rate-schedule_medicaid_b_non-clinician_04-01-2022 by Vaya Health

Standard Rate Schedule: Medicaid 1915(b) Non-Clinician-Based Q C D E

Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment extended to 06/30/2022 DCW adjustment included EVV adjustment included Revised 04/01/2022

Rate as of 1/1/2022

Service

96138 ‐ PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING 96139 ‐ add on PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING

97157 ‐ Multiple‐family group adaptive behavior treatment guidance H0010 ‐ DETOX‐NON‐HSP‐MED H0012HB ‐ Community Residential Tx‐Adult H0013 ‐ SA Med Mon Community Residential Tx H0014 ‐ AMBULATORY DETOX H0015 ‐ SA IOP H0019HK ‐ HRI L4, BH LT Res H0019HQ ‐ HRI L3, <=4 beds, BH LT Res H0019TJ ‐ HRI L3, 5+ beds, BH LT Res H0019UR ‐ Residential Level IV (5+ Beds) H0020 ‐ Outpatient Opioid Treatment H0035 ‐ MH PARTIAL HOSP, < 24 HR

Rate as of 3/1/2022

Rate as of 4/1/2022

32.64

1.74

Q Q Q Q

$ $ $ $

31.25 53.65 20.00 10.00

$ $ $ $

31.25 53.65 20.00 10.00

$ $ $ $

31.25 53.65 20.00 10.00

$ $ $ $

31.25 53.65 20.00 10.00

28.00

30.00

10.00

$ $ $ $ $ $ $ $ $ $ $

325.58 163.60 253.90 21.25 131.56 393.47 267.81 218.21 342.15 16.60 132.32

$ $ $ $ $ $ $ $ $ $ $

325.58 163.60 253.90 21.25 131.56 393.47 267.81 218.21 342.15 16.60 132.32

$ $ $ $ $ $ $ $ $ $ $

325.58 163.60 253.90 21.25 133.72 393.47 267.81 218.21 342.15 16.60 135.20

$ $ $ $ $ $ $ $ $ $ $

325.58 163.60 253.90 21.25 133.72 368.07 253.62 210.49 342.15 16.60 135.20

96146 ‐ PSYCH OR NEUROPSYCH AUTOMATED TESTING AND RESULT 97151 ‐ Behavior identification assessment 97152 ‐ Behavior identification supporting assessment, tech 97153 ‐ Adaptive behavior treatment by protocol, tech 97154 ‐ Group adaptive behavior treatment by protocol, tech 97155 ‐ Adaptive behavior treatment with protocol modification, QHP 97156 ‐ Family adaptive behavior treatment guidance

Rate as of 2/1/2022

C C D D D D

Standard Rate Schedule: Medicaid 1915(b) Non-Clinician-Based Q C D E

Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment extended to 06/30/2022 DCW adjustment included EVV adjustment included Revised 04/01/2022

H0038 ‐ Peer Support Services (PSS) ‐ individual H0038HQ ‐ Peer Support Services (PSS) ‐ group H0040 ‐ ACTT H004022 ‐ ACTT > 4 events per month H0045HQU4HA ‐ (B3) Child Group Respite H0045HQU4HB ‐ (B3) Adult Group Respite H0045U4HA ‐ (B3) Child Individual Respite H0045U4HB ‐ (B3) Adult Individual Respite H0046 ‐ High Risk Res L1 H2011 ‐ CRISIS SERVICES H2011U4HI ‐ DI Crisis Intervention and Stabilization Supports with Technical Amendment H2012HA ‐ DAY TREATMENT CHILD H2015HQU4 ‐ DI Community Networking ‐ Group

D D

H2015HTHN ‐ CST ‐ QP/AP ‐ Community Support Team H2015HTHO ‐ CST ‐ Team Lead ‐ Community Support Team H2015HTU1 ‐ CST ‐ PSS ‐ Community Support Team H2015U4 ‐ DI Community Networking ‐ Individual H2016HIU4 ‐ DI Level 4‐Residential Supports H2016HIU4U2 ‐ DI Level 4 AFL‐Residential Supports H2016U4 ‐ DI Level 1‐Residential Supports H2016U4U2 ‐ DI Level 1 AFL Residential Supports H2017 ‐ PSYCHOSOCIAL REHAB

