NOTICES
Proposed Fee Schedule Rates and Department-Established Fees for Consolidated and Person/Family Directed Support Waivers Services, Targeted Service Management and the Community Intellectual Disability Base-Funded Program
[46 Pa.B. 3373]
[Saturday, June 25, 2016]
The purpose of this notice is to announce the Department of Human Services (Department) proposed Fee Schedule Rates for Targeted Service Management and select services funded through the Consolidated and Person/Family Directed Support (P/FDS) waivers as well as the Department-established fees for residential ineligible services effective July 1, 2016. These proposed Fee Schedule Rates also serve as the Department-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 an intellectual disability under the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4104—4704), 55 Pa. Code Chapter 4300 (relating to county mental health and intellectual disability fiscal manual) and 55 Pa. Code Chapter 51 (relating to Office of Developmental Programs home and community-based services). The proposed Fee Schedule Rates and Department-established fees effective July 1, 2016, are unchanged from the final rates established for Fiscal Year (FY) 2015-2016.
Fee Schedule Rates
The Fee Schedule Rates are identified under the following categories: Select Community-Based Services and Agency with Choice/Financial Management Services (AWC/FMS), including benefit allowance and excluding benefit allowance.
The Select Community-Based Services include behavior support, companion, home and community habilitation unlicensed, homemaker/chore, licensed day habilitation (adult training), prevocational services, therapy (physical, occupational, speech and language, individual behavior, group behavior and orientation, mobility and vision), nursing, older adult day, supplemental habilitation, additional individualized staffing, supported employment, supports broker, supports coordination, targeted service management, transitional work and all waiver-funded respite care services, excluding respite camp which is a vendor service.
AWC/FMS (including and excluding benefit allowance) include home and community habilitation unlicensed, companion services, unlicensed in-home and out-of-home respite, supported employment, supports broker and homemaker/chore services. There are two separate tables for AWC/FMS—one provides the Fee Schedule Rate including a benefit allowance and the other provides the Fee Schedule Rate excluding a benefit allowance. The benefit allowance is provided as an option for the Managing Employer to include benefits such as disability insurance, life insurance, retirement savings and paid time off to the support service worker.
The Office of Developmental Programs (ODP) will be using the proposed Fee Schedule Rates to support claims processing in the Provider Reimbursement and Operations Management Information System in electronic format (PROMISeTM). A notice will be published announcing the Final Fee Schedule rates once a budget bill is passed and enacted for FY 2016-2017.
Enhanced Communication Services
The Enhanced Communication Services modifier, U1, is available for the following Consolidated Waiver fee schedule services: behavioral support; companion; supported employment; transitional work; prevocational services; home and community habilitation unlicensed; licensed day habilitation (adult training); therapy (physical, occupational, speech and language, individual behavior, group behavior and orientation, mobility and vision); nursing; older adult day; supplemental habilitation; additional individualized staffing; supports broker and all waiver-funded respite care services; excluding respite camp which is a vendor service.
Enhanced Communication Services can be provided to individuals who meet all of the following:
• Enrolled in the Consolidated Waiver.
• Deaf.
• Determined to need services that are provided by staff who are proficient in sign language.
Providers who wish to receive the Enhanced Communication Services Rate must be approved to do so by the Department. Requests for enhanced rates should be directed to the Deaf Services Coordinator at RA-ODPDeafServices@pa.gov.
Department-Established Fees
The Department-established fees represent a per-person, per-day net fee based on the size of the home (such as a one-individual home or two-individual home) and type of home (defined by licensed, unlicensed or family living home). The fee does not include consideration for payment by the participant, as it is the provider's responsibility to collect that portion of payment from the participant.
The ODP will be using the proposed Department-established fees to support claims processing in PROMISeTM. A notice will be published announcing the final Department-established fees once a budget bill is passed and enacted for FY 2016-2017.
