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AMENDMENT #5 TO
BEACON FACILITY AGREEMENT
This fifth amendment ("Amendment') amends the Beacon Facility Agreement ("Agreement') entered into by Beacon Health
Options, Inc, ("Beacon") and Grant Integrated Services ("Facility"). Unless otherwise defined herein, all capitalized terms used
in this Amendment shall have the same meaning as set forth in the Agreement.
WHEREAS, the Agreement permits amendments to the Agreement by Beacon and Facility; and
WHEREAS, Beacon and Facility desire to amend the Agreement to make certain changes to it.
NOW, THEREFORE, in consideration of the promises and mutual covenants contained herein and other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, the Agreement is hereby amended as follows,
effective January 1, 2020:
1. Exhibit B -2.A4 Maximum Contract Amounts is removed and replaced with Exhibit B -2.A5 Maximum Contract Amounts,
to add $20,000 from the Dedicated Marijuana Account fund source and add $35,500 from the Substance Abuse Block
Grant fund source.
2. This Amendment shall be effective upon the date set forth by Beacon following signature by both Beacon and Facility.
3. Except as amended herein, all other terms and conditions of the Agreement shall remain in full force and effect without
modification.
4. Scope of work pursuant with contract terms between Beacon and Health Care Authority as dictated in contract
amendment dated January 1, 2020.
Facility: Grant Integrated Services
Address: 840 E. Plum, Moses Lake, WA 98837
NPI: 1689677833, 1982792537
B H O -F -COM -MA -MCD/ 11 /2015
(AG — VO STD FACILITY)
Page 1 of 6
DocuSign Envelope ID: E5CCCD24-B961-4574-8A4E-D439C0935A5F
Intending to be legally bound the parties have caused their authorized representatives to execute this Agreement
effective as of the date set forth by Beacon below.
Facility:
Beacon Health Options, Inc.:
DocuSig ned by:
-
3/6/2020
Signature Date Signa ure Date
Melissa Nichols
QGL, SVP, Network Performance & Planning
Print Name & Title Print Name & Title
Federal Tax Identification Number
Address for Notice: Address for Notice:
Beacon Health Options, Inc.
P,O. Box 41055
Norfolk, VA 23541-1055
Attn: National Provider Network Operations
Please do NOT write below this line. For Beacon office use ONLY.
January 1, 2020
EFFECTIVE DATE
Negotiated by: Karen Black
Print Name
Contract Development Manager
3/6/2020
Date Received by Beacon
Please check if included: ❑
011
B HO-F-COM-MA-MCD/11 /2015
(AG - VO STD FACILITY)
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Exhihit R -2 -AS
Maximum Contract Amounts
Beacon shall have no obligation to pay for costs or claims in excess of the amounts listed below for the identified periods, unless
this Exhibit is amended pursuant to the terms of the Agreement.
I: Definitions.
(1) Payment Types:
a. Capacity means the Facility will submit monthly invoices to Beacon for 1/12 of the annual contract maximum and
will also submit encounters to document any direct services provided. Encounters must be submitted within
timely filing limits.
b. Cost Reimbursement means the Facility will submit monthly invoices to Beacon for actual costs to be reimbursed
and will also submit encounters to document any direct services provided. Encounters must be submitted within
timely filing limits.
c. Fee for Service (FFS) means the Facility will submit clean claims within timely filing limits to receive payment for
direct services provided. Claims should be submitted with the rate on the rate schedules in this contract.
II: Maximum Contract Amounts,
(1) The following tables outline the maximum amounts funded under this contract for the stated period.
