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Exhibit A Rate Table <br /> Provider Rate Payment Calculation Payment <br /> Codes <br /> Out-of home in a $10.03 hr <br /> Adult day care center Not to exceed 8 hours in a 24 8177, <br /> (must be contracted Daily = $80.24 hour period. 8277, <br /> with the Area Agency [8 hrs x $10.03] 8377, <br /> on Aging (AAA) Prior approval required to 8777 <br /> authorize more than 8 hours <br /> Camp and other $17.46 hr Community Settings will be <br /> community settings reimbursed at the Contractor's 8177, <br /> providing respite published fee for services 8277, <br /> provided unless the number of 8377, <br /> hours authorized exceeds the 8777 <br /> number of hours of respite <br /> provided. <br /> The maximum rate for one <br /> hour of service $17.46. <br /> Number of respite Hours = <br /> Cost of service (published fee) <br /> $17.46. <br /> Notes: <br /> • Respite and personal care cannot be paid at the same time for the same <br /> service. Respite services include any personal care and supervision that is <br /> needed. <br /> ■ SSPS authorizations will be authorized at an hourly rate. <br /> • A copy of the Contractor's Published Service and Fee Schedule can be <br /> located at the following web site . A printed copy of the Contractor's <br /> Published Service and Fee Schedule shall be maintained in the Contractor's <br /> Contract file for each year services are provided by this Contract. <br /> DSHS Central Contract Services <br /> 1803LP DDD Respite in Community Settings(5-6-11) Page 16 <br />