HomeMy WebLinkAboutAgreements/Contracts - GRIS (002)K20-037
Supported Living / Group Home -Exhibit C
July 1, 2019 - June 30, 2020
Revision #: 200201
Grant County 200012501 1963-57191 1N 1/24/20 13
Contractor Name Provider P1 ID Contract No. Region Process Date No. of Clients (excluding SSP funded)
The undersigned hereby affirm that the following are the agreed upon number of clients and reimbursement rates associated with the indicated contract and contract period. This
rate sheet revision supersedes all previous rate sheets as of the effective date.
Contractor Signature
2`t alb
Date Signed
DSHS Regional Administrator or Designee uate z>Ignea
Grant County
Revision #: 200201
FEB j 3 2020
CCtie4 YCORllM1,Slfl�`FRS
Page 1 of 2
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Rate
Prof Svs
Prof Svs
ISS Prof
CRST
ISS Hold
Harmles
Total ISS
Daily
Admin
Admin
Hold
Admin
CRST Tier
Cert
Transp.
Other
Non-
Total
Non4SS
Total
Daily
P1
Service
Revision
Program
Effective
ISS Tier
ISS Daily
Prof Svs
Hrly Rate
Prof Svs
Hrly Rate
Svs Daily
ISS
fer Rate
Rate
Rate
Rate
ISS
Dail
Rate
#
Name
Client Name
Client P1 ID
Date
Rate
Tier Rate
Hrs PCD 1
1
Hrs PCD 2
2
Rate
Tier Rate
s Rate
Rate
SA716-
GRANT
COUNTY -
$0.00
0.00
$0.00
$0.00
$1.16
$11.36
$75.08
$22.64
$2.25
$0.28
$2.36
$4.54
$0.00
$32.07
$107.15
3603
2002
DIRECTIONS
100195167WA
01/01/2020
1
$62.56
0.00
SA716-
GRANT
COUNTY -
0.00
$0.00
$0.00
$6.02
$11.36
$343.05
$41.36
$2.25
$1.51
$2.36
$4.54
$0.00
$52.02
$395.07
3603
20020
DIRECTIONS
100325622WA
01/01/2020
4
$325.67
0.00
$0.00
GRANT
SA716-
COUNTY-
DIRECTIONS
100388693WA
01/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$11.36
$75.08
$22.64
$2.25
$0.28
$2.36
$4.54
$0.00
$32.07
$107.15
3603
20020
GRANT
SA716-
COUNTY-
DIRECTIONS
100388695WA
01/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$265.56
$39.87
$2.25
$1.16
$2.36
$5.68
$0.00
$51.32
$316.88
3603
200
GRANT
SA716-
COUNTY-
DIRECTIONS
100420644WA
02/01/2020
5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$11.36
$425.70
$45.54
$2.25
$1.88
$2.36
$4.54
$0.00
$56.57
$482.27
3603
200201.
GRANT
SA716-
COUNTY-
DIRECTIONS
100460423WA
01/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$11.36
$75.08
$22.64
$2.25
$0.28
$2.36
$4.54
$0.00
$32.07
$107.15
3603
20
GRANT
SA716-
COUNTY-
DIRECTIONS
100598316WA
01/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$265.56
$39.87
$2.25
$1.16
$2.36
$4.54
$0.00
$50.18
$315.74
3603
200
GRANT
1$265.56
SA716-
COUNTY -
DIRECTIONS
100783401WA
01/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$39.87
$2.25
$1.16
2.36
$5.68
$0.00
$5 1.32
$316.88
3603
20
GRANT
SA716-
COUNTY-
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6.02
$11.36
343.05
1.36
$2.25
$1.51
2.36
$4.54
0.00
$52.02
$395.07
3603
200
DIRECT, Ns
t0o807715WA
01/01/2020
Grant County
Revision #: 200201
FEB j 3 2020
CCtie4 YCORllM1,Slfl�`FRS
Page 1 of 2
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Program
Name
Client Name
Client P1 ID
Rate
Effective
Date
ISS Tier
Rate
ISS Daily
Tier Rate
Prof Svs
Hrs PCD 1
Prof Svs
Nrly Rate
1
Prof Svs
Hrs PCD 2
Prof Svs
Hrly Rate
2
ISS Prof
Svs Daily
Rate
ISS CRST
Tier Rate
ISS Hold
Harmles
s Rate
Total ISS
Daily
Rate
Admin
Tier Rate
Admin
Hold
Admin
CRST Tier
Rate
Cert
Rate
Transp.
Rate
Other
Non-
ISS
Total
Non -ISS
Daily
Total
Daily
Rate
P1
Service
Revision
p
GRANT
COUNTY-
DIRECTIONS
100859024WA
01/01/2020
5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
1 $11.36
$425.70
1 $45.54
$2.25
1 $1.88
$2.36
1 $5.68
$0.00
1 $57.71
$483.41
SA716-
1 3603
1200200
GRANT
COUNTY-
DIRECTIONS
100867261 WA
01/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$265.56
$39.87
$2.25
$1.16
$2.36
$4.54
$0.00
$50.18
$315.74
SA716-
1 3603
200200
GRANT
COUNTY-
DIRECTIONS
101158242WA
01/01/2020
2
$161.67
0.00
$0.00
0.00
$0.00
$0.00
$2.99
$11.36
$176.02
$37.86
$2.25
$0.75
$2.36
$4.54
$0.00
$47.76
$223.78
SA716-
3603
200200
GRANT
COUNTY -
DIRECTIONS
102327903WA
01/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$265.56
$39.87
$2.25
$1.16
$2.36
$4.54
$0.00
$50.18
$315.74
SA716-
3603
200200
Grant County Revision #: 200201 Page 2 of 2