Standard Rate Schedule: Medicaid 1915(c) * This service is subject to the targeted rate enhancement under COVID‐19. The enhanced rate of 10% above the rate shown here will remain in effect until further notified. rev 7/23/2020
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 ‐ AWC ‐ Community Networking Service ‐ Ind H2015 ‐ Community Networking Service ‐ Ind H2015 ‐ EOR ‐ Community Networking Service ‐ Ind H2015HQ ‐ AWC ‐ Community Networking Group H2015HQ ‐ Community Networking Group H2015HQ ‐ EOR ‐ Community Networking Group H2016 ‐ Level 1‐Residential Supports * H2016HI ‐ Level 4‐Residential Supports * H2016HIU2 ‐ Level 4 AFL‐Residential Supports * H2016U2 ‐ Level 1 AFL Residential Supports * H2025 ‐ AWC ‐ Supported Employment ‐ Ind H2025 ‐ EOR ‐ Supported Employment ‐ Ind H2025 ‐ Supported Employment ‐ Ind H2025HQ ‐ AWC ‐ Supported Employment Group H2025HQ ‐ EOR ‐ Supported Employment Group H2025HQ ‐ Supported Employment Group H2025TS ‐ AWC ‐ Supported Employment – Long Term Follow‐up H2025TS ‐ EOR ‐ Supported Employment – Long Term Follow‐up H2025TS ‐ Supported Employment – Long Term Follow‐up H2025TSHQ ‐ AWC ‐ Supported Employment – Long Term Follow‐up ‐ Group H2025TSHQ ‐ EOR Supported Employment – Long Term Follow‐up ‐ Group H2025TSHQ ‐ Supported Employment – Long Term Follow‐up ‐ Group S5110 ‐ Natural Supports Education: Individual S5150 ‐ AWC ‐ Respite ‐ Non‐inst Individual
EffectiveDate 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020
EndDate 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021
Rate $ 0.55 $ 3.29 $ 1.62 $ 0.69 $ 0.57 $ 1.97 $ 1.42 $ 2.55 $ 3.73 $ 0.64 $ 0.64 $ 0.55 $ 1.86 $ 3.86
7/1/2020
6/30/2021 $ 9.00
7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020
6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021
7/1/2020
6/30/2021 $ 2.53
7/1/2020
6/30/2021 $ 2.40
7/1/2020 7/1/2020 7/1/2020
6/30/2021 $ 2.53 6/30/2021 $ 8.36 6/30/2021 $ 4.00
$ 5.74 $ 5.74 $ 5.45 $ 3.10 $ 3.10 $ 2.56 $ 105.25 $ 165.15 $ 170.30 $ 110.25 $ 7.62 $ 7.24 $ 7.62 $ 2.69 $ 2.56 $ 2.69 $ 7.39 $ 7.02 $ 7.39
Service S5150 ‐ EOR ‐ Respite ‐ Non‐inst Individual S5150 ‐ Respite ‐ Non‐inst Individual * S5150HQ ‐ AWC ‐ Respite ‐ Group S5150HQ ‐ EOR ‐ Respite ‐ Group S5150HQ ‐ Respite ‐ Group * S5150US ‐ Respite: Facility * 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 * T2013TF ‐ AWC ‐ Community Living and Supports T2013TF ‐ Community Living and Supports T2013TF ‐ EOR ‐ Community Living and Supports T2013TFHQ ‐ AWC ‐ Community Living and Supports‐ Group T2013TFHQ ‐ Community Living and Supports‐ Group T2013TFHQ ‐ EOR ‐ Community Living and Supports‐ Group T2014 ‐ Level 2 ‐ Residential Supports * T2014U2 ‐ Level 2 AFL ‐ Residential Supports * T2020 ‐ Level 3 ‐ Residential Supports * T2020U2 ‐ Level 3 AFL ‐ Residential Supports * T2021 ‐ Day Support ‐ Individual T2021HQ ‐ Day Support Group T2025 ‐ Specialized Consultative Service T2025HO ‐ Specialized Consultative Services: BCBA T2025U1 ‐ Financial Support Services T2025U2U1 ‐ Employer Supplies ‐ start‐up costs T2025U3 ‐ Crisis Services: Crisis Consultation T2027 ‐ Day Supports: Developmental Day T2033 ‐ AWC ‐ Supported Living – Level 1 T2033 ‐ EOR ‐ Supported Living – Level 1 T2033 ‐ Supported Living – Level 1 * T2033HI ‐ AWC ‐ Supported Living – Level 2 T2033HI ‐ EOR ‐ Supported Living – Level 2 T2033HI ‐ Supported Living – Level 2 * T2033TF ‐ AWC ‐ Supported Living – Level 3 T2033TF ‐ EOR ‐ Supported Living – Level 3 T2033TF ‐ Supported Living – Level 3 * T2033U1 ‐ EOR ‐ Supported Living ‐ Periodic T2033U1 ‐ Supported Living ‐ Periodic T2033U2 ‐ Supported Living ‐ Transition T2034 ‐ Crisis Services: Out of Home T2041 ‐ Community Navigator: Monthly T2041U1 ‐ Community Navigator: Periodic T2041U1U6 ‐ Community Navigator: IFDS Orientation
EffectiveDate 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020 7/1/2020
EndDate 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021 6/30/2021
Rate $ 3.80 $ 4.00 $ 2.90 $ 2.76 $ 2.90 $ 129.95 $ 9.18 $ 8.72 $ 9.18 $ 9.18 $ 8.72 $ 9.18 $ 5.07 $ 5.07 $ 4.82 $ 2.66 $ 2.66 $ 2.53 $ 126.29 $ 131.44 $ 145.73 $ 150.88 $ 25.88 $ 15.84 $ 26.56 $ 26.56 $ 175.00 $ 150.00 $ 19.92 $ 24.16 $ 152.47 $ 144.85 $ 152.47 $ 184.09 $ 174.89 $ 184.09 $ 215.17 $ 204.41 $ 215.17 $ 5.24 $ 5.52 $ 5.52 $ 249.69 $ 150.00 $ 620.00 $ 35.00