Standard Rate Schedule: Medicaid 1915(b) Q C D E
Requires LQASP - Licensed Qualified Autism Services Practitioner COVID adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included
Service 96138 - PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING 96139 - add on PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING 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 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 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
Q Q Q Q Q Q Q C C D D D D
D D D
D D D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 1/1/2022 32.64 32.64 1.74 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 18.00 4.32 456.27 0.01 5.51 5.51 7.13 7.13
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of2 2/1/2022 32.64 32.64 1.74 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 18.00 4.32 456.27 0.01 5.51 5.51 7.13 7.13
rev. 06/08/22
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of3 Revised Rate 3/1/2022 as of 4/1/22 32.64 32.64 1.74 31.25 53.65 20.00 10.00 28.00 30.00 10.00 325.58 163.60 253.90 21.25 133.72 393.47 $ 423.28 267.81 $ 291.66 218.21 $ 242.06 342.15 $ 393.47 16.60 135.20 18.00 $ 18.81 4.32 $ 4.53 456.27 $ 456.27 0.01 5.51 $ 5.92 5.51 $ 5.92 7.13 $ 7.94 7.13 $ 7.94
Standard Rate Schedule: Medicaid 1915(b) Q C D E
Requires LQASP - Licensed Qualified Autism Services Practitioner COVID adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included
Service 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 H2015HTHF - CST - SA Professional - Community Support Team H2015HTHM - CST - Paraprofessional - Community Support Team 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 H2020 - Child Residential Level II – Program Type H2021 - Outpatient Plus H2021HQ - Group Outpatient Plus H2022 - INTENSIVE-IN-HOME H2022U4 - (b)(3) Transitional Living H2023HQU4 - IDD non-DI Initial Group Supported Employment H2023U4 - IDD non-DI Initial Individual Supported Employment H2023U4HH - MHSA Initial Individual Supported Employment H2025HQU4 - DI Group - Supported Employment H2025TSHQU4 - DI Supported Employment – Long Term Follow-up - Group H2025TSU4 - DI Supported Employment – Long Term Follow-up H2025U4 - DI Individual Supported Employment H2026HQU4 - IDD non-DI Maint Group Supported Employment
D C D D D
D D D D D D D D
E D D D D D D D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 1/1/2022 86.25 94.50 9.00 31.41 3.60 38.87 38.87 38.87 38.87 38.87 6.60 196.12 201.12 121.79 126.79 4.04 145.26 13.67 7.49 284.02 41.38 3.04 13.45 24.63 3.88 3.04 9.31 9.31 3.04
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of2 2/1/2022 86.25 94.50 9.00 31.41 3.60 38.87 38.87 38.87 38.87 38.87 6.60 196.12 201.12 121.79 126.79 4.04 145.26 13.67 7.49 284.02 45.52 3.04 13.45 24.63 3.88 3.04 9.31 9.31 3.04
rev. 06/08/22
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of3 Revised Rate 3/1/2022 as of 4/1/22 86.25 $ 93.70 94.50 9.00 32.13 3.78 $ 4.00 38.87 38.87 $ 38.87 $ 39.68 38.87 $ 38.87 38.87 $ 38.87 38.87 $ 39.68 6.93 $ 7.58 205.93 $ 221.36 221.36 211.18 $ 127.88 $ 143.78 133.13 $ 149.03 4.04 $ 4.31 145.26 $ 161.15 13.67 7.49 284.02 $ 284.02 45.52 3.04 $ 3.36 14.10 13.45 $ 24.63 $ 30.20 3.88 $ 4.20 3.04 $ 3.36 9.31 $ 9.96 9.31 $ 9.96 3.04 $ 3.36
Standard Rate Schedule: Medicaid 1915(b) Q C D E
Requires LQASP - Licensed Qualified Autism Services Practitioner COVID adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included
