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L 'f N A <br />HEALTHCARE <br />CONFIDENTIAL & PROPRIETARY <br />TRANSMITTED BY EMAILIFAX TO: <br />Britta Cantu / britta.cantu.sh@co.kittitas.wa.us <br />September 17, 2025 <br />County of Kittitas dba Kittitas County <br />205 W 5' Ave, Suite 105 <br />Ellensburg, WA 98926 <br />Interim Period Reimbursement (Single Case Rate) Agreement <br />Provider Name: <br />Kittitas County dba Kittitas County Sheriff's Office - Jail <br />Line of Business: <br />Medicaid <br />Dates of Service: <br />07/01/2025 through 06/30/2026 OR until such time a Provider Services Agreement is <br />executed between Provider and Molina Healthcare; whichever occurs first. <br />Type of Services: <br />Reentry Initiative Services <br />Dear Provider: <br />This letter is to serve as an interim period reimbursement rate agreement ("Agreement") between Molina <br />Healthcare of Washington, Inc. (Molina Healthcare or Health Plan) and County of Kittitas dba Kittitas County / <br />TIN# 91-6001349 ("Provider") for the Type of Services listed above (hereafter "Covered Reentry Initiative <br />Services"), to specific Molina Healthcare members ("Members"). Molina Healthcare shall pay Provider for <br />Covered Reentry Initiative Services that Provider provides to Molina Members in accordance with applicable law, <br />regulations and the applicable Molina billing and claims policies and procedures, pursuant to the Health Care <br />Authority's ("HCA") rates set forth below. By execution of this Agreement, Provider agrees to accept the rate(s) <br />listed below as payment in full for these services and shall not balance bill the Members for Covered Reentry <br />Initiative Services. <br />1. Reimbursement Rate and Agreements: <br />1.1 Covered Reentry Initiative Services shall be paid at 100% of the prevailing local and geographically <br />adjusted State of Washington Medicaid Fee -For -Service Program fee schedule in effect on the date of <br />service. <br />1.2 This Agreement only covers reimbursement for Covered Reentry Initiative Services. The term "Covered <br />Reentry Initiative Services" refers to Reentry services, as defined by HCA in the Reentry Initiative Policy <br />and Operations Guide and included in the Apple Health Reentry Initiative Covered Procedure Code List. <br />1.3 Provider shall promptly submit to Health Plan claims ("Claims") for Covered Reentry Initiative Services <br />rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Health Plan <br />and shall include any and all medical records pertaining to the Claim if requested by Health Plan or <br />otherwise required by Health Plan's policies and procedures. Claims must be submitted by Provider to <br />Health Plan within three hundred sixty-five (365) days of providing the Covered Reentry Initiative <br />Services that are the subject of the claim. Except as otherwise provided by law or provided by <br />government sponsored program requirements, any Claims that are not submitted by Provider to Health <br />Plan within the timelines stated above shall not be eligible for payment, and Provider hereby waives any <br />right to payment, therefore. <br />MHWCBHSSCA.082025 Revised Aug2025 (MHW) Page I of 12 <br />