />Inpatient Services: N/A% of Medicare Fee Schedule <br />for all Covered Services described therein; and <br />NiA% of the Washington State Health Care <br />Authority' s ("HCA' s") Apple Health (Medicaid) <br />Fee Schedule for all Covered Services for which <br />no Medicare fee exists. <br />Outpatient Services:N/A% of Medicare Fee Schedule <br />for all Covered Services described therein; and <br />N/A% of the Washington State Health Care <br />Authority' s ("HCA's") Apple Health (Medicaid) <br />Fee Schedule for all Covered Services for which <br />no Medicare fee exists. <br />Professional Services:N/A% of Medicare Fee Schedule <br />for all Covered Services described therein; and <br />N/A% of the Washington State Health Care <br />Authority's ("HCA's") Apple Health (Medicaid) <br />Fee Schedule for all Covered Services for which <br />no Medicare fee exists. <br />B. Non-Affiliated "Cascade Care" Public Option Plans: <br />Network Name: CHPW Cascade Care Non-Affiliate Network <br />Inpatient Services: N/A% of Medicare Fee Schedule <br />for all Covered Services described therein; and <br />N/A% of the Washington State Health Care <br />Authority's ("HCA's") Apple Health (Medicaid) <br />Fee Schedule for all Covered Services for which no <br />Medicare fee exists. <br />1 <br />2021Facitity Exh B4A - 3PHBERates Page 48 of5L Contract #5908 -662684