NOTICES
Medical Assistance Program Fee Schedule for Select Services in the Consolidated and Person/Family Directed Support Waivers and Community Mental Retardation Base Program
[39 Pa.B. 3238]
[Saturday, June 27, 2009]Purpose
This notice is to announce the Department of Public Welfare's (Department) addition of payment rates for select services provided in the Consolidated waiver and Person/Family Directed Support (P/FDS) waiver to the Medical Assistance (MA) Program Fee Schedule. These fee schedule payment rates will also serve as the Department's established fees under 55 Pa. Code § 4300.115(a) (relating to Department established fees) for base-funded services managed through county programs for individuals with mental retardation under the Mental Health and Mental Retardation Act of 1966 (50 P. S. §§ 4104--4704) and 55 Pa. Code Chapter 4300 (relating to county mental health and mental retardation fiscal manual).
The Department is responsible for management of the Consolidated and P/FDS waivers (waivers). As a condition of approving renewal of the Consolidated and the P/FDS waivers, the Federal Centers for Medicare and Medicaid Services (CMS) directed that the Department develop a Statewide rate-setting methodology for both waivers. The Department established a Financial Implementation Advisory Team (FIAT), consisting of representatives from consumers, providers and county stakeholders, to provide input to the Department in establishing the payment methodology.
Based on input from the FIAT, the Department determined that payment rates for select services under the waivers would be placed on a fee schedule, while payment rates for other services would be established through submission of cost reports by providers. The services selected for inclusion on the fee schedule are listed as follows under the following categories: Select Community-Based Services; Unlicensed Out-of-Home Respite and Respite Camp ''Ineligible'' Services (Room and Board); Agency with Choice/Financial Management Services, Excluding Benefits; and Agency with Choice/Financial Management Services, Including Benefits.
To establish the fee schedule payment rates for these categories of services, the Department established rate ranges for each of the selected services based on allowable cost components. The Department reviewed the rate ranges, selected a rate within the range, and adjusted each rate by geographical area factors that consider differences in wages across this Commonwealth.
Specifically, the Department developed the rate ranges by evaluating independent data sources to reflect expected expenses for major cost categories, such as wages for direct care workers and other staff; staff benefits; employer taxes; staff productivity; staff ratios; and program-related expenses for transportation, supplies, staff training and occupancy. Administrative expenses were also considered, except for the Agency with Choice/Financial Management Services (AWC/FMS) rates. Administrative expenses for AWC/FMS providers were negotiated by the Department and the AWC/FMS providers, and will be paid as a separate administrative fee to these providers.
The resulting rate ranges were compared to rates for comparable services in other Department service delivery systems, and to rates and utilization data for comparable services in the waivers. For services with low Statewide utilization data, the Department assigned the midpoint rate to that service. For other services, the Department assigned a rate based on the factors identified previously and the type of service, work performed and qualifications necessary to render the service.
As a final step in determining the fee schedule rates, the Department adjusted the payment rates based on wage differences for four geographic areas as identified as follows. These adjustments were not made to the rates for ineligible services for unlicensed out-of-home respite. Rates for those services were based on expected meal costs consistent with data published by the United States Department of Agriculture and do not vary by area.
Geographic Areas:
Area 1:
Bucks, Chester, Delaware, Lehigh, Montgomery, Northampton, Philadelphia
Area 2:
Adams, Allegheny, Beaver, Berks, Carbon, Cumberland, Dauphin, Erie, Franklin, Fulton, Greene, Lancaster, Lawrence, Lebanon, Monroe, Perry, Pike, Schuylkill, Washington, York
Area 3:
Armstrong, Bradford, Butler, Cameron, Centre, Clarion, Clinton, Columbia, Crawford, Elk, Forest, Indiana, Huntingdon, Juniata, Lackawanna, Luzerne, Lycoming, McKean, Mercer, Mifflin, Montour, Northumberland, Potter, Snyder, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Westmoreland, Wyoming
Area 4:
Bedford, Blair, Cambria, Clearfield, Fayette, Jefferson, Somerset
Fee Schedule Rates:
Select Community-Based Services
Service Procedure Code Modifier Provider Type Specialty Code Unit Area 1 Area 2 Area 3 Area 4 Nursing Services: LPN T2025 TE 05
