Washington State Page 1 of 342 Contract #_______
Health Care Authority
Apple Health - Integrated Managed Care 7/1/22
Washington Apple Health
Integrated Managed Care
Contract
HCA Contract Number:
«Contract»
Resulting from Solicitation Number (If
applicable):
THIS CONTRACT is made by and between the Washington State Health Care Authority (“HCA”) and the party whose
name appears below ("Contractor").
CONTRACTOR NAME
«Organization_Name»
CONTRACTOR doing business as (DBA)
CONTRACTOR ADDRESS
«City», «State» «Zip_Code»
WASHINGTON UNIFORM
BUSINESS IDENTIFIER (UBI)
UBI»
HCA INDEX NUMBER
CONTRACTOR CONTACT
«Contact_Fname» «Contact_LName»
CONTRACTOR TELEPHONE
«PhoneNo»
CONTRACTOR E-MAIL ADDRESS
«EmailAddress»
HCA PROGRAM
Medicaid Contracts Unit
HCA DIVISION/SECTION
Medicaid Programs Division/Medicaid Contracts and
Compliance
HCA CONTACT NAME AND TITLE
Johnny Shults
Unit Supervisor
HCA CONTACT ADDRESS
PO Box 45530
Olympia, WA 98504-5502
HCA CONTACT TELEPHONE
360-725-0480
HCA CONTACT E-MAIL ADDRESS
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?
YES NO
CFDA NUMBER(S)
; ; ;
CONTRACT START DATE
January 1, 2020
CONTRACT END DATE
December 31, 2022
PRIOR MAXIMUM CONTRACT AMOUNT
N/A
AMOUNT OF INCREASE OR
DECREASE
N/A
TOTAL MAXIMUM CONTRACT
AMOUNT
Per Member Per Month
PURPOSE OF CONTRACT: Integrated Managed Care (AH-IMC) services to Apple Health Enrollees.
ATTACHMENTS/EXHIBITS. When the box below is marked with an X, the following Exhibits/Attachments are attached and are
incorporated into this Contract by reference:
Exhibit(s) (specify): Exhibit A, IMC Rates; Exhibit A, BHSO Rates; Exhibit B, [intentionally left blank]; Exhibit C, [intentionally
left blank]; Exhibit D, Value-Based Purchasing; Exhibit E, Challenge Pool Value-Based Purchasing Incentives [Removed July
2022]; Exhibit F, Instructions for Medical Loss Ratio (MLR) Reporting; Exhibit G, Data Use, Security and Confidentiality; Exhibit H,
Health Homes; Exhibit I, Regional Service Areas; Exhibit J, RAC Codes; Exhibit K, [intentionally left blank]; Exhibit L, Medicaid
Managed Care Addendum for Indian Health Care Providers (IHCPs); and Exhibit M, Scope of Benefits.
Attachment(s) (specify): Attachment 1, [intentionally left blank]; Attachment 2, HEDIS Performance Measures; Attachment
3, [intentionally left blank]; Attachment 4, Oral Health Connections Pilot; Attachment 5, ABCD Program, Attachment 6, RFP 15-008
–Apple Health – Integrated Managed Care – Southwest Region (incorporated by reference, available upon request); Attachment
7, Contractor’s Response to RFP 15-008 – Apple Health – Integrated Managed Care – Southwest Region (incorporated by
reference, available upon request); Attachment 8 – RFP 1812 – Apple Health – Integrated Managed Care – North Central Region
(incorporated by reference, available upon request); Attachment 9 – Contractor’s Response to RFP 1812 – Apple Health –
Integrated Managed Care –North Central Region (incorporated by reference, available upon request); Attachment 10, RFP 2567,
2019/Integrated Managed Care RFP (incorporated by reference, available upon request); Attachment 11, Contractor’s Response
to RFP 2567 – 2019/2020 Integrated Managed Care RFP (incorporated by reference, available upon request) Attachment 12, RFP
2020HCA5 – 2021 Integrated Managed Care – Expanded Access RFP (incorporated by reference, available upon request); and
Attachment 13, Contractor’s Response to RFP 2020HCA5 – 2021 Integrated Managed Care – Expanded Access RFP
(incorporated by reference, available upon request).
Approval from the federal Centers for Medicare and Medicaid Services (CMS) is required for this Contract. Should CMS fail to
approve, this Contract is null and void. The terms and conditions of this Contract are an integration and representation of the final,
entire and exclusive understanding between the parties, superseding and merging all previous agreements, writings, and
communications, oral or otherwise, regarding the subject matter of this Contract. The parties signing below warrant that they have
read and understand this Contract, and have authority to execute this Contract. This Contract shall be binding on HCA only upon
signature by HCA.
CONTRACTOR SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
HCA SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
THIS DOCUMENT REPRESENTS ALL INCORPORATED AMENDMENTS, EXHIBITS AND ATTACHMENTS FROM
JANUARY 2020 THROUGH AMENDMENT #13. AMENDMENT #13 IS EFFECTIVE July 1, 2022.