Service H2026U4 - IDD non-DI Maint Individual Supported Employment D H2033 - MULTI-SYSTEMIC-THER H2035 - SA Comprehensive Outpatient Trt Prog D Q3014GT - TELEHEALTH ORIG SITE FEE S5110U4 - DI Natural Supports Education - Individual S5145 - CTSP Residential II D S5145HA - CTSP FAM TYPE RES II IAFT D S5145HK - Enh Rate Therapeutic Foster Care D S5145U5 - Enhanced Therapeutic Foster Care D S5150HQU4 - DI Respite - Group D S5150U4 - DI Respite - Individual D S5150USU4 - DI Respite - Facility D S9484 - FAC BASED CRISIS HR C S9484HA - FAC BASED CRISIS HR - Child & Adol C 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 D, E T1019U4TS - Individual Support - non-EVV, only in the community D T1023 - DIAGNOSTIC-ASSESSMENT T2012GCHQU4 - DI Community Living and Supports - Group, relative as provider lives in hom D T2012GCU4 - DI Community Living and Supports, relative as provider lives in home D T2012HQU4 - DI Community Living and Supports - Group, only in the community D T2012U4 - DI Community Living and Supports, only in the community D T2013TFHQU4 - DI Community Living and Supports- Group D, E T2013TFU4 - DI Community Living and Supports D, E T2013U4 - B3 non-DI In Home Skill Building D, E
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 1/1/2022 13.45 37.32 45.35 21.25 10.30 101.87 265.79 101.87 101.87 4.35 6.00 149.44 31.50 31.50 15.60 15.60 15.60 15.60 15.00 12.00 12.00 231.30 4.07 6.19 4.07 6.19 4.27 5.89 11.45
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of2 2/1/2022 13.45 37.32 45.35 21.25 10.30 101.87 265.79 101.87 101.87 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 4.07 6.19 4.07 6.19 4.27 6.48 12.60
rev. 06/08/22
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of3 Revised Rate 3/1/2022 as of 4/1/22 13.45 $ 14.10 37.32 46.07 21.25 10.30 $ 10.30 101.87 $ 111.81 265.79 $ 285.66 101.87 $ 111.81 101.87 $ 111.81 4.76 4.35 $ 6.00 $ 6.81 149.44 $ 169.48 31.50 31.50 15.60 $ 15.60 15.60 $ 15.60 15.60 $ 15.60 15.60 $ 15.60 15.00 13.74 12.54 231.30 4.27 $ 4.71 6.50 $ 7.15 4.27 $ 4.71 6.50 $ 7.15 4.48 $ 5.13 7.15 $ 7.80 13.14
Standard Rate Schedule: Medicaid 1915(b) Q C D E
Requires LQASP - Licensed Qualified Autism Services Practitioner COVID adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included
Service T2014U4 - DI Level 2 - Residential Supports T2014U4U2 - DI Level 2 AFL - Residential Supports T2016U5 - Behavioral Health Crisis Risk Assessment and Intervention (BH-CAI) T2016U5U1 - L1 Long-term Community Supports T2016U5U2 - L2 Long-term Community Supports T2016U5U3 - L3 Long-term Community Supports T2016U5U4 - L4 Long-term Community Supports T2016U5U5 - L5 Long-term Community Supports T2020U4 - DI Level 3 - Residential Supports T2020U4U2 - DI Level 3 AFL - Residential Supports T2021HQU4 - DI Day Supports - Group T2021U4 - DI Day Supports - Individual T2025HOU4 - DI Specialized Consultative Services - BCBA T2025U3U4 - DI Crisis Services: Crisis Consultation T2025U4 - DI Specialized Consultative Services T2027U4 - DI Developmental Day T2033HIU4 - DI Supported Living – Level 2 T2033TFU4 - DI Supported Living – Level 3 T2033U1U4 - DI Supported Living - Periodic T2033U2U4 - DI Supported Living - Transition T2033U4 - DI Supported Living – Level 1 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
D D
$ $ $ D $ D $ D $ D $ $ D $ D $ D $ D $ $ $ $ D $ D $ D $ D, E $ D $ D $ $ $ $ $
Rate as of 1/1/2022 145.51 151.16 450.00 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 8.28 228.71 249.69 620.00 150.00 150.00
rev. 06/08/22
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of2 Rate as of3 Revised Rate 2/1/2022 3/1/2022 as of 4/1/22 145.51 $ 160.43 $ 177.11 151.16 $ 165.68 $ 183.15 450.00 $ 450.00 96.60 $ 101.28 $ 116.47 124.20 $ 125.28 $ 144.07 135.70 $ 135.70 $ 155.57 147.20 $ 147.20 $ 163.09 158.94 $ 138.21 $ 158.94 170.82 $ 188.34 $ 205.02 210.27 173.51 $ 193.59 $ 15.84 $ 17.39 25.88 $ 29.44 39.90 $ 39.90 19.92 $ 19.92 39.90 $ 39.90 24.75 $ 25.29 276.14 $ 304.44 $ 358.87 322.76 $ 355.85 $ 437.49 8.28 $ 9.27 $ 10.42 8.28 $ 8.69 $ 9.54 228.71 $ 252.15 $ 279.36 249.69 $ 249.69 620.00 $ 620.00 150.00 $ 150.00 150.00 $ 150.00