Standard Rate Schedule: Medicaid 1915(c) Inv Invoice‐based ‐ Provider submits actual costs to Finance department E
EVV adjustment included
D
DCW adjustment included Rev. 04/01/2022
Rate as of 1/1/2022
Service
B4100BO ‐ Food thickener B4103BO ‐ Enteral Formulae ‐ Pediatric B4149BO ‐ Enteral Formulae ‐ Mfg Blend Natural Foods B4150BO ‐ Enteral Formulae B4152BO ‐ Ent Form Caloric Dense B4153BO ‐ Ent Form Hydrolyzed Proteins B4154BO ‐ Ent Form Special Met Needs, Excl Inherit Dis B4155BO ‐ Ent Form Incomplete/Modular B4157BO ‐ Ent Form Special Met Needs, Incl Inherit Dis B4158BO ‐ Ent Form Complete ‐ Pediatric B4159BO ‐ Ent Form Complete Soy‐based ‐ Pediatric B4160BO ‐ Ent Form Caloric Dense ‐ Pediatric B4161BO ‐ Ent Form Hydrolyzed Protiens ‐ Pediatric B4162BO ‐ Ent Form Special Metabolic ‐ Pediatric H2011HI ‐ Crisis Intervention and Stabilization Supports with Technical Amendment H2015 ‐ Community Networking Service ‐ Ind H2015 ‐ EOR Community Networking Service ‐ Ind H2015HQ ‐ Community Networking Group H2015HQ ‐ EOR Community Networking Group
Rate as of 2/1/2022
Rate as of 3/1/2022
Rate as of 4/1/2022
Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv
$ $ $ $ $ $ $ $ $ $ $ $ $ $
0.58 3.45 1.70 0.72 0.60 2.07 1.49 2.68 3.92 0.67 0.67 0.58 1.95 4.05
$ $ $ $ $ $ $ $ $ $ $ $ $ $
0.58 3.45 1.70 0.72 0.60 2.07 1.49 2.68 3.92 0.67 0.67 0.58 1.95 4.05
$ $ $ $ $ $ $ $ $ $ $ $ $ $
0.58 3.45 1.70 0.72 0.60 2.07 1.49 2.68 3.92 0.67 0.67 0.58 1.95 4.05
$ $ $ $ $ $ $ $ $ $ $ $ $ $
0.58 3.45 1.70 0.72 0.60 2.07 1.49 2.68 3.92 0.67 0.67 0.58 1.95 4.05
D D D D
$ $ $ $ $
9.00 6.60 6.27 3.60 3.42
$ $ $ $ $
9.00 $ 6.60 $ 6.27 $ 3.60 $ 3.42 $
9.00 6.60 6.27 3.60 3.42
$ $ $ $ $
9.00 6.28 5.96 3.31 3.14
3.13 $
3.13 $
3.31
$
3.31
2.97 $ 1.00 $ 1.00 $
2.97 $ 1.00 $ 1.00 $
3.14 $ 1.00 $ 1.00 $
3.14 1.00 1.00
5.74 $
5.74 $
6.28
6.28
H2015HQXUCR ‐ Community Networking Group, retainer pymt, disaster related D $ H2015HQXUCR ‐ EOR Community Networking Group, retainer pymt, disaster related D $ H2015U1 ‐ Community Networking ‐ Class & Conf Inv $ H2015U2 ‐ Community Networking ‐ Transportation Inv $ H2015XUCR ‐ Community Networking Service ‐ Ind, retainer pymt, disaster related D $
$
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice‐based ‐ Provider submits actual costs to Finance department E
EVV adjustment included
D
DCW adjustment included Rev. 04/01/2022
Rate as of 1/1/2022
Service
H2015XUCR ‐ EOR Community Networking Service ‐ Ind, retainer pymt, disaster related H2016 ‐ Level 1‐Residential Supports H2016HI ‐ Level 4‐Residential Supports H2016HIU2 ‐ Level 4 AFL‐Residential Supports H2016HIXUCR ‐ Level 4‐Residential Supports, retainer pymt, disaster related H2016HIXUCRU2 ‐ Level 4 AFL‐Residential Supports, retainer pymt, disaster related H2016U2 ‐ Level 1 AFL Residential Supports H2016XUCR ‐ Level 1‐Residential Supports, retainer pymt, disaster related H2016XUCRU2 ‐ Level 1 AFL Residential Supports, retainer pymt, disaster related H2025 ‐ EOR Supported Employment ‐ Ind H2025 ‐ Supported Employment ‐ Ind H2025HQ ‐ EOR Supported Employment Group H2025HQ ‐ Supported Employment Group H2025HQXUCR ‐ EOR Supported Employment Group, retainer pymt, disaster related H2025HQXUCR ‐ Supported Employment Group, retainer pymt, disaster related H2025TS ‐ EOR Supported Employment – Long Term Follow‐up H2025TS ‐ Supported Employment – Long Term Follow‐up H2025TSHQ ‐ EOR Supported Employment – Long Term Follow‐up ‐ Group H2025TSHQ ‐ Supported Employment – Long Term Follow‐up ‐ Group H2025TSXUCR ‐ EOR Supported Employment – Long Term Follow‐up, retainer pymt, disaster related
Rate as of 2/1/2022
Rate as of 3/1/2022
Rate as of 4/1/2022
D D D D
$ $ $ $
5.45 121.04 189.92 196.12
$ $ $ $
5.45 $ 121.04 $ 189.92 $ 196.12 $
5.97 121.04 189.92 196.12
$ $ $ $
5.97 119.07 178.97 183.97
D
$
170.30 $
170.30 $
184.12
$
178.97
D D D
$ $ $
170.30 $ 126.79 $ 110.25 $
170.30 $ 126.79 $ 110.25 $
189.12 126.79 124.07
$ $ $
183.97 124.07 119.07
D D D D D
$ $ $ $ $
110.25 8.85 9.31 3.69 3.88
110.25 $ 8.85 $ 9.31 $ 3.69 $ 3.88 $
129.07 8.85 9.31 3.69 3.88
$ $ $ $ $
124.07 7.89 8.30 3.33 3.50
D
$
3.07 $
3.07
$
3.33
$
3.33
D D D D D
$ $ $ $ $
3.23 8.85 9.31 2.89 3.04
3.23 $ 8.85 $ 9.31 $ 2.89 $ 3.04 $
3.50 8.85 9.31 2.89 3.04
$ $ $ $ $
3.50 7.89 8.30 2.66 2.80
D
$
7.37 $
7.37
7.89
$
7.89
$ $ $ $ $
$ $ $ $ $
$
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice‐based ‐ Provider submits actual costs to Finance department E
EVV adjustment included
D
DCW adjustment included Rev. 04/01/2022
Rate as of 1/1/2022
Service
Rate as of 2/1/2022
Rate as of 3/1/2022
Rate as of 4/1/2022
H2025TSXUCR ‐ Supported Employment – Long Term Follow‐up, retainer pymt, disaster related
D
$
7.76 $
7.76 $
8.30
$
8.30
H2025XUCR ‐ EOR Supported Employment ‐ Ind, retainer pymt, disaster related
D
$
7.37 $
7.37
$
7.89
$
7.89
H2025XUCR ‐ Supported Employment ‐ Ind, retainer pymt, disaster related S5110 ‐ Natural Supports Education: Individual S5111 ‐ Natural Supports Education: Conference S5150 ‐ EOR Respite ‐ Non‐inst Individual S5150 ‐ Respite ‐ Non‐inst Individual S5150HQ ‐ EOR Respite ‐ Group S5150HQ ‐ Respite ‐ Group S5150US ‐ Respite: Facility S5165 ‐ Home Modifications T1005TD ‐ AWC ‐ Nursing Respite, RN T1005TD ‐ EOR ‐ Nursing Respite, RN T1005TD ‐ Nursing Respite, RN T1005TE ‐ AWC ‐ Nursing Respite, LPN T1005TE ‐ EOR ‐ Nursing Respite, LPN T1005TE ‐ Nursing Respite, LPN T1999 ‐ Individual Goods and Services T2012 ‐ Community Living and Supports, only in the community
D
7.76 10.30 1.00 5.70 6.00 4.13 4.35 149.44 1.00 15.60 14.82 15.60 15.60 14.82 15.60 1.00 6.19
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
8.30 10.30 1.00 5.70 6.00 4.13 4.35 149.44 1.00 15.60 14.82 15.60 15.60 14.82 15.60 1.00 6.19
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
