Standard Rate Schedule: Medicaid 1915(c) * This service is subject to a COVID‐19/PHE Rate Enhancement. rev. 11/29/21
Service
* Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
Rate $ 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
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 9.00 $ 5.74 $ 5.74 $ 5.45 $ 3.13 $ 3.13 $ 2.97 $ 105.25 $ 165.15 $ 170.30 $ 110.25 $ 7.76 $ 7.37 $ 7.76 $ 3.23 $ 3.07 $ 3.23 $ 7.76 $ 7.37 $ 7.76
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 ‐ AWC ‐ Community Networking Service ‐ Ind H2015 ‐ Community Networking Service ‐ Ind H2015 ‐ EOR ‐ Community Networking Service ‐ Ind H2015HQ ‐ AWC ‐ Community Networking Group H2015HQ ‐ Community Networking Group H2015HQ ‐ EOR ‐ Community Networking Group H2016 ‐ Level 1‐Residential Supports H2016HI ‐ Level 4‐Residential Supports H2016HIU2 ‐ Level 4 AFL‐Residential Supports H2016U2 ‐ Level 1 AFL Residential Supports H2025 ‐ AWC ‐ Supported Employment ‐ Ind H2025 ‐ EOR ‐ Supported Employment ‐ Ind H2025 ‐ Supported Employment ‐ Ind H2025HQ ‐ AWC ‐ Supported Employment Group H2025HQ ‐ EOR ‐ Supported Employment Group H2025HQ ‐ Supported Employment Group H2025TS ‐ AWC ‐ Supported Employment – Long Term Follow‐up H2025TS ‐ EOR ‐ Supported Employment – Long Term Follow‐up H2025TS ‐ Supported Employment – Long Term Follow‐up
* * * * * * * * * * * * * * * * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
H2025TSHQ ‐ AWC ‐ Supported Employment – Long Term Follow‐up ‐ Group
*
1/1/2022
6/30/2022 $ 2.53
H2025TSHQ ‐ EOR Supported Employment – Long Term Follow‐up ‐ Group H2025TSHQ ‐ Supported Employment – Long Term Follow‐up ‐ Group S5110 ‐ Natural Supports Education: Individual S5150 ‐ AWC ‐ Respite ‐ Non‐inst Individual S5150 ‐ EOR ‐ Respite ‐ Non‐inst Individual S5150 ‐ Respite ‐ Non‐inst Individual
* *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
* * *
$ 2.40 $ 2.53 $ 8.96 $ 4.00 $ 3.80 $ 4.00
Standard Rate Schedule: Medicaid 1915(c) * This service is subject to a COVID‐19/PHE Rate Enhancement. rev. 11/29/21
Service S5150HQ ‐ AWC ‐ Respite ‐ Group S5150HQ ‐ EOR ‐ Respite ‐ Group S5150HQ ‐ Respite ‐ Group S5150US ‐ Respite: Facility 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
* Effective Date * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022
T2012 ‐ Community Living and Supports ‐ Non‐EVV, only in the community * T2012GC ‐ Community Living and Supports ‐ Non‐EVV, relative as provider lives in home * T2012HQ ‐ Community Living and Supports ‐ Group ‐Non‐EVV, only in the community * T2012GCHQ ‐ Community Living and Supports ‐ Group ‐ Non‐EVV, relative as provider lives in home * T2013TF ‐ AWC ‐ Community Living and Supports * T2013TF ‐ Community Living and Supports * T2013TF ‐ EOR ‐ Community Living and Supports * T2013TFHQ ‐ AWC ‐ Community Living and Supports‐ Group * T2013TFHQ ‐ Community Living and Supports‐ Group * T2013TFHQ ‐ EOR ‐ Community Living and Supports‐ Group * * T2014 ‐ Level 2 ‐ Residential Supports T2014U2 ‐ Level 2 AFL ‐ Residential Supports * T2020 ‐ Level 3 ‐ Residential Supports * T2020U2 ‐ Level 3 AFL ‐ Residential Supports * T2021 ‐ Day Support ‐ Individual T2021HQ ‐ Day Support Group 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 T2033 ‐ AWC ‐ Supported Living – Level 1 * T2033 ‐ EOR ‐ Supported Living – Level 1 * T2033 ‐ Supported Living – Level 1 * T2033HI ‐ AWC ‐ Supported Living – Level 2 * * T2033HI ‐ EOR ‐ Supported Living – Level 2 T2033HI ‐ Supported Living – Level 2 * T2033TF ‐ AWC ‐ Supported Living – Level 3 * T2033TF ‐ EOR ‐ Supported Living – Level 3 *
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
Rate $ 2.90 $ 2.76 $ 2.90 $ 129.95 $ 10.40 $ 9.88 $ 10.40 $ 10.40 $ 9.88 $ 10.40
1/1/2022
6/30/2022 $ 5.38
1/1/2022
6/30/2022 $ 5.38
1/1/2022
6/30/2022 $ 3.54
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 3.54 $ 5.38 $ 5.38 $ 5.11 $ 3.54 $ 3.54 $ 3.36 $ 132.86 $ 132.86 $ 155.97 $ 155.97 $ 25.88 $ 15.84 $ 39.90 $ 39.90 $ 175.00 $ 150.00 $ 19.92 $ 25.75 $ 160.09 $ 152.09 $ 160.09 $ 193.29 $ 183.63 $ 193.29 $ 225.93 $ 214.63
Standard Rate Schedule: Medicaid 1915(c) * This service is subject to a COVID‐19/PHE Rate Enhancement. rev. 11/29/21
Service T2033TF ‐ Supported Living – Level 3 T2033U1 ‐ AWC ‐ Supported Living ‐ Periodic T2033U1 ‐ EOR ‐ Supported Living ‐ Periodic T2033U1 ‐ Supported Living ‐ Periodic T2033U2 ‐ Supported Living ‐ Transition T2034 ‐ Crisis Services: Out of Home T2041 ‐ Community Navigator: Monthly T2041U1 ‐ Community Navigator: Periodic and Start Up Training T2041U1U6 ‐ Community Navigator: IFDS Orientation
* Effective Date * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 * 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
Rate $ 225.93 $ 5.52 $ 5.24 $ 5.52 $ 5.52 $ 249.69 $ 150.00 $ 620.00 $ 35.00