NOTICES

Medical Assistance Program Fee Schedule for Select Services in the Consolidated and Person/Family Directed Support Waivers and Community Mental Retardation Base Program

[40 Pa.B. 3621]
[Saturday, June 26, 2010]

Purpose of Notice

 This notice announces the Department of Public Welfare's (Department) proposed payment rates for select services provided in the Consolidated and Person/Family Directed Support (P/FDS) waivers (waivers) to the Medical Assistance (MA) Program Fee Schedule effective July 1, 2010. These proposed fee schedule payment rates 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 services selected for inclusion on the MA 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.

 In addition, three services are added to Select Community-Based services on the 2010-2011 MA Program Fee Schedule: supplemental habilitation, additional individualized staffing and older adult day habilitation. Supplemental habilitation and additional individualized staffing services will also require prior authorization from the Department.

 The Department established proposed rates for each of the selected services on the MA Program Fee Schedule based on allowable cost components. Some of the Fiscal Year (FY) 2010-2011 (10-11) allowable cost components were adjusted from the FY 2009-2010 (09-10) rates. Specifically, for some of the FY 10-11 rates on the Select Community-Based Services table, the Department factored in a travel reimbursement rate obtained from actual FY 09-10 therapy providers in each of the four geographic areas. The Department also factored in a productivity time which reflects current practice Statewide for all therapy services. Similar adjustments for travel reimbursement and productivity time were made for the nursing and supports broker services in FY 10-11.

 Once the proposed fee schedule rates were established, the Department adjusted the proposed rates based on wage differences for four geographic areas as identified as follows. These geographic area adjustments were not made to the proposed rates for unlicensed out-of-home respite and respite camp ineligible services. Proposed 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 geographic area.

 There is no Cost of Living Adjustment (COLA) applied to any of the proposed fee schedule rates in FY 10-11. The Governor's executive budget for FY 10-11 included a 1.0286% reduction in the appropriation for waiver services. The Department reduced all proposed fee schedule rates by 1.0286% to account for the proposed appropriation reduction.

 The proposed fee schedule rates are contingent on the final budget enacted by the General Assembly. The proposed fee schedule rates should be used to process claims submitted to the Provider Reimbursement and Operations Management Information System in electronic format (PROMISe^TM) during FY 10-11 until a notice announcing final fee schedule rates is published.

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 Tables:

Select Community-Based Services*

 * Modifier ET must be used with applicable procedures codes when billing for temporary base-funded services.

 (PA) Prior authorization by ODP must be obtained for this service.

1 hour $22.63 $21.17 $20.08 $18.25

Service	Procedure Code	Modifier	Provider Type	Specialty Code	Unit	Area 1	Area 2	Area 3	Area 4
Nursing Services: LPN	T2025	TE	05	051	15 minutes	$10.91	$10.20	$9.68	$8.80
		TE & ET
		TE	16	161
		TE & ET
Nursing Services: RN	T2025	TD	05	051	15 minutes	$16.38	$15.32	$14.53	$13.21
		TD & ET
		TD	16	160
		TD & ET
Physical Therapy	T2025	GP	17	170	15 minutes	$19.99	$18.70	$17.74	$16.12
		GP & ET
Occupational Therapy	T2025	GO	17	171	15 minutes	$21.07	$19.71	$18.69	$16.99
		GO & ET
Speech and Language Therapy	T2025	GN	17	173	15 minutes	$21.50	$20.11	$19.07	$17.34
		GN & ET
Individual Behavioral Therapy	T2025	HE	19	208	15 minutes	$20.58	$19.25	$18.25	$16.59
		HE & ET
Group Behavioral Therapy	T2025	HE & HQ	19	208	15 minutes	$5.15	$4.81	$4.57	$4.15
		HE, HQ & ET
Visual/ Mobility Therapy	W7246		51	517	15 minutes	$21.51	$20.12	$19.08	$17.34
		ET
Companion Services, Basic staff support	W1724		51	363	15 minutes	$ .77	$ .72	$ .68	$ .62
		ET
Companion Services, level 1	W1725		51	363	15 minutes	$ .97	$ .91	$ .86	$ .78
		ET
Companion Services, level 2	W1726		51	363	15 minutes	$2.05	$1.92	$1.82	$1.65
		ET
Companion Services, level 3	W1727		51	363	15 minutes	$4.60	$4.31	$4.08	$3.71
		ET
Supplemental Habilitation, 1:1(PA)	W7070		52	456, 520, 521 or 522	15 minutes	$4.82	$4.51	$4.28	$3.89
		ET
Supplemental Habilitation, 2:1(PA)	W7084		52	456, 520, 521 or 522	15 minutes	$9.65	$9.03	$8.56	$7.78
		ET
Additional Individualized Staffing, 1:1(PA)	W7085		52	456, 520, 521 or 522	15 minutes	$4.82	$4.51	$4.28	$3.89
Additional Individualized Staffing, 2:1(PA)	W7086		52	456, 520, 521 or 522	15 minutes	$9.65	$9.03	$8.56	$7.78
Older Adult Day Habilitation	W7094		51	410	15 minutes	$2.85	$2.67	$2.53	$2.30
		ET
Behavioral Support	W7095		51	510	15 minutes	$21.30	$19.92	$18.89	$17.18
		ET
Supports Broker	W7096		51	510	15 minutes	$10.74	$10.05	$9.53	$8.66
Homemaker/ Chore (permanent)	W7283		43	430
			51	430 or 431
			55	430 or 431
Homemaker/ Chore (temporary)	W7283	UA	43	430
		UA & ET
		UA	51	430 or 431
		UA & ET
		UA	45	430 or 431
		UA & ET

