HomeMy WebLinkAboutContract AmendmentHCA 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
3. Statement of Work Section 7 Timely Filing and Overpayment Requirements. This section is
replaced in its entirety to read as follows:
The Contractor must submit invoices for reimbursement to HCA for review and approval within
one hundred twenty (120) calendar days following the end of each Billing Quarter. Upon
approval, the Contractor must submit a signed A 19-1A invoice voucher within thirty (30) calendar
days.
a) Invoices submitted after one hundred twenty (120) calendar days following the end
of the Billing Quarter may result in corrective action.
b) HCA will not offset negative balances against future A 19s. The contractor must
immediately remit a check to HCA for any funds requiring repayment.
c) HCA is not a recovery agent and any overpayments that are at or beyond the one
hundred eighty (180) calendar day mark will be turned over to the Office of
Financial Recovery (OFR).
d) HCA will not seek reimbursement for any invoice received after the 23rd month of
the two-year federal filing deadline.
4. This Amendment will be effective as of the last date of the signature shown below ("Effective
Date").
5. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the
Contract.
6. All other terms and conditions of the Contract remain unchanged and in full force and effect.
The parties signing below warrant that they have read and understand this Amendment and have
authority to execute the Amendment. This Amendment will be binding on HCA only upon signature by
HCA.
HCA Contract No. K1407-02
PRINTED NAME AND TITLE
6 bi ~~ , l~CLu( A,{,vt;u ~,'
PRINTED NAME AND TITLE
Annette Schuffenhauer, Chief Legal Officer
Division of Legal Services
DATE SIGNED
DATE SIGNED
s/s)I~
Page 2 of 2
Kittitas County
Review Form
Grants & Contract Agreement it L(cJ-1-b {
Today's Date
03/23/2018
Fund/Department
116-Public Health
Contract/Grant Information
Agenda Date LJ 17
Contract /Grant Agency: Health Care Authority Amendment #2 (Admatch)
Period Begin Date: 01/01/2017 I I Period End Date: 12/31/2018
Total Grant/Contract Amount: Fee for Service
Grant/Contract Number: K1407
Contract/Grant Summary:
The Healthcare Authority Amendment 2 amends the contract manager information and replaces the
Statement of Work section in original contract.
Recommendation for Board of Health and Board of Health Review on
Date:~~
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM :
Date
Signature of Board of Health member Date
Financial Information
Total Amount$ NO MAX State Funds $ Federal Funds$ NO MAX
Percentage County Funds Matching Funds $ CFDA# 93. 778
In-Kind$
Explain
Is Equipment being purchased? Who owns equipment?
Grant/Contract Review Page 1
New Personnel being hired? I Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County:
Bu dget Information
Budget Amendment Needed? Yes D attach budget form No[] Why not
New Division Created? Included in budget process
Revenue Code 116.612.95.333.93.778-NO MAX
Expense Code
116.612. 95 .Sxxxx
Pass Thro ugh Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review I Has the Prosecutor reviewed this agreement? I Yes D No 0
Cou nty De pa rtments Im pact ed
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature:
Department:
I Date:
Assi gn ment of Trackin g Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
[ Reviewer I Date
Grant/Contract Review Page 2