8.30 8.96 1.00 4.31 4.54 3.02 3.17 147.37 1.00 10.40 9.88 10.40 10.40 9.88 10.40 1.00 5.92
T2012GC ‐ Community Living and Supports, relative as provider lives in home T2012GCHQ ‐ Community Living and Supports ‐ Group, relative as provider lives in home T2012HQ ‐ Community Living and Supports ‐ Group, only in the community T2013TF ‐ Community Living and Supports
$ $ Inv $ D $ D $ D $ D $ D $ Inv $ $ $ $ $ $ $ Inv $ D $
7.76 10.30 1.00 5.70 6.00 4.13 4.35 149.44 1.00 15.60 14.82 15.60 15.60 14.82 15.60 1.00 6.19
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
D
$
6.19 $
6.19 $
6.19
$
5.92
D
$
4.07 $
4.07 $
4.07
$
3.90
D $ E, D $
4.07 $ 6.19 $
4.07 $ 6.81 $
4.07 6.81
$ $
3.90 6.46
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice‐based ‐ Provider submits actual costs to Finance department E
EVV adjustment included
D
DCW adjustment included Rev. 04/01/2022
Rate as of 1/1/2022
Service
Rate as of 2/1/2022
Rate as of 3/1/2022
Rate as of 4/1/2022
T2013TF ‐ EOR Community Living and Supports E, D $ T2013TFHQ ‐ Community Living and Supports‐ Group E, D $ T2013TFHQ ‐ EOR Community Living and Supports‐Group E, D $ T2013TFHQXUCR ‐ Community Living and Supports‐ Group, retainer pymt, disaster related D $ T2013TFHQXUCR ‐ EOR Community Living and Supports‐ Group, retainer pymt, disaster related D $
5.88 $ 4.07 $ 3.87 $
6.47 $ 4.48 $ 4.26 $
6.47 4.48 4.26
$ $ $
6.14 4.25 4.04
3.54 $
3.54 $
3.90
$
3.90
3.36 $
3.36
$
3.70
$
3.70
T2013TFXUCR ‐ Community Living and Supports, retainer pymt, disaster related T2013TFXUCR ‐ EOR Community Living and Supports, retainer pymt, disaster related T2014 ‐ Level 2 ‐ Residential Supports T2014U2 ‐ Level 2 AFL ‐ Residential Supports
D
$
5.38 $
5.38 $
5.92
$
5.92
D D D
$ $ $
5.11 $ 152.79 $ 152.79 $
5.11 $ 152.79 $ 152.79 $
5.62 152.79 157.79
$ $ $
5.62 146.68 151.68
T2014XUCR ‐ Level 2 ‐ Residential Supports, retainer pymt, disaster related T2020 ‐ Level 3 ‐ Residential Supports T2020U2 ‐ Level 3 AFL ‐ Residential Supports
D D D
$ $ $
132.86 $ 179.37 $ 179.37 $
132.86 $ 179.37 $ 179.37 $
146.68 179.37 184.37
$ $ $
146.68 169.79 174.79
T2020XUCR ‐ Level 3 ‐ Residential Supports, retainer pymt, disaster related T2020XUCRU2 ‐ Level 3 AFL ‐ Residential Supports, retainer pymt, disaster related T2021 ‐ Day Support ‐ Individual T2021HQ ‐ Day Support Group T2021HQXUCR ‐ Day Support Group, retainer pymt, disaster related T2021XUCR ‐ Day Support ‐ Individual, retainer pymt, disaster related T2025 ‐ Specialized Consultative Service T2025HO ‐ Specialized Consultative Services: BCBA T2025U1 ‐ Financial Support Services
D
$
155.97 $
155.97 $
169.79
$
169.79
D D D D D
$ $ $ $ $ $ $ $
155.97 25.88 15.84 15.84 25.88 39.90 39.90 175.00
155.97 25.88 15.84 15.84 25.88 39.90 39.90 175.00
174.79 28.04 16.56 16.56 28.04 39.90 39.90 175.00
$ $ $ $ $ $ $ $
174.79 28.04 16.56 16.56 28.04 39.90 39.90 175.00
$ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice‐based ‐ Provider submits actual costs to Finance department E