Unlicensed Out-of-Home Respite and Respite Camp Ineligible Services (Room and Board)

1 day $12.00/unit, max of 1 ineligible unit per day 15 minutes $4.00/unit, max of 3 ineligible units per day

Service	Procedure Code	Provider Type	Specialty Code	Unit	Areas 1 through 4
Respite—unlicensed, out of home, ineligible	W6060	51	513
	W6061	51	513
	W6062	51	513
		54	540 or 541
	W6063	51	513
		54	540 or 541
	W6064	51	513
		54	540 or 541
	W6065	51	513
		54	540 or 541
	W6066	51	513
	W6067	51	513
	W6068	51	513
		54	540 or 541
	W6069	51	513
		54	540 or 541
	W6070	51	513
		54	540 or 541
	W6071	51	513
		54	540 or 541
Respite—camp, ineligible	W8400	55	555	15 minutes	$4.00/unit, max of 3 ineligible units per day
		54	540 or 541
	W8401	55	554	1 day	$12.00/unit, max of 1 ineligible unit per day
		54	540 or 541

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
Companion, level 3	W1727	U4	54	540	15 minutes	$3.03	$2.84	$2.69	$2.45
Unlicensed Habilitation, level 3	W7060	U4	54	540	15 minutes	$5.02	$4.70	$4.45	$4.05
Unlicensed Habilitation, level 3, enhanced	W7061	U4	54	540	15 minutes	$8.30	$7.77	$7.36	$6.70
		TD & U4
		TE & U4
Unlicensed Habilitation, level 4	W7068	U4	54	540	15 minutes	$10.03	$9.38	$8.90	$8.09
Unlicensed Habilitation, level 4, enhanced	W7069	U4	54	540	15 minutes	$16.60	$15.53	$14.72	$13.38
		TD & U4
		TE & U4
Supports Broker	W7096	U4	54	540	15 minutes	$6.09	$5.70	$5.40	$4.91
Respite— unlicensed, in home, level 2	W7250	U4	54	540	1 day	$220.84	$206.59	$195.91	$178.10
	W7258	U4	54	540	15 minutes	$3.45	$3.23	$3.06	$2.78
Respite— unlicensed, in home, level 2, enhanced	W7251	U4	54	540	1 day	$473.73	$443.17	$420.25	$382.04
			TD & U4
		TE & U4
	W7264	U4	54	540	15 minutes	$7.40	$6.93	$6.57	$5.97
		TD & U4
		TE & U4
Respite— unlicensed in home, level 3	W7252	U4	54	540	1 day	$441.68	$413.19	$391.81	$356.19
	W7265	U4	54	540	15 minutes	$6.90	$6.46	$6.12	$5.57
Respite— unlicensed, in home, level 3, enhanced	W7253	U4	54	540	1 day	$947.46	$886.34	$840.49	$764.08
		TD & U4
		TE & U4
	W7266	U4	54	540	15 minutes	$14.80	$13.84	$13.13	$11.93
		TD & U4
		TE & U4
Homemaker/ Chore	W7283	U4	54	540	1 hour	$13.28	$12.43	$11.78	$10.71
		UA & U4
Respite— unlicensed, out of home, level 2	W8002	U4	54	540	1day	$220.84	$206.59	$195.91	$178.10
	W8012	U4	54	540	15 minutes	$3.45	$3.23	$3.06	$2.78
Respite— unlicensed, out of home, level 2, enhanced	W8003	U4	54	540	1 day	$473.73	$443.17	$420.25	$382.04
		TD & U4
		TE & U4
	W8013	U4	54	540	15 minutes	$7.40	$6.93	$6.57	$5.97
		TD & U4
		TE & U4
Respite— unlicensed, out of home, level 3	W8004	U4	54	540	1 day	$441.68	$413.19	$391.81	$356.19
	W8014	U4	54	540	15 minutes	$6.90	$6.46	$6.12	$5.57
Respite— unlicensed, out of home, level 3, enhanced	W8005	U4	54	540	1 day	$947.46	$886.34	$840.49	$764.08
		TD & U4
		TE & U4
	W8015	U4	54	540	15 minutes	$14.80	$13.84	$13.13	$11.93
		TD & U4
		TE & U4