Geographic Areas
The geographic areas are as follows:
Area 1: Adams, Cumberland, Dauphin, Delaware, Lancaster, Lebanon, Lehigh, Montgomery, Northampton, Perry, Philadelphia, York
Area 2: Allegheny, Berks, Bucks, Chester, Franklin, Fulton
Area 3: Armstrong, Beaver, Bedford, Blair, Bradford, Butler, Cambria, Cameron, Carbon, Centre, Clarion, Clearfield, Clinton, Columbia, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lawrence, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montour, Northumberland, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming
Fee Schedule Rates and Department-Established Fees Tables: Effective July 1, 2016
Modifier ET must be used with applicable procedure codes when billing for temporary Base-funded services.
The Supports Coordination fee identified as follows and billed with procedure code W7210 is also applicable to base funded supports coordination.
Prior authorization must be obtained from the Department for services denoted by (PA) in the service row in the following table.
Fee Schedule Rates
| Service | Procedure Code | Modifier | Provider Type | Specialty Code | Unit | Area 1 | Area 2 | Area 3 |
|---|
| Nursing Services: LPN | T2025 | TE | 05 | 051 | 15 min. | $11.36 | $10.76 | $10.05 |
| TE & ET |
| TE | 16 | 161 |
| TE & ET |
| Nursing Services: RN | T2025 | TD | 05 | 051 | 15 min. | $14.72 | $13.94 | $13.03 |
| TD & ET |
| TD | 16 | 160 |
| TD & ET |
| Physical Therapy | T2025 | GP | 17 | 170 | 15 min. | $21.61 | $20.46 | $19.12 |
| GP & ET |
| Occupational Therapy | T2025 | GO | 17 | 171 | 15 min. | $20.93 | $19.82 | $18.52 |
| GO & ET |
| Speech and Language Therapy | T2025 | GN | 17 | 173 | 15 min. | $19.23 | $18.21 | $17.02 |
| GN & ET |
| Individual Behavioral Therapy | T2025 | HE | 19 | 208 | 15 min. | $25.29 | $23.95 | $22.38 |
| HE & ET |
| Group Behavioral Therapy | T2025 | HE & HQ | 19 | 208 | 15 min. | $8.09 | $7.66 | $7.16 |
| HE, HQ & ET |
| Visual/Mobility Therapy | W7246 | | 51 | 517 | 15 min. | $19.23 | $18.21 | $17.02 |
| ET |
| Companion, Basic staff support | W1724 | | 51 | 363 | 15 min. | $1.26 | $1.19 | $1.12 |
| ET |
| Companion, level 1 | W1725 | | 51 | 363 | 15 min. | $1.46 | $1.38 | $1.29 |
| ET |
| Companion, level 2 | W1726 | | 51 | 363 | 15 min. | $2.23 | $2.11 | $1.97 |
| ET |
| Companion, level 3 | W1727 | | 51 | 363 | 15 min. | $6.11 | $5.79 | $5.41 |
| ET |
| Supplemental Habilitation, 1:1(PA) | W7070 | | 52 | 456, 520, 521 or 522 | 15 min. | $5.41 | $5.12 | $4.79 |
| ET |