______
16051, 160, 161 15 minutes $11.02 $10.31 $9.78 $8.89 Nursing Services: RN T2025 TD 05
______
16051, 160, 161 15 minutes $16.55 $15.48 $14.68 $13.35 Physical Therapy T2025 GP 17 170 15 minutes $15.64 $14.63 $13.87 $12.61 Occupational Therapy T2025 GO 17 171 15 minutes $17.12 $16.02 $15.19 $13.81 Speech/
Language TherapyT2025 GN 17 173 15 minutes $18.73 $17.52 $16.62 $15.10 Individual Behavioral Therapy T2025 HE 19 208 15 minutes $16.50 $15.44 $14.64 $13.31 Group Behavioral Therapy T2025 HE & HQ 19 208 15 minutes $4.12 $3.85 $3.65 $3.32 Visual/
Mobility TherapyW7246 51 517 15 minutes $18.73 $17.52 $16.62 $15.10 Home Finding W7277 51
______
55571 15 minutes $9.99 $9.35 $8.86 $8.06 Behavioral Support W7095 51 510 15 minutes $17.96 $16.80 $15.93 $14.48 Homemaker/
ChoreW7283
______
UA43, 51, 55 430, 431 Hour $22.87 $21.39 $20.29 $18.44 Companion Services, Basic Staff Support W1724 51 363 15 minutes $ .79 $ .74 $ .70 $ .64 Companion Services, Level 1 W1725 51 363 15 minutes $ .99 $ .93 $ .88 $ .80 Companion Services, Level 2 W1726 51 363 15 minutes $2.09 $1.96 $1.85 $1.69 Companion Services, Level 3 W1727 51 363 15 minutes $4.69 $4.39 $4.16 $3.78 Supports Broker W7096 51 510 15 minutes $10.85 $10.15 $9.63 $8.75
Unlicensed Out-of-Home Respite and Respite Camp Ineligible Services (Room and Board)
Service Procedure Code Provider Type Specialty Code Unit Areas 1 through 4 Respite-- Unlicensed out of home, ineligible W6066 51 513 15 minutes $4.00/unit, max of 3 units per day W6067 51 513 15 minutes $4.00/unit, max of 3 units per day W6068 51 513 15 minutes $4.00/unit, max of 3 units per day W6069 51 513 15 minutes $4.00/unit, max of 3 units per day W6070 51 513 15 minutes $4.00/unit, max
of 3 units per dayW6071 51 513 15 minutes $4.00/unit, max
of 3 units per dayW6060 51 513 Day $12.00/unit, max
of 1 unit per dayW6061 51 513 Day $12.00/unit, max
of 1 unit per dayW6062 51 513 Day $12.00/unit, max
of 1 unit per dayW6063 51 513 Day $12.00/unit, max
of 1 unit per dayW6064 51 513 Day $12.00/unit, max
of 1 unit per dayW6065 51 513 Day $12.00/unit, max
of 1 unit per dayRespite--Camp, Ineligible W8400 51, 55
______
51, 55554, 555
______
554, 55515 minutes $4.00/unit, max
of 3 units per dayW8401 51, 55
______
51, 55554, 555
______
554, 555Day $12.00/unit, max
of 1 unit per day
Agency with Choice/Financial Management Services, Excluding Benefits* * Modifier U4 must be used with all procedures codes when billing for services excluding benefits.
Service Procedure code Modifier Provider Type Specialty Code Unit Area 1 Area 2 Area 3 Area 4 Homemaker/
ChoreW7283 U4
______
U4 & UA43, 51, 55 430
431Hour $13.42 $12.55 $11.91 $10.82 Companion, Level 3 W1727 U4 51 363 15 minutes $3.06 $2.87 $2.72 $2.47 Supports Broker W7096 U4 51 510 15 minutes $6.15 $5.76 $5.46 $4.96 Respite--
Unlicensed out of home, Level 2W8012
______U4
______51
______513
______15 minutes
______
Day$3.48
______$3.26
______$3.09
______$2.81
______W8002 U4 51 513 $223.14 $208.74 $197.94 $179.95 Respite--
Unlicensed out of home, Level 3W8014
______U4
______51
______513
______15 minutes
______$6.97
______$6.52
______$6.19
______$5.62
______W8004 U4 51 513 Day $446.27 $417.48 $395.89 $359.90 Supported Employment W7235 U4 53 531 15 minutes $6.12 $5.73 $5.43 $4.94 Respite--
Unlicensed out of home, Level 2 enhancedW8013
______U4
______51
______513
______15 minutes
______$7.48
______$7.00
______$6.64
______$6.03
______W8003 U4 51 513 Day $478.66 $447.77 $424.61 $386.01 Respite--
Unlicensed out of home, Level 3 enhancedW8015
______U4
______51
______513
______15 minutes
______$14.95
______$13.99
______$13.26
______$12.06
______W8005 U4 51 513 Day $957.31 $895.55 $849.23 $772.02 Respite--
Unlicensed in home, Level 2W7258
______U4
______51
______512
______15 minutes
______$3.48
______$3.26
______$3.09
______$2.81
______W7250 U4 51 512 Day $223.14 $208.74 $197.94 $179.95 Respite--
Unlicensed in home, Level 3W7265
______U4
______51
______512
______15 minutes
______$6.97
______$6.52
______$6.19
______$5.62
______W7252 U4 51 512 Day $446.27 $417.48 $395.89 $359.90 Respite--
Unlicensed in home, Level 2 enhancedW7264
______U4
______51
______512
______15 minutes
______$7.48
______$7.00
______$6.64
______$6.03
______W7251 U4 51 512 Day $478.66 $447.77 $424.61 $386.01 Respite--
Unlicensed in home, Level 3 enhancedW7266
______U4
______51
______512
______15 minutes
______$14.95
______$13.99
______$13.26
______$12.06
______W7253 U4 51 512 Day $957.31 $895.55 $849.23 $772.02 Unlicensed Habilitation, Level 3 W7060 U4 51 510 15 minutes $5.07 $4.74 $4.50 $4.09 Unlicensed Habilitation, Level 4 W7068 U4 51 510 15 minutes $10.13 $9.48 $8.99 $8.17 Unlicensed Habilitation, Level 3 enhanced W7061 U4 51 510 15 minutes $8.39 $7.85 $7.44 $6.77 Unlicensed Habilitation, Level 4 enhanced W7069 U4 51 510 15 minutes $16.77 $15.69 $14.88 $13.52
Agency with Choice/Financial Management Services, Including Benefits** ** No modifier is needed to indicate the benefit allowance is included.