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
Companion, level 3	W1727		54	540	15 minutes	$3.84	$3.59	$3.41	$3.10
Unlicensed Habilitation, level 3	W7060		54	540	15 minutes	$6.35	$5.94	$5.64	$5.12
Unlicensed Habilitation, level 3, enhanced	W7061		54	540	15 minutes	$10.51	$9.83	$9.32	$8.48
		TD
		TE
Unlicensed Habilitation, level 4	W7068		54	540	15 minutes	$12.70	$11.88	$11.26	$10.24
Unlicensed Habilitation, level 4, enhanced	W7069		54	540	15 minutes	$21.01	$19.66	$18.64	$16.94
		TD
		TE
Supports Broker	W7096		54	540	15 minutes	$7.71	$7.21	$6.84	$6.22
Respite— unlicensed, in home, level 2	W7250		54	540	1 day	$279.58	$261.55	$248.02	$225.47
	W7258		54	540	15 minutes	$4.36	$4.08	$3.87	$3.52
Respite— unlicensed, in home, level 2, enhanced	W7251		54	540	1 day	$599.74	$561.05	$532.03	$483.66
		TD
		TE
	W7264		54	540	15 minutes	$9.37	$8.77	$8.31	$7.56
		TD
		TE
Respite— unlicensed, in home, level 3	W7252		54	540	1 day	$559.17	$523.09	$496.04	$450.94
	W7265		54	540	15 minutes	$8.74	$8.18	$7.75	$7.05
Respite— unlicensed, in home, level 3, enhanced	W7253		54	540	1 day	$1,199.49	$1,122.10	$1,064.06	$967.33
		TD
		TE
	W7266		54	540	15 minutes	$18.74	$17.53	$16.62	$15.11
		TD
		TE
Homemaker/ Chore	W7283		54	540	1 hour	$16.82	$15.73	$14.92	$13.56
UA
Respite— unlicensed, out of home, level 2	W8002		54	540	1 day	$279.58	$261.55	$248.02	$225.47
	W8012		54	540	15 minutes	$4.36	$4.08	$3.87	$3.52
Respite— unlicensed, out of home, level 2, enhanced	W8003		54	540	1 day	$599.74	$561.05	$532.03	$483.66
		TD
		TE
	W8013		54	540	15 minutes	$9.37	$8.77	$8.31	$7.56
		TD
		TE
Respite— unlicensed, out of home, level 3	W8004		54	540	1 day	$559.17	$523.09	$496.04	$450.94
	W8014		54	540	15 minutes	$8.74	$8.18	$7.75	$7.05
Respite— unlicensed, out of home, level 3, enhanced	W8005		54	540	1 day	$1,199.49	$1,122.10	$1,064.06	$967.33
		TD
		TE
	W8015		54	540	15 minutes	$18.74	$17.53	$16.62	$15.11
		TD
		TE

Fiscal Impact

 It is estimated that implementation of the Medical Assistance Program Fee Schedule rates included in this Public Notice will result in decreased State fund costs totaling approximately $0.318 million.

Public Comment

 Copies of this notice may be obtained at the local Mental Health/Mental Retardation (MH/MR) County Program, Administrative Entity (AE) or regional Office of Developmental Programs (ODP) in the corresponding regions:

 • Western region: Piatt Place, Room 4900, 301 5th Avenue, Pittsburgh, PA 15222, (412) 565-5144.

 • Northeast region: Room 315, Scranton State Office Building, 100 Lackawanna Avenue, Scranton, PA 18503, (570) 963-4749.

 • Southeast region: 801 Market Street, Suite 5071, Philadelphia, PA 19107, (215) 560-2242 or (215) 560-2245.

 • Central region: Room 430 Willow Oak Building, P. O. Box 2675, DGS Annex Complex, Harrisburg, PA 17105, (717) 772-6507.

 Contact information for the local MH/MR County Program or AE may be found through a link on the Internet at: https://www.hcsis.state.pa.us/hcsis-ssd/pgm/asp/PRCNT.ASP, or contact the previously referenced ODP regional office.

 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: ra-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
Forster and Commonwealth Avenues
Harrisburg, PA 17120

 Persons 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).

HARRIET DICHTER, 
Secretary

 Fiscal Note: 14-NOT-645. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 10-1178. Filed for public inspection June 25, 2010, 9:00 a.m.]

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