Standard Rate Schedule: Medicaid 1915(c) Inv Invoice-based - Provider submits actual costs to Finance Dept. E EVV adjustment included D DCW adjustment included 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 H2015HQXUCR - Community Networking Group, retainer pymt, disaster related H2015HQXUCR - EOR Community Networking Group, retainer pymt, disaster related H2015U1 - Community Networking - Class & Conf H2015U2 - Community Networking - Transportation H2015XUCR - Community Networking Service - Ind, retainer pymt, disaster related H2015XUCR - EOR Community Networking Service - Ind, retainer pymt, disaster related H2016 - Level 1-Residential Supports H2016U2 - Level 1 AFL 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 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
Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ D $ D $ D $ D $ D $ D $ Inv $ Inv $ D $ D $ D $ D $ D $ D $ D $ D $ D $ D $ D $ D $ D $ D $
Rate as of 1/1/2022 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 9.00 6.60 6.27 3.60 3.42 3.13 2.97 1.00 1.00 5.74 5.45 121.04 126.79 189.92 196.12 170.30 170.30 110.25 110.25 8.85 9.31 3.69 3.88
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 2/1/2022 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 9.00 6.60 6.27 3.60 3.42 3.13 2.97 1.00 1.00 5.74 5.45 121.04 126.79 189.92 196.12 170.30 170.30 110.25 110.25 8.85 9.31 3.69 3.88
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 3/1/2022 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 9.00 6.93 6.58 3.78 3.59 3.48 3.30 1.00 1.00 6.59 6.27 127.09 133.13 199.42 205.93 193.33 198.58 130.27 135.52 8.85 9.31 3.69 3.88
rev. 06/08/22
Revised Rate 4/1/2022
$ $ $ $
7.58 7.20 4.00 3.79
$ $ $ $
143.78 149.03 216.11 221.36
$ $ $ $
9.47 9.96 4.00 4.20
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice-based - Provider submits actual costs to Finance Dept. E EVV adjustment included D DCW adjustment included Service 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 H2025TSXUCR - Supported Employment – Long Term Follow-up, retainer pymt, disaster related H2025XUCR - EOR Supported Employment - Ind, retainer pymt, disaster related 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 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 T2013TF - EOR Community Living and Supports T2013TFHQ - Community Living and Supports- Group T2013TFHQ - EOR Community Living and Supports-Group T2013TFHQXUCR - Community Living and Supports- Group, retainer pymt, disaster related T2013TFHQXUCR - EOR Community Living and Supports- Group, retainer pymt, disaster related T2013TFXUCR - Community Living and Supports, retainer pymt, disaster related T2013TFXUCR - EOR Community Living and Supports, retainer pymt, disaster related
D D D D D D D D D D Inv D D D D D Inv
Inv D D D D E, D E, D E, D E, D D D D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 1/1/2022 3.07 3.23 8.85 9.31 2.89 3.04 7.37 7.76 7.37 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 6.19 4.07 4.07 6.19 5.88 4.07 3.87 3.54 3.36 5.38 5.11
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 2/1/2022 3.07 3.23 8.85 9.31 2.89 3.04 7.37 7.76 7.37 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 6.19 4.07 4.07 6.81 6.50 4.48 4.28 3.54 3.36 5.38 5.11
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 3/1/2022 3.33 3.50 8.85 9.31 2.89 3.04 7.89 8.30 7.89 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 6.50 6.50 4.27 4.27 7.15 6.83 4.70 4.49 4.10 3.89 6.22 5.90
rev. 06/08/22
Revised Rate 4/1/2022
$ $ $ $
9.47 9.96 3.19 3.36
$
10.30
$ $ $ $ $
6.47 6.81 4.53 4.76 169.48
$ $ $ $ $ $
15.60 14.82 15.60 15.60 14.82 15.60
$ $ $ $ $ $ $ $
7.15 7.15 4.71 4.71 7.80 7.43 5.13 4.89
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice-based - Provider submits actual costs to Finance Dept. E EVV adjustment included D DCW adjustment included Service T2014 - Level 2 - Residential Supports T2014U2 - Level 2 AFL - Residential Supports T2014XUCR - Level 2 - Residential Supports, retainer pymt, disaster related T2020 - Level 3 - Residential Supports T2020U2 - Level 3 AFL - Residential Supports 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 T2025U2U1 - Employer Supplies - start-up costs T2025U2U1 - Employer Supplies - start-up costs T2025U3 - Crisis Services: Crisis Consultation T2027 - Day Supports: Developmental Day T2027XUCR - Day Supports: Developmental Day, retainer pymt, disaster related T2029 - Assistive Technology - Equip & Supplies T2033 - EOR Supported Living – Level 1 T2033 - Supported Living – Level 1 T2033HI - EOR Supported Living – Level 2 T2033HI - Supported Living – Level 2 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 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 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
D D D D D D D D D D D
Inv D D Inv D D D D D D D D D D E, D E, D D D D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 1/1/2022 152.79 152.79 132.86 179.37 179.37 155.97 155.97 25.88 15.84 15.84 25.88 39.90 39.90 175.00 150.00 1.00 19.92 24.75 24.75 1.00 228.13 240.14 275.44 289.94 183.63 193.29 321.96 338.90 214.63 225.93 7.87 8.28 5.24 8.28 152.09 160.09 249.69
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 2/1/2022 152.79 152.79 132.86 179.37 179.37 155.97 155.97 25.88 15.84 15.84 25.88 39.90 39.90 175.00 150.00 1.00 19.92 24.75 24.75 1.00 228.13 240.14 275.44 289.94 183.63 193.29 321.96 338.90 214.63 225.93 8.70 9.11 5.24 8.28 152.09 160.09 249.69
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 3/1/2022 160.43 165.68 154.01 188.34 193.59 178.28 183.53 29.44 17.39 17.39 29.44 39.90 39.90 175.00 150.00 1.00 19.92 25.29 25.29 1.00 239.54 252.15 289.21 304.44 227.29 239.24 338.06 355.85 277.07 291.66 8.70 9.57 6.04 8.69 176.93 186.24 249.69
rev. 06/08/22
Revised Rate 4/1/2022 $ 177.11 $ 183.15 $ $
205.02 210.27
$ $ $ $
265.40 279.36 340.92 358.87
$ $
415.61 437.49
$ $
9.42 10.42
$
9.54
Standard Rate Schedule: Medicaid 1915(c) Inv Invoice-based - Provider submits actual costs to Finance Dept. E EVV adjustment included D DCW adjustment included 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 $ $ $ $
Rate as of Rate as of Rate as of 1/1/2022 2/1/2022 3/1/2022 1.00 $ 1.00 1.00 $ 1.00 $ 1.00 $ 1.00 150.00 $ 150.00 $ 150.00 620.00 $ 620.00 $ 620.00 35.00 $ 35.00 $ 35.00
rev. 06/08/22
Revised Rate 4/1/2022