Rate as of

$ $ $ $ $ $ $ $ $ $

18.00 4.32 456.27 0.01 5.51 5.51 7.13 7.13 86.25 94.50

$ $ $ $ $ $ $ $ $ $

18.00 4.32 456.27 0.01 5.51 5.51 7.13 7.13 86.25 94.50

$ $ $ $ $ $ $ $ $ $

18.00 $ 4.32 $ 456.27 $ 0.01 $ 5.51 $ 5.51 $ 7.13 $ 7.13 $ 86.25 $ 94.50 $

9.00

$ $

31.41 3.60

$ $

31.41 3.60

$ $

32.13 3.60

$ $

32.13 3.31

38.87

25.91

38.87

26.45

D D D D D D D

$ $ $ $ $ $ $ $ $

38.87 38.87 38.87 6.60 196.12 201.12 121.79 126.79 4.04

$ $ $ $ $ $ $ $ $

38.87 $ 38.87 $ 38.87 $ 6.60 $ 196.12 $ 201.12 $ 121.79 $ 126.79 $ 4.04 $

38.87 38.87 38.87 6.60 196.12 201.12 121.79 126.79 4.04

$ $ $ $ $ $ $ $ $

25.91 25.91 26.45 6.28 178.97 183.97 119.07 124.07 2.87

D D D D D C

D D

H2015HTHF ‐ CST ‐ SA Professional ‐ Community Support Team H2015HTHM ‐ CST ‐ Paraprofessional ‐ Community Support Team

Rate as of

12.54 3.02 304.18 0.01 3.94 3.94 5.29 5.29 81.48 94.50

Standard Rate Schedule: Medicaid 1915(b) Non-Clinician-Based Q C D E

Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment extended to 06/30/2022 DCW adjustment included EVV adjustment included Revised 04/01/2022

H2020 ‐ Child Residential Level II – Program Type H2021 ‐ Outpatient Plus H2021HQ ‐ Group Outpatient Plus H2022 ‐ INTENSIVE‐IN‐HOME H2022U4 ‐ (b)(3) Transitional Living

Rate as of

$ $ $ $ $

145.26 13.67 7.49 258.20 41.38

$ $ $ $ $

145.26 13.67 7.49 258.20 45.52

$ $ $ $ $

145.26 $ 13.67 $ 7.49 $ 258.20 $ 45.52 $

H2023HQU4 ‐ IDD non‐DI Initial Group Supported Employment

3.04

2.80

H2023U4 ‐ IDD non‐DI Initial Individual Supported Employment

13.45

11.75

H2023U4HH ‐ MHSA Initial Individual Supported Employment H2025HQU4 ‐ DI Group ‐ Supported Employment H2025TSHQU4 ‐ DI Supported Employment – Long Term Follow‐up ‐ Group

D D

$ $

24.63 3.88

$ $

24.63 3.88

$ $

24.63 3.88

$ $

25.17 3.50

3.04

2.80

H2025TSU4 ‐ DI Supported Employment – Long Term Follow‐up

9.31

8.30

H2025U4 ‐ DI Individual Supported Employment

9.31

8.30

H2026HQU4 ‐ IDD non‐DI Maint Group Supported Employment

3.04

2.80

H2026U4 ‐ IDD non‐DI Maint Individual Supported Employment

13.45

11.75

$ $ $ $ $ $ $

37.32 45.35 21.25 10.30 101.87 265.79 101.87

$ $ $ $ $ $ $

37.32 $ 46.07 $ 21.25 $ 10.30 $ 101.87 $ 265.79 $ 101.87 $

37.32 46.07 21.25 8.96 97.22 248.40 97.22

H2033 ‐ MULTI‐SYSTEMIC‐THER H2035 ‐ SA Comprehensive Outpatient Trt Prog Q3014GT ‐ TELEHEALTH ORIG SITE FEE S5110U4 ‐ DI Natural Supports Education ‐ Individual S5145 ‐ CTSP Residential II S5145HA ‐ CTSP FAM TYPE RES II IAFT S5145HK ‐ Enh Rate Therapeutic Foster Care

D D D

37.32 $ 45.35 $ 21.25 $ 10.30 $ 101.87 $ 265.79 $ 101.87 $

140.13 13.67 7.49 258.20 45.52

Standard Rate Schedule: Medicaid 1915(b) Non-Clinician-Based Q C D E

Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment extended to 06/30/2022 DCW adjustment included EVV adjustment included Revised 04/01/2022

S5145U5 ‐ Enhanced Therapeutic Foster Care S5150HQU4 ‐ DI Respite ‐ Group S5150U4 ‐ DI Respite ‐ Individual S5150USU4 ‐ DI Respite ‐ Facility S9484 ‐ FAC BASED CRISIS HR S9484HA ‐ FAC BASED CRISIS HR ‐ Child & Adol T1005TDU4 ‐ AWC ‐ DI Respite ‐ Nursing RN T1005TDU4 ‐ DI Respite ‐ Nursing RN T1005TEU4 ‐ AWC ‐ DI Respite ‐ Nursing LPN T1005TEU4 ‐ DI Respite ‐ Nursing LPN T1016CR ‐ Case Support ‐ Special Situation T1019U4 ‐ Individual Support T1019U4TS ‐ Individual Support ‐ non‐EVV, only in the community T1023 ‐ DIAGNOSTIC‐ASSESSMENT T2012GCHQU4 ‐ DI Community Living and Supports ‐ Group, relative as provider lives in home T2012GCU4 ‐ DI Community Living and Supports, relative as provider lives in home T2012HQU4 ‐ DI Community Living and Supports ‐ Group, only in the community T2012U4 ‐ DI Community Living and Supports, only in the community T2013TFHQU4 ‐ DI Community Living and Supports‐ Group T2013TFU4 ‐ DI Community Living and Supports T2013U4 ‐ B3 non‐DI In Home Skill Building T2014U4 ‐ DI Level 2 ‐ Residential Supports

