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. 5413]
[Saturday, September 18, 2010]This notice announces the Department of Public Welfare's (Department) finalized payment rates for select services provided in the Consolidated and Person/Family Directed Support waivers (waivers) to the Medical Assistance (MA) Program Fee Schedule effective July 1, 2010. These fee schedule final 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 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.
The Department established proposed rates for each of the selected services on the MA fee schedule and published those proposed rates at 40 Pa.B. 3621 (June 26, 2010). The Department finalized these payment rates for the MA Program Fee Schedule effective July 1, 2010, based on the enacted budget. As a result of the increase to the appropriation, the finalized rates were adjusted from the proposed rates accordingly.
The Unlicensed Out-of-Home Respite and Respite Camp Ineligible proposed payment rates did not provide for the impact of the 1% cost containment initiative assumed in the Governor's Executive Budget for Fiscal Year (FY) 2010-2011. However, the enacted budget also did not provide for a 1% cost containment initiative. Therefore, as a result, the final payment rates for these services are the same as the initial proposed payment rates.
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, Lacka- wanna, 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 procedure code when billing for temporary base-funded services.
(PA) Prior authorization by the Office of Developmental Programs (ODP) must be obtained for this service.
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 $11.02 $10.31 $9.78 $8.89 TE & ET TE 16 161 TE & ET Nursing Services: RN T2025 TD 05 051 15 minutes $16.55 $15.48 $14.68 $13.35 TD & ET TD 16 160 TD & ET Physical Therapy T2025 GP 17 170 15 minutes $20.20 $18.90 $17.92 $16.29 GP & ET Occupational Therapy T2025 GO 17 171 15 minutes $21.29 $19.92 $18.89 $17.17 GO & ET Speech and Language Therapy T2025 GN 17 173 15 minutes $21.72 $20.32 $19.27 $17.52 GN & ET Individual Behavioral Therapy T2025 HE 19 208 15 minutes $20.79 $19.45 $18.44 $16.77 HE & ET Group Behavioral Therapy T2025 HE & HQ 19 208 15 minutes $5.20 $4.86 $4.61 $4.19 HE, HQ & ET Visual/Mobility Therapy W7246 51 517 15 minutes $21.73 $20.33 $19.28 $17.52 ET Companion Services, Basic staff support W1724 51 363 15 minutes $ .78 $ .73 $ .69 $ .63 ET Companion Services, level 1 W1725 51 363 15 minutes $ .98 $ .92 $.87 $ .79 ET Companion Services, level 2 W1726 51 363 15 minutes $2.07 $1.94 $1.84 $1.67 ET Companion Services, level 3 W1727 51 363 15 minutes $4.65 $4.35 $4.13 $3.75 ET Supplemental Habilitation, 1:1 (PA) W7070 52 456, 520, 521 or 522 15 minutes $4.87 $4.56 $4.32 $3.93 ET Supplemental Habilitation, 2:1 (PA) W7084 52 456, 520, 521 or 522 15 minutes $9.75 $9.12 $8.65 $7.86 ET Additional Individualized Staffing, 1:1 (PA) W7085 52 456, 520, 521 or 522 15 minutes $4.87 $4.56 $4.32 $3.93 Additional Individualized Staffing, 2:1 (PA) W7086 52 456, 520, 521 or 522 15 minutes $9.75 $9.12 $8.65 $7.86 Older Adult Day Habilitation W7094 51 410 15 minutes $2.88 $2.69 $2.55 $2.32 ET Behavioral Support W7095 51 510 15 minutes $21.52 $20.13 $19.09 $17.35 ET Supports Broker W7096 51 510 15 minutes $10.85 $10.15 $9.63 $8.75 Homemaker/Chore (permanent) W7283 43 430 1 hour $22.87 $21.39 $20.29 $18.44 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)
Service Procedure Code Provider Type Specialty Code Unit Areas 1 through 4 Respite—unlicensed, out of home, ineligible W6060 51 513 1 day $12.00/unit, max of 1 ineligible unit per day 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 15 minutes $4.00/unit, max of 3 ineligible units per day 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 procedure code 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 $3.06 $2.87 $2.72 $2.47 Home & Community Habilitation— unlicensed, level 3 W7060 U4 54 540 15 minutes $5.07 $4.74 $4.50 $4.09 Home & Community Habilitation— unlicensed, level 3, enhanced W7061 U4 54 540 15 minutes $8.39 $7.85 $7.44 $6.77 TD & U4 TE & U4 Home & Community Habilitation— unlicensed, level 4 W7068 U4 54 540 15 minutes $10.13 $9.48 $8.99 $8.17 Home & Community Habilitation— unlicensed, level 4, enhanced W7069 U4 54 540 15 minutes $16.77 $15.69 $14.88 $13.52 TD & U4 TE & U4 Supports Broker W7096 