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 06/30/2022 DCW adjustment included EVV adjustment included Rev. 12/01/2022
Enhanced Rate (includes PHE) as of 07/01/2022
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 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
Q Q Q Q Q Q Q C C D D D D
D D D
D D D D D C D D D
D D D D D D D D
E D D D D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
32.64 32.64 1.74 31.25 53.65 20.00 10.00 28.00 30.00 10.00 341.86 163.60 253.90 22.31 140.41 423.28 291.66 242.06 393.47 17.43 141.96 18.81 4.53 456.27 0.01 5.92 5.92 7.94 7.94 93.70 94.50 9.00 33.74 4.00 38.87 39.68 38.87 38.87 39.68 7.58 221.36 221.36 143.78 149.03 4.31 161.15 13.67 7.49 284.02 45.52 3.36 14.10 30.20 4.20 3.36
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 06/30/2022 DCW adjustment included EVV adjustment included Rev. 12/01/2022
Enhanced Rate (includes PHE) as of 07/01/2022
Service
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 S5110U4 ‐ DI Natural Supports Education ‐ Individual S5145 ‐ CTSP Residential II S5145HA ‐ CTSP FAM TYPE RES II IAFT S5145HK ‐ Enh Rate Therapeutic Foster Care S5145U5 ‐ Enhanced Therapeutic Foster Care S5150HQU4 ‐ DI Respite ‐ Group S5150U4 ‐ DI Respite ‐ Individual S5150USU4 ‐ DI Respite ‐ Facility S9484 ‐ FAC BASED CRISIS HR S9484HA ‐ FAC BASED CRISIS HR ‐ Child & Adol 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 T1019U4TS ‐ Individual Support ‐ non‐EVV, only in the community T1023 ‐ DIAGNOSTIC‐ASSESSMENT T2012GCHQU4 ‐ DI Community Living and Supports ‐ Group, relative as provider lives in ho T2012GCU4 ‐ DI Community Living and Supports, relative as provider lives in home T2012HQU4 ‐ DI Community Living and Supports ‐ Group, only in the community T2012U4 ‐ DI Community Living and Supports, only in the community T2013TFHQU4 ‐ DI Community Living and Supports‐ Group T2013TFU4 ‐ DI Community Living and Supports T2013U4 ‐ B3 non‐DI In Home Skill Building 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
D D D D D
D D D D D D D C C
D, E D D D D D D, E D, E D, E D D D D D D D D D D
D D D D, E D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
9.96 9.96 3.36 14.10 39.19 48.37 21.25 10.30 175.00 285.66 175.00 175.00 4.76 6.81 169.48 31.50 31.50 15.60 15.60 15.60 15.60 15.00 13.74 12.54 242.87 4.71 7.15 4.71 7.15 5.13 7.80 13.14 177.11 183.15 450.00 116.47 144.07 155.57 163.09 158.94 205.02 210.27 17.39 29.44 39.90 19.92 39.90 25.29 358.87 437.49 10.42 9.54 279.36 249.69 620.00
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 06/30/2022 DCW adjustment included EVV adjustment included Rev. 12/01/2022
Enhanced Rate (includes PHE) as of 07/01/2022
Service
T2041U4 ‐ B‐3 DI Community Navigator ‐ Monthly T2041U4U5 ‐ B‐3 Community Guide ‐ Monthly
$ $
150.00 150.00