Rate as of

D D D D C C

$ $ $ $ $ $ $ $ $ $ $ D, E $ D

D D D D D, E D, E D, E D

Rate as of

101.87 4.35 6.00 149.44 31.50 31.50 15.60 15.60 15.60 15.60 15.00 12.00

$ $ $ $ $ $ $ $ $ $ $ $

101.87 4.35 6.00 149.44 31.50 31.50 15.60 15.60 15.60 15.60 15.00 13.20

$ $ $ $ $ $ $ $ $ $ $ $

12.00

231.30

Rate as of

101.87 $ 4.35 $ 6.00 $ 149.44 $ 31.50 $ 31.50 $ 15.60 $ 15.60 $ 15.60 $ 15.60 $ 15.00 $ 13.74 $ 12.54

97.22 3.17 4.54 147.37 31.50 31.50 10.40 10.40 10.40 10.40 15.00 13.74

12.54

231.30 $

231.30

4.07 $

4.07

3.90

6.19 $

6.19

5.92

4.07 $

4.07

3.90

$ $ $ $ $

6.19 $ 4.27 $ 5.89 $ 11.45 $ 145.51 $

6.19 $ 4.27 $ 6.48 $ 12.60 $ 145.51 $

6.19 $ 4.27 $ 6.81 $ 13.14 $ 152.79 $

5.92 4.25 6.46 13.14 146.68

Standard Rate Schedule: Medicaid 1915(b) Non-Clinician-Based Q C D E

Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment extended to 06/30/2022 DCW adjustment included EVV adjustment included Revised 04/01/2022

T2014U4U2 ‐ DI Level 2 AFL ‐ Residential Supports D T2016U5 ‐ Behavioral Health Crisis Risk Assessment and Intervention (BH‐CAI) T2016U5U1 ‐ L1 Long‐term Community Supports D T2016U5U2 ‐ L2 Long‐term Community Supports D T2016U5U3 ‐ L3 Long‐term Community Supports D T2016U5U4 ‐ L4 Long‐term Community Supports D T2016U5U5 ‐ L5 Long‐term Community Supports T2020U4 ‐ DI Level 3 ‐ Residential Supports D T2020U4U2 ‐ DI Level 3 AFL ‐ Residential Supports D T2021HQU4 ‐ DI Day Supports ‐ Group D T2021U4 ‐ DI Day Supports ‐ Individual D T2025HOU4 ‐ DI Specialized Consultative Services ‐ BCBA T2025U3U4 ‐ DI Crisis Services: Crisis Consultation T2025U4 ‐ DI Specialized Consultative Services T2027U4 ‐ DI Developmental Day D T2033HIU4 ‐ DI Supported Living – Level 2 D T2033TFU4 ‐ DI Supported Living – Level 3 D T2033U1U4 ‐ DI Supported Living ‐ Periodic D, E T2033U2U4 ‐ DI Supported Living ‐ Transition D T2033U4 ‐ DI Supported Living – Level 1 D T2034U4 ‐ DI Crisis Services ‐ Out of Home T2041U1U4 ‐ B‐3 DI Community Navigator: Periodic and Start up Training T2041U4 ‐ B‐3 DI Community Navigator ‐ Monthly T2041U4U5 ‐ B‐3 Community Guide ‐ Monthly

Rate as of

151.16

157.79 $

151.68

450.00

450.00 $

450.00

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

96.60 124.20 135.70 147.20 158.94 170.82 173.51 15.84 25.88 39.90 19.92 39.90 24.75 276.14 322.76 8.28 8.28 228.71 249.69

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

96.60 $ 124.20 $ 135.70 $ 147.20 $ 158.94 $ 170.82 $ 173.51 $ 15.84 $ 25.88 $ 39.90 $ 19.92 $ 39.90 $ 24.75 $ 276.14 $ 322.76 $ 8.28 $ 8.28 $ 228.71 $ 249.69 $

101.28 125.28 135.70 147.20 138.21 179.37 184.37 16.56 28.04 39.90 19.92 39.90 25.29 289.94 338.90 8.83 8.28 240.14 249.69

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

101.28 125.28 135.28 141.82 138.21 169.79 174.79 16.56 28.04 39.90 19.92 39.90 25.29 227.85 277.77 6.61 6.06 177.37 249.69

620.00

620.00 $

620.00

$ $

150.00 150.00

$ $

150.00 150.00

$ $

150.00 $ 150.00 $

150.00 150.00