Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Non-Clinician-Based Q C D E
Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included Rev. 05/26/22
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 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 H0046 ‐ High Risk Res L1 H2011 ‐ CRISIS SERVICES
Q Q Q Q Q Q Q C C D D D D
D D D
D D D D D C
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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 86.25 94.50
Rate as of 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 86.25 94.50
Rate as of 3/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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 21.25 133.72 393.47 267.81 218.21 342.15 16.60 135.20 18.00 4.32 456.27 0.01 5.51 5.51 7.13 7.13 86.25 94.50
Rate as of 4/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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 21.25 133.72 368.07 253.62 210.49 342.15 16.60 135.20 12.54 3.02 304.18 0.01 3.94 3.94 5.29 5.29 81.48 94.50
PHE %
Revised Rate as of 4/1/22
15% 15% 15% 15%
$ $ $ $
423.28 291.66 242.06 393.47
50% 50% 50%
$ $ $
18.81 4.53 456.27
50% 50% 50% 50% 15%
$ $ $ $ $
5.92 5.92 7.94 7.94 93.70
Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Non-Clinician-Based Q C D E
Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included Rev. 05/26/22
Rate as of 1/1/2022
Service
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 H2026U4 ‐ IDD non‐DI Maint Individual Supported Employment H2033 ‐ MULTI‐SYSTEMIC‐THER H2035 ‐ SA Comprehensive Outpatient Trt Prog Q3014GT ‐ TELEHEALTH ORIG SITE FEE
D D D
D D D D D D D D
E D D D D D D D D D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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 7.49 258.20 41.38 3.04 13.45 24.63 3.88 3.04 9.31 9.31 3.04 13.45 37.32 45.35 21.25
Rate as of 2/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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 7.49 258.20 45.52 3.04 13.45 24.63 3.88 3.04 9.31 9.31 3.04 13.45 37.32 45.35 21.25
Rate as of 3/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
9.00 32.13 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 7.49 258.20 45.52 3.04 13.45 24.63 3.88 3.04 9.31 9.31 3.04 13.45 37.32 46.07 21.25
Rate as of 4/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
9.00 32.13 3.31 25.91 26.45 25.91 25.91 26.45 6.28 178.97 183.97 119.07 124.07 2.87 140.13 13.67 7.49 258.20 45.52 2.80 11.75 25.17 3.50 2.80 8.30 8.30 2.80 11.75 37.32 46.07 21.25
PHE %
Revised Rate as of 4/1/22
15% 50% 50% 50% 50% 50% 15% 15% 15% 15% 15% 50% 15%
$ $ $ $ $ $ $ $ $ $ $ $ $
3.81 38.87 39.68 38.87 38.87 39.68 7.22 205.82 210.82 136.93 141.93 4.31 161.15
20% 20% 20% 20% 20% 20% 20% 20% 20%
$ $ $ $ $ $ $ $ $
3.36 14.10 30.20 4.20 3.36 9.96 9.96 3.36 14.10
Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Non-Clinician-Based Q C D E
Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included Rev. 05/26/22
Service
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 ho 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 T2014U4 ‐ DI Level 2 ‐ Residential Supports D 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
Rate as of 1/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
10.30 175.00 265.79 175.00 175.00 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 11.45 145.51 151.16 450.00 96.60 124.20 135.70
Rate as of 2/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
10.30 175.00 265.79 175.00 175.00 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 12.60 145.51 151.16 450.00 96.60 124.20 135.70
Rate as of 3/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
10.30 175.00 265.79 175.00 175.00 4.35 6.00 149.44 31.50 31.50 15.60 15.60 15.60 15.60 15.00 13.74 12.54 231.30 4.07 6.19 4.07 6.19 4.27 6.81 13.14 152.79 157.79 450.00 101.28 125.28 135.70
Rate as of 4/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
8.96 175.00 248.40 175.00 175.00 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 3.90 5.92 3.90 5.92 4.25 6.46 13.14 146.68 151.68 450.00 101.28 125.28 135.28
PHE %
Revised Rate as of 4/1/22
15%
$
10.30
15%
$
285.66
50% 50% 15%
$ $ $
4.76 6.81 169.48
50% 50% 50% 50%
$ $ $ $
15.60 15.60 15.60 15.60
15% 15% 15% 15% 15% 15%
$ $ $ $ $ $
4.49 6.81 4.49 6.81 4.89 7.43
15% 15%
$ $
168.68 173.68
15% 15% 15%
$ $ $
116.47 144.07 155.57
Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Non-Clinician-Based Q C D E
Requires LQASP ‐ Licensed Qualified Autism Services Practitioner COVID‐19 adjustment previously extended to 6/30/2022 DCW adjustment included EVV adjustment included Rev. 05/26/22
Rate as of 1/1/2022
Service
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, E $ D $ D $ $ $ $ $
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
Rate as of 2/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Rate as of 3/1/2022
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 $
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 8.28 240.14 249.69 620.00 150.00 150.00
Rate as of 4/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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 6.06 177.37 249.69 620.00 150.00 150.00
PHE %
Revised Rate as of 4/1/22
15% 15% 15% 15%
$ $ $ $
163.09 158.94 195.26 200.26
50% 50% 50% 50% 50%
$ $ $ $ $
341.78 416.66 9.92 9.09 266.06