| Supplemental Habilitation, 2:1(PA) | W7084 | | 52 | 456, 520, 521 or 522 | 15 min. | $10.81 | $10.24 | $9.57 |
| ET |
| Additional Individualized Staffing, 1:1(PA) | W7085 | | 52 | 456, 520, 521 or 522 | 15 min. | $5.41 | $5.12 | $4.79 |
| Additional Individualized Staffing, 2:1(PA) | W7086 | | 52 | 456, 520, 521 or 522 | 15 min. | $10.81 | $10.24 | $9.57 |
| Older Adult Day Habilitation | W7094 | | 51 | 410 | 15 min. | $2.57 | $2.43 | $2.27 |
| ET |
| Behavioral Support | W7095 | | 51 | 510 | 15 min. | $19.42 | $18.39 | $17.19 |
| ET |
| Supports Broker | W7096 | | 51 | 510 | 15 min. | $8.65 | $8.19 | $7.65 |
| Licensed Day—Adult | W7072 | | 51 | 514 | 15 min. | $2.90 | $2.75 | $2.57 |
| W7073 | | 51 | 514 | 15 min. | $3.55 | $3.36 | $3.14 |
| W7074 | | 51 | 514 | 15 min. | $4.50 | $4.26 | $3.98 |
| W7075 | | 51 | 514 | 15 min. | $9.16 | $8.67 | $8.11 |
| W7076 | | 51 | | 15 min. | $13.35 | $12.64 | $11.81 |
| W7035 | | | | 15 min. | $17.20 | $16.29 | $15.22 |
| W7036 | | | | 15 min. | $25.57 | $24.21 | $22.63 |
| Prevocational | W7087 | | | | 15 min. | $2.06 | $1.95 | $1.82 |
| W7088 | | | | 15 min. | $2.43 | $2.30 | $2.15 |
| W7089 | | | | 15 min. | $3.26 | $3.09 | $2.88 |
| W7090 | | | | 15 min. | $9.06 | $8.58 | $8.02 |
| W7091 | | | | 15 min. | $12.59 | $11.92 | $11.14 |
| W7092 | | | | 15 min. | $17.75 | $16.81 | $15.71 |
| W7093 | | | | 15 min. | $24.82 | $23.50 | $21.96 |
| Supports Coordination | W7210 | | 21 | 218 | 15 min. | $21.70 | $20.55 | $19.20 |
| Targeted Services Management | T1017 | | 21 | 218 | 15 min. | $21.70 | $20.55 | $19.20 |
| Supported Employment | W7235 | | 53 | 530
531 | 15 min. | $17.75 | $16.81 | $15.71 |
| Transitional Work | W7237 | | 51 | 516 | 15 min. | $2.65 | $2.51 | $2.35 |
| W7239 | | 51 | 516 | 15 min. | $3.55 | $3.36 | $3.14 |
| W7241 | | 51 | 516 | 15 min. | $4.65 | $4.40 | $4.12 |
| W7245 | | 51 | 516 | 15 min. | $11.63 | $11.01 | $10.29 |
Unlicensed Home and Community Habilitation W7057 | | 51 | 510 | 15 min. | $2.54 | $2.41 | $2.25
| | W7058 | | 51 | 510 | 15 min. | $3.52 | $3.33 | $3.12 |
| W7059 | | 51 | 510 | 15 min. | $4.47 | $4.23 | $3.96 |
| W7060 | | 51 | 510 | 15 min. | $7.21 | $6.83 | $6.38 |
| W7061 | | 51 | 510 | 15 min. | $11.09 | $10.50 | $9.81 |
| TD |
| TE |
| W7068 | | 51 | 510 | 15 min. | $13.96 | $13.22 | $12.35 |
| W7069 | | 51 | 510 | 15 min. | $23.97 | $22.70 | $21.21 |
| TD |
| TE |
In Home Respite—
24 hours | W7247 | | 51 | 512 | Day | $85.20 | $80.68 | $75.40 |
| W7248 | | 51 | 512 | Day | $110.80 | $104.92 | $98.05 |
| W7250 | | 51 | 512 | Day | $241.92 | $229.07 | $214.09 |