EVV adjustment included
D
DCW adjustment included Rev. 04/01/2022
Rate as of 1/1/2022
Service
T2025U2U1 ‐ Employer Supplies ‐ start‐up costs T2025U2U1 ‐ Employer Supplies ‐ start‐up costs T2025U3 ‐ Crisis Services: Crisis Consultation T2027 ‐ Day Supports: Developmental Day
Rate as of 3/1/2022
Rate as of 4/1/2022
150.00 $ 1.00 $ 19.92 $ 24.75 $
150.00 1.00 19.92 24.75
$ $ $ $
150.00 $ 1.00 $ 19.92 $ 25.29 $
150.00 1.00 19.92 25.29
T2027XUCR ‐ Day Supports: Developmental Day, retainer pymt, disaster related D $ T2029 ‐ Assistive Technology ‐ Equip & Supplies Inv $ T2033 ‐ EOR Supported Living – Level 1 D $ T2033 ‐ Supported Living – Level 1 D $ T2033HI ‐ EOR Supported Living – Level 2 D $ T2033HI ‐ Supported Living – Level 2 D $
24.75 1.00 228.13 240.14 275.44 289.94
$ $ $ $ $ $
24.75 1.00 228.13 240.14 275.44 289.94
$ $ $ $ $ $
25.29 $ 1.00 $ 228.13 $ 240.14 $ 275.44 $ 289.94 $
25.29 1.00 168.51 177.37 216.46 227.85
T2033HIXUCR ‐ EOR Supported Living – Level 2, retainer pymt, disaster related T2033HIXUCR ‐ Supported Living – Level 2, retainer pymt, disaster related T2033TF ‐ EOR Supported Living – Level 3 T2033TF ‐ Supported Living – Level 3
D D D D
$ $ $ $
183.63 193.29 321.96 338.90
$ $ $ $
183.63 $ 193.29 $ 321.96 $ 338.90 $
216.46 227.85 321.96 338.90
$ $ $ $
216.46 227.85 263.88 277.77
T2033TFXUCR ‐ EOR Supported Living – Level 3, retainer pymt, disaster related T2033TFXUCR ‐ Supported Living – Level 3, retainer pymt, disaster related T2033U1 ‐ EOR Supported Living ‐ Periodic T2033U1 ‐ Supported Living ‐ Periodic T2033U1XUCR ‐ EOR Supported Living ‐ Periodic, retainer pymt, disaster related T2033U2 ‐ Supported Living ‐ Transition
D D E, D E, D
$ $ $ $
214.63 225.93 7.87 8.28
$ $ $ $
214.63 $ 225.93 $ 8.65 $ 9.11 $
263.88 277.77 8.39 9.11
$ $ $ $
263.88 277.77 6.28 6.61
D D
$ $
5.24 $ 8.28 $
5.24 $ 8.28 $
5.75 8.28
$ $
5.75 6.06
D D
$ $ $
152.09 $ 160.09 $ 249.69 $
152.09 $ 160.09 $ 249.69 $
168.51 177.37 249.69
$ $ $
168.51 177.37 249.69
T2033XUCR ‐ EOR Supported Living – Level 1, retainer pymt, disaster related T2033XUCR ‐ Supported Living – Level 1, retainer pymt, disaster related T2034 ‐ Crisis Services: Out of Home
$ Inv $ $ D $
Rate as of 2/1/2022
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice‐based ‐ Provider submits actual costs to Finance department E
EVV adjustment included
D
DCW adjustment included Rev. 04/01/2022
Rate as of 1/1/2022
Service
T2038 ‐ Community Transition T2039 ‐ Vehicle Modifications T2041 ‐ Community Navigator: Monthly T2041U1 ‐ Community Navigator: Periodic and Start Up Training T2041U1U6 ‐ Community Navigator: IFDS Orientation
Inv $ Inv $ $ $ $
1.00 $ 1.00 $ 150.00 $ 620.00 $ 35.00 $
Rate as of 2/1/2022
1.00 1.00 150.00 620.00 35.00
Rate as of 3/1/2022
$ $ $ $ $
1.00 $ 1.00 $ 150.00 $ 620.00 $ 35.00 $
Rate as of 4/1/2022
1.00 1.00 150.00 620.00 35.00