U4 54 540 15 minutes $6.15 $5.76 $5.46 $4.96 Respite—unlicensed, in home, level 2 W7250 U4 54 540 1 day $223.14 $208.74 $197.94 $179.95 W7258 U4 54 540 15 minutes $3.48 $3.26 $3.09 $2.81 Respite—unlicensed, in home, level 2, enhanced W7251 U4 54 540 1 day $478.66 $447.77 $424.61 $386.01 TD & U4 TE & U4 W7264 U4 54 540 15 minutes $7.48 $7.00 $6.64 $6.03 TD & U4 TE & U4 Respite—unlicensed in home, level 3 W7252 U4 54 540 1 day $446.27 $417.48 $395.89 $359.90 W7265 U4 54 540 15 minutes $6.97 $6.52 $6.19 $5.62 Respite—unlicensed, in home, level 3, enhanced W7253 U4 54 540 1 day $957.31 $895.55 $849.23 $772.02 TD & U4 TE & U4 W7266 U4 54 540 15 minutes $14.95 $13.99 $13.26 $12.06 TD & U4 TE & U4 TD & U4 TE & U4 Respite—unlicensed, out of home, level 2 W8002 U4 54 540 1 day $223.14 $208.74 $197.94 $179.95 W8012 U4 54 540 15 minutes $3.48 $3.26 $3.09 $2.81 Respite—unlicensed, out of home, level 2, enhanced W8003 U4 54 540 1 day $478.66 $447.77 $424.61 $386.01 TD & U4 TE & U4 W8013 U4 54 540 15 minutes $7.48 $7.00 $6.64 $6.03 TD & U4 TE & U4 Respite—unlicensed, out of home, level 3 W8004 U4 54 540 1 day $446.27 $417.48 $395.89 $359.90 W8014 U4 54 540 15 minutes $6.97 $6.52 $6.19 $5.62 Respite—unlicensed, out of home, level 3, enhanced W8005 U4 54 540 1 day $957.31 $895.55 $849.23 $772.02 TD & U4 TE & U4 W8015 U4 54 540 15 minutes $14.95 $13.99 $13.26 $12.06 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 $3.88 $3.63 $3.44 $3.13 Home & Community Habilitation— unlicensed, level 3 W7060 54 540 15 minutes $6.42 $6.01 $5.70 $5.18 Home & Community Habilitation— unlicensed, level 3, enhanced W7061 54 540 15 minutes $10.62 $9.93 $9.42 $8.56 TD TE Home & Community Habilitation— unlicensed, level 4 W7068 54 540 15 minutes $12.83 $12.00 $11.38 $10.35 Home & Community Habilitation— unlicensed, level 4, enhanced W7069 54 540 15 minutes $21.23 $19.86 $18.83 $17.12 TD TE Supports Broker W7096 54 540 15 minutes $7.79 $7.29 $6.91 $6.28 Respite—unlicensed, in home, level 2 W7250 54 540 1 day $282.49 $264.26 $250.60 $227.81 W7258 54 540 15 minutes $4.41 $4.13 $3.91 $3.56 Respite—unlicensed, in home, level 2, enhanced W7251 54 540 1 day $605.98 $566.88 $537.56 $488.69 TD TE W7264 54 540 15 minutes $9.47 $8.86 $8.40 $7.64 TD TE Respite—unlicensed, in home, level 3 W7252 54 540 1 day $564.98 $528.53 $501.19 $455.63 W7265 54 540 15 minutes $8.83 $8.26 $7.83 $7.12 Respite—unlicensed, in home, level 3, enhanced W7253 54 540 1 day $1,211.96 $1,133.76 $1,075.12 $977.38 TD TE W7266 54 540 15 min. $18.93 $17.71 $16.79 $15.27 TD TE Homemaker/ Chore W7283 54 540 1 hour $16.99 $15.89 $15.07 $13.70 UA Respite—unlicensed, out of home, level 2 W8002 54 540 1 day $282.49 $264.26 $250.60 $227.81 W8012 54 540 15 minutes $4.41 $4.13 $3.91 $3.56 Respite—unlicensed, out of home, level 2, enhanced W8003 54 540 1 day $605.98 $566.88 $537.56 $488.69 TD TE W8013 54 540 15 minutes $9.47 $8.86 $8.40 $7.64 TD TE Respite—unlicensed, out of home, level 3 W8004 54 540 1 day $564.98 $528.53 $501.19 $455.63 W8014 54 540 15 minutes $8.83 $8.26 $7.83 $7.12 Respite—unlicensed, out of home, level 3, enhanced W8005 54 540 1 day $1,211.96 $1,133.76 $1,075.12 $977.38 TD TE W8015 54 540 15 minutes $18.93 $17.71 $16.79 $15.27 TD TE Fiscal Impact
It is estimated that implementation of the MA Program Fee Schedule final rates, with the exception of the supplemental habilitation rates, will result in increased State-fund costs totaling approximately $0.346 million.
The increase State-fund costs will be offset by a projected reduction in the provision of supplemental habilitation staffing. Supplemental habilitation must be pre-authorized in FY 2010-2011. The preauthorization will significantly reduce the units utilized from the number of units utilized during FY 2009-2010.
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 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 accessed through https://www.hcsis.state.pa.us/hcsis-ssd/pgm/asp/PRCNT.ASP, or contact the previously referenced regional ODP.
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 ODP's 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 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).
HARRIET DICHTER,
SecretaryFiscal Note: 14-NOT-657. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 10-1800. Filed for public inspection September 17, 2010, 9:00 a.m.]
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