Table 1
Maximum Contract Amounts 07101/2019 —1213112019
Program or Service
Exhibit
Funding Source
Fund
payment Type
Contract
Code
Maximum
Mobile Crisis and
State General Fund
$212,570
Designated Crisis
B-4
NWRF
Capacity
Responder Services
Medicaid
$287,430
Mental Health Block Grant
Cost
$55,000
Mobile Outreach Team
B-10
N/A
Reimbursement
State General Fund
$10,000
Substance Use
B-11
FFS
$10,000
Disorder Services
Substance Abuse Block
Grant
NWSA
Mobile Outreach Team
Addendum to
Cost
$20,000
Peer Support Specialist
B-11
Reimbursement
Residential Beds Start-
B-20
ESSB 5883
N/A
Cost
$135,000
up Funds
Reimbursement
Total Maximum Amount Funded This Period
$730,000
B H O -F -COM -MA -MCD/ 1112015
(AG — VO STD FACILITY) Page 3 of 6
Table 2
Maximum Contract Amounts 01101/2020 — 0613012020*
Program or Service
Exhibit
Funding Source
Fund
Code
payment Type
Contract
Maximum
Mobile Crisis and
State General Fund
$212,570
Designated Crisis
B-4
NWRF
Capacity
Medicaid
$287,430
Responder Services'
Mental Health Block Grant
$55,000
Substance Abuse BlockGrant
$26,000
Mobile Outreach Team
B-10
NIA
SABG
State General Fund
Cost
Reimbursement
$10,000
Certified Mental Health
Professional with
Dedicated Marijuana
N/A
$20,000
Chemical Dependency
B-1 1
Account
Certification
Substance Use
FFS
$19,500
Disorder Services
SABG
NWSA
Mobile Outreach Team
Addendum to
Cost
$20,000
Peer Support Specialist
B-11
Reimbursement
Total Maximum Amount Funded This Period
$650,500
* Contingent upon Beacon's receipt of signed HCA Amendment confirming funding for this period.
III. Performance Incentives.
(1) Designated Crisis Responder and Mobile Crisis Outreach Team
a. Upon achievement of the performance targets in Table 3 below, the Facility is eligible to earn up to $12,500 in
quality bonus payments semiannually (up to $25,000 per year).
b. The incentive payments will be paid proportionately to their achievement. For example, if Facility achieves all
five, then the entire $12,500 is paid semiannually. If Facility achieves three, then $7,500 (3/5 X $12,500) is paid,
etc.
c. These bonus payments are in addition to the Contract Maximums in the Tables 1 and 2 above.
B H O -F -COM -MA -MCD/ 11 /2015
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Table 3
Designated Crisis Responder and Mobile Crisis Outreach Team
07/01/2019 — 06/30/2020
Performance Metric
Definition
Measurement Data and Source
Facility will execute 18 interagency agreements
with key organizations documenting provisions of
crisis response to include ITA process or
mobile crisis intervention including an outline
of roles and responsibilities and workflows
• Key law enforcement agencies (e.g.,
Ephrata Police Department, Grant
July 1, — December 31, 2019:
County Sheriff, Moses Lake Police
Execution of 25% of interagency
Department, Quincy Police Department,
agreements and MOUs
Interagency agreements
Soap Lake Police Department,
and MOU's
Washington State Patrol -Grant County)
January 1, —June 30, 2020;
• Grant County Jail
Execution of 90% of interagency
• Hospitals (e.g., Samaritan, Columbia
agreements and MOUs
Basin, Quincy Valley, Coulee Medical)
• Schools (e.g., Royal SD, Ephrata SD,
Quincy SD, Warden SD, Moses Lake
SD, Wahulke SD, Wilson Creek SD,
Coulee-Hartline SD)
• Crisis Triage and Stabilization Facility
(ABHS Parkside)
Upon receiving requests for response, DCR or
MCI will triage request within 15 minutes and
respond in person within 90 minutes of receiving
request
Measurement will be based on
Time of Response
July 1, — December 31, 2019:
management report provided by Facility
70% of mobile crisis interventions will be in
on a semiannual basis.
the designated time period.
January 1, —June 30, 2020:
75% of mobile crisis interventions will be in
the designated time period.
At least 50% of all mobile crisis interventions
# of H2O11 encounters with a place of
Community-based
will be conducted in the community outside of
service code excluding office/Community
mobile crisis
the office/Community Mental Health Center, ED
Mental Health Center, ED and hospital/
interventions
or hospital setting.
total H201 encounters
Facility will provide 7 day follow up services as
means of supporting individuals in resolution of
crisis.
July 1, — December 31, 2019:
Measurement will be based on service
Enrollment 7 day follow-
Enrollment in 7 -day follow-up of 40% individuals
encounter submission and provider
up
provided with mobile crisis outreach
medical record reporting
January 1, — June 30, 2020:
Enrollment in 7 -day follow-up of 80% individuals
provided with mobile crisis outreach
B H O -F -COM -MA -MCD/ 1112015
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Performance Metric Definition Measurement Data and Source
When responding outside of the ED or hospital
setting, the second person on the mobile crisis
interventions team will be an individual with Measurement will be based on service
Peer -based Mobile lived experience. encounter submission and provider
Crisis Intervention medical record reporting (H0038 and/or
January 1, — June 30, 2020: use of HK modifier)
60% of mobile crisis interventions include a
peer as the second responder
BHO-F-COM-MA-MCD/11 /2015
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