| W7251 | | 51 | 512 | Day | $381.84 | $361.57 | $337.91 |
| W7252 | | 51 | 512 | Day | $475.82 | $450.56 | $421.08 |
| W7253 | | 51 | 512 | Day | $755.66 | $715.54 | $668.73 |
| TD |
| TE |
In Home Respite—
15 minutes | W7255 | | 51 | 512 | 15 min. | $2.13 | $2.02 | $1.88 |
| W7256 | | 51 | 512 | 15 min. | $2.77 | $2.62 | $2.45 |
| W7258 | | 51 | 512 | 15 min. | $6.11 | $5.79 | $5.41 |
| W7264 | | 51 | 512 | 15 min. | $9.55 | $9.04 | $8.45 |
| W7265 | | 51 | 512 | 15 min. | $11.90 | $11.27 | $10.53 |
| W7266 | | 51 | 512 | 15 min. | $18.89 | $17.89 | $16.72 |
| TD |
| TE |
| Respite—unlicensed out of home—24 hour | W8000 | | 51 | 513 | Day | $85.20 | $80.68 | $75.40 |
| W8001 | | 51 | 513 | Day | $110.80 | $104.92 | $98.05 |
| W8002 | | 51 | 513 | Day | $241.92 | $229.07 | $214.09 |
| W8003 | | 51 | 513 | Day | $381.84 | $361.57 | $337.91 |
| W8004 | | 51 | 513 | Day | $475.82 | $450.56 | $421.08 |
| W8005 | | 51 | 513 | Day | $755.66 | $715.54 | $668.73 |
| TD |
| TE |
Respite—unlicensed out of home—15 minute W8010 | | 51 | 513 | 15 min. | $2.13 | $2.02 | $1.88
| | W8011 | | 51 | 513 | 15 min. | $2.77 | $2.62 | $2.45 |
| W8012 | | 51 | 513 | 15 min. | $6.11 | $5.79 | $5.41 |
| W8013 | | 51 | 513 | 15 min. | $9.55 | $9.04 | $8.45 |
| TD |
| TE |
| W8014 | | 51 | 513 | 15 min. | $11.90 | $11.27 | $10.53 |
| W8015 | | 51 | 513 | 15 min. | $18.89 | $17.89 | $16.72 |
| TD |
| TE |
Respite—licensed out of home—24 hour W7259 | | 51 | 513 | Day | $111.11 | $105.21 | $98.33
| | U2 |
| W7260 | | 51 | 513 | Day | $203.96 | $193.13 | $180.50 |
| U2 |
| W7262 | | 51 | 513 | Day | $269.98 | $255.64 | $238.92 |
| U2 |
| W7263 | | 51 | 513 | Day | $416.51 | $394.39 | $368.59 |
| U2 |
| W7299 | | 51 | 513 | Day | $524.61 | $496.75 | $464.26 |
| U2 |
| W7300 | | 51 | 513 | Day | $817.68 | $774.26 | $723.61 |
| TD |
| TE |
| U2 |
Respite—licensed out of home—15 minutes W7267 | | 51 | 513 | 15 min. | $2.78 | $2.63 | $2.46
| | W7268 | | 51 | 513 | 15 min. | $3.68 | $3.48 | $3.26 |
| W7270 | | 51 | 513 | 15 min. | $6.75 | $6.39 | $5.97 |
| W7400 | | 51 | 513 | 15 min. | $10.41 | $9.86 | $9.21 |
| TD |
| TE |
| W7401 | | 51 | 513 | 15 min. | $13.12 | $12.42 | $11.61 |
| W7402 | | 51 | 513 | 15 min. | $20.44 | $19.35 | $18.09 |
| TD |
| TE |
| Homemaker/Chore (permanent) | W7283 | | 43 | 430 | 1 hour | $19.44 | $18.41 | $17.20 |
| 51 | 430 or 431 |
| Homemaker/Chore (temporary) | W7283 | UA | 43 | 430 | 1 hour | $19.44 | $18.41 | $17.20 |
| UA & ET |
| UA | 51 | 430 or 431 |
| UA & ET |