Service Procedure Code Modifier Provider Type Specialty Code Unit Area 1 Area 2 Area 3 Area 4 Homemaker/ Chore W7283
______
UA43, 51, 55 430 431 Hour $16.99 $15.89 $15.07 $13.70 Companion Level 3 W1727 51 363 15 minutes $3.88 $3.63 $3.44 $3.13 Supports Broker W7096 51 510 15 minutes $7.79 $7.29 $6.91 $6.28 Respite--
Unlicensed out of home, Level 2W8012
______
______51
______513
______15 minutes
______$4.41
______$4.13
______$3.91
______$3.56
______W8002 51 513 Day $282.49 $264.26 $250.60 $227.18 Respite--
Unlicensed out of home, Level 3W8014
______
______51
______513
______15 minutes
______$8.83
______$8.26
______$7.83
______$7.12
______W8004 51 513 Day $564.98 $528.53 $501.19 $455.63 Respite--
Unlicensed out of home, Level 2 enhancedW8013
______
______51
______513
______15 minutes
______$9.47
______$8.86
______$8.40
______$7.64
______W8003 51 513 Day $605.98 $566.88 $537.56 $488.69 Respite-- Unlicensed out of home, Level 3 enhanced W8015
______
______51
______513
______15 minutes
______$18.93
______$17.71
______$16.79
______$15.27
______W8005 51 513 Day $1,211.96 $1,133.76 $1,075.12 $977.38 Respite--
Unlicensed in home, Level 2W7258
______
______51
______512
______15 minutes
______$4.41
______$4.13
______$3.91
______$3.56
______W7250 51 512 Day $282.49 $264.26 $250.60 $227.81 Respite--
Unlicensed
in home, Level 3W7265
______
______51
______512
______15 minutes
______$8.83
______$8.26
______$7.83
______$7.12
______W7252 51 512 Day $564.98 $528.53 $501.19 $455.63 Respite--
Unlicensed in home, Level 2 enhancedW7264
______
______51
______512
______15 minutes
______$9.47
______$8.86
______$8.40
______$7.64
______W7251 51 512 Day $605.98 $566.88 $537.56 $488.68 Respite--
Unlicensed in home, Level 3 enhancedW7266
______
______51
______512
______15 minutes
______$18.93
______$17.71
______$16.79
______$15.27
______W7253 51 512 Day $1,211.96 $1,133.76 $1,075.12 $977.38 Unlicensed Habilitation, Level 3 W7060 51 510 15 minutes $6.42 $6.01 $5.70 $5.18 Unlicensed Habilitation, Level 4 W7068 51 510 15 minutes $12.83 $12.00 $11.38 $10.35 Unlicensed Habilitation, Level 3 enhanced W7061 51 510 15 minutes $10.62 $9.93 $9.42 $8.56 Unlicensed Habilitation, Level 4 enhanced W7069 51 510 15 minutes $21.23 $19.83 $18.83 $17.12
Fiscal Impact
There is no anticipated fiscal impact.
Public Comment
Copies of this notice and the description of the methodology used to establish the fee schedule payment rates may be obtained at your local Mental Health/Mental Retardation (MH/MR) County Program/Administrative Entity or regional Office of Developmental Programs in the corresponding regions:
Western Region: Room 302, Pittsburgh State Office Building, 300 Liberty Avenue, Pittsburgh, PA 15222, (412) 880-0535
Northeast Region: Room 315, Scranton State Office Building, 100 Lackawanna Avenue, Scranton, PA 18503, (570) 963-3166
Southeast Region: Room 306, Philadelphia State Office Building, 1400 Spring Garden Street, Philadelphia, PA 19130, (215) 560-2245
Central Region: Room 430, Willow Oak Building, P. O. Box 2675, Harrisburg, PA, (717) 772-6507
Individuals who need contact information for the local MH/MR County Program/Administrative Entity in your region, contact the previously referenced Regional Office of Developmental Programs.
Interested persons are invited to submit written comments regarding this notice to the Department at the following addresses:
By E-mail:
Use subject header ''PN Fee Schedule'' to the Office of Developmental Programs rate setting mailbox at re-ratesetting@state.pa.us.
By postal mail:
Department of Public Welfare
Office of Developmental Programs
Division of Provider Assistance and Rate Setting
4th Floor, Health and Welfare Building
Harrisburg, PA 17120Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-609. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 09-1165. Filed for public inspection June 26, 2009, 9:00 a.m.]
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