Standard Rate Schedule: Medicaid 1915(c) Inv
Invoice‐based: Provider submits actual costs to the Vaya Health
E
EVV adjustment included
D
DCW adjustment included Rev. 12/01/2022
Enhanced Rate (includes PHE) as of 07/01/2022
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
Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv
$ $ $ $ $ $ $ $ $ $ $ $ $ $
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
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
D D D D D
$ $ $ $ $ $
9.00 7.58 7.20 4.00 3.79 3.48
H2015HQXUCR ‐ EOR Community Networking Group, retainer pymt, disaster related H2015U1 ‐ Community Networking ‐ Class & Conf H2015U2 ‐ Community Networking ‐ Transportation
D Inv Inv
$ $ $
3.30 ‐ ‐
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
D
$
6.59
D D D D D D
$ $ $ $ $ $
6.27 143.78 149.03 216.11 221.36 193.33
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
D D D D D D D
$ $ $ $ $ $ $
198.58 130.27 135.52 9.47 9.96 4.00 4.20
Standard Rate Schedule: Medicaid 1915(c) Inv
Invoice‐based: Provider submits actual costs to the Vaya Health
E
EVV adjustment included
D
DCW adjustment included Rev. 12/01/2022
Enhanced Rate (includes PHE) as of 07/01/2022
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
D D D D D D
$ $ $ $ $ $
3.33 3.50 9.47 9.96 3.19 3.36
D
$
7.89
D D D
Inv D D
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
8.30 7.89 8.30 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
D D E, D E, D E, D E, D
$ $ $ $ $ $
4.71 4.71 7.80 7.43 5.13 4.89
D
$
4.10
D D
$ $
3.89 6.22
Inv D D D D D Inv
Standard Rate Schedule: Medicaid 1915(c) Inv
Invoice‐based: Provider submits actual costs to the Vaya Health
E
EVV adjustment included
D
DCW adjustment included Rev. 12/01/2022
Enhanced Rate (includes PHE) as of 07/01/2022
Service
T2013TFXUCR ‐ EOR Community Living and Supports, retainer pymt, disaster related 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 T2025U3 ‐ Crisis Services: Crisis Consultation T2027 ‐ Day Supports: Developmental Day T2027XUCR ‐ Day Supports: Developmental Day, retainer pymt, disaster related T2029 ‐ Assistive Technology ‐ Equip & Supplies T2029MM ‐ ATES ‐ Monitoring / Connectivity and Nutritional Charges 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 T2038 ‐ Community Transition T2039 ‐ Vehicle Modifications T2041 ‐ Community Navigator: Monthly
D D D D D D D D D D D D
Inv D D Inv Inv D D D D D D D D D D E, D E, D D D D D Inv Inv
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
5.90 177.11 183.15 154.01 205.02 210.27 178.28 183.53 29.44 17.39 17.39 29.44 39.90 39.90 175.00 ‐ 19.92 25.29 25.29 ‐ ‐ 265.40 279.36 340.92 358.87 227.29 239.24 415.61 437.49 277.07 291.66 9.42 10.42 6.04 9.54 176.93 186.24 249.69 ‐ ‐ 150.00
Standard Rate Schedule: Medicaid 1915(c) Inv
Invoice‐based: Provider submits actual costs to the Vaya Health
E
EVV adjustment included
D
DCW adjustment included Rev. 12/01/2022
Service
T2041U1 ‐ Community Navigator: Periodic and Start Up Training T2041U1U6 ‐ Community Navigator: IFDS Orientation
Enhanced Rate (includes PHE) as of 07/01/2022
$ $
620.00 35.00