Enhanced Communication Services for Consolidated Waiver—Requires ODP Approval
| Service | Procedure Code | Modifier | Provider Type | Specialty Code | Unit | Area 1 | Area 2 | Area 3 |
|---|
| Nursing Services: LPN | T2025 | TE & U1 | 5 | 51 | 15 min. | $12.56 | $11.89 | $11.12 |
| TE & U1 | 16 | 161 |
| Nursing Services: RN | T2025 | TD & U1 | 5 | 51 | 15 min. | $16.33 | $15.46 | $14.45 |
| TD & U1 | 16 | 160 |
| Physical Therapy | T2025 | GP & U1 | 17 | 170 | 15 min. | $23.82 | $22.56 | $21.08 |
| Occupational Therapy | T2025 | GO & U1 | 17 | 171 | 15 min. | $23.06 | $21.84 | $20.41 |
| Speech and Language Therapy | T2025 | GN & U1 | 17 | 173 | 15 min. | $21.15 | $20.03 | $18.72 |
| Individual Behavioral Therapy | T2025 | HE & U1 | 19 | 208 | 15 min. | $27.96 | $26.48 | $24.74 |
| Group Behavioral Therapy | T2025 | HE & HQ & U1 | 19 | 208 | 15 min. | $9.41 | $8.91 | $8.33 |
| Visual/Mobility Therapy | W7246 | U1 | 51 | 517 | 15 min. | $21.15 | $20.03 | $18.72 |
| Companion, Basic staff support | W1724 | U1 | 51 | 363 | 15 min. | $1.46 | $1.38 | $1.29 |
| Companion, level 1 | W1725 | U1 | 51 | 363 | 15 min. | $1.68 | $1.59 | $1.49 |
| Companion, level 2 | W1726 | U1 | 51 | 363 | 15 min. | $2.61 | $2.47 | $2.31 |
| Companion, level 3 | W1727 | U1 | 51 | 363 | 15 min. | $6.67 | $6.32 | $5.90 |
| Supplemental Habilitation, 1:1(PA) | W7070 | U1 | 52 | 456, 520, 521 or 522 | 15 min. | $5.96 | $5.64 | $5.27 |
| Supplemental Habilitation, 2:1(PA) | W7084 | U1 | 52 | 456, 520, 521 or 522 | 15 min. | $11.92 | $11.29 | $10.55 |
| Additional Individualized Staffing, 1:1(PA) | W7085 | U1 | 52 | 456, 520, 521 or 522 | 15 min. | $5.96 | $5.64 | $5.27 |
| Additional Individualized Staffing, 2:1(PA) | W7086 | U1 | 52 | 456, 520, 521 or 522 | 15 min. | $11.92 | $11.29 | $10.55 |
| Older Adult Day Habilitation | W7094 | U1 | 51 | 410 | 15 min. | $2.81 | $2.66 | $2.49 |
| Behavioral Support | W7095 | U1 | 51 | 510 | 15 min. | $21.36 | $20.23 | $18.90 |
| Supports Broker | W7096 | U1 | 51 | 510 | 15 min. | $9.57 | $9.06 | $8.47 |
Licensed Day—Adult W7072 | U1 | 51 | 514 | 15 min. | $3.18 | $3.01 | $2.81
| | W7073 | U1 | 51 | 514 | 15 min. | $3.94 | $3.73 | $3.49 |
| W7074 | U1 | 51 | 514 | 15 min. | $5.08 | $4.81 | $4.50 |
| W7075 | U1 | 51 | 514 | 15 min. | $9.86 | $9.34 | $8.73 |
| W7076 | U1 | 51 | 514 | 15 min. | $14.56 | $13.79 | $12.88 |
| TD & U1 |
| TE & U1 |
| W7035 | U1 | 51 | 514 | 15 min. | $18.59 | $17.60 | $16.45 |
| W7036 | U1 | 51 | 514 | 15 min. | $28.00 | $26.51 | $24.78 |
| TD & U1 |
| TE & U1 |
Prevocational W7087 | U1 | 51 | 515 | 15 min. | $2.27 | $2.15 | $2.01
| | W7088 | U1 | 51 | 515 | 15 min. | $2.73 | $2.59 | $2.42 |
| W7089 | U1 | 51 | 515 | 15 min. | $3.76 | $3.56 | $3.33 |
| W7090 | U1 | 51 | 515 | 15 min. | $9.84 | $9.32 | $8.71 |
| W7091 | U1 | 51 | 515 | 15 min. | $13.81 | $13.08 | $12.22 |
| TD & U1 |
| TE & U1 |
| W7092 | U1 | 51 | 515 | 15 min. | $19.30 | $18.28 | $17.08 |
| W7093 | U1 | 51 | 515 | 15 min. | $27.25 | $25.80 | $24.12 |
| TD & U1 |
| TE & U1 |
| Supported Employment | W7235 | U1 | 53 | 530 or 531 | 15 min. | $19.31 | $18.28 | $17.09 |
| Transitional Work | W7237 | U1 | 51 | 516 | 15 min. | $3.10 | $2.94 | $2.74 |
| W7239 | U1 | 51 | 516 | 15 min. | $4.17 | $3.95 | $3.69 |
| W7241 | U1 | 51 | 516 | 15 min. | $5.46 | $5.17 | $4.83 |
| W7245 | U1 | 51 | 516 | 15 min. | $12.67 | $12.00 | $11.21 |
Unlicensed Home and Community Habilitation W7057 | U1 | 51 | 510 | 15 min. | $2.93 | $2.77 | $2.59
| | W7058 | U1 | 51 | 510 | 15 min. | $4.08 | $3.86 | $3.61 |
| W7059 | U1 | 51 | 510 | 15 min. | $5.21 | $4.93 | $4.61 |
| W7060 | U1 | 51 | 510 | 15 min. | $7.86 | $7.44 | $6.96 |
| W7061 | U1 | 51 | 510 | 15 min. | $12.22 | $11.57 | $10.81 |
| TD & U1 |
| TE & U1 |
| W7068 | U1 | 51 | 510 | 15 min. | $15.25 | $14.44 | $13.50 |
| W7069 | U1 | 51 | 510 | 15 min. | $26.44 | $25.04 | $23.40 |
| TD & U1 |
| TE & U1 |
In Home Respite—
24 hours W7247 | U1 | 51 | 512 | Day | $99.69 | $94.40 | $88.22
| | W7248 | U1 | 51 | 512 | Day | $130.23 | $123.32 | $115.25 |
| W7250 | U1 | 51 | 512 | Day | $264.17 | $250.14 | $233.78 |
| W7251 | U1 | 51 | 512 | Day | $421.55 | $399.17 | $373.05 |
| TD & U1 |
| TE & U1 |
| W7252 | U1 | 51 | 512 | Day | $520.29 | $492.66 | $460.43 |
| W7253 | U1 | 51 | 512 | Day | $835.06 | $790.72 | $738.99 |
| TD & U1 |
| TE & U1 |
In Home Respite—
15 minutes W7255 | U1 | 51 | 512 | 15 min. | $2.50 | $2.37 | $2.21
| | W7256 | U1 | 51 | 512 | 15 min. | $3.27 | $3.10 | $2.89 |
| W7258 | U1 | 51 | 512 | 15 min. | $6.67 | $6.32 | $5.90 |
| W7264 | U1 | 51 | 512 | 15 min. | $10.55 | $9.99 | $9.34 |
| TD & U1 |
| TE & U1 |
| W7265 | U1 | 51 | 512 | 15 min. | $13.02 | $12.33 | $11.52 |
| W7266 | U1 | 51 | 512 | 15 min. | $20.88 | $19.77 | $18.48 |
| TD & U1 |
| TE & U1 |
Respite—unlicensed out of home—24 hour W8000 | U1 | 51 | 513 | Day | $99.66 | $94.37 | $88.19
| | W8001 | U1 | 51 | 513 | Day | $130.20 | $123.29 | $115.22 |
| W8002 | U1 | 51 | 513 | Day | $264.15 | $250.12 | $233.76 |
| W8003 | U1 | 51 | 513 | Day | $421.56 | $399.18 | $373.06 |
| TD & U1 |
| TE & U1 |
| W8004 | U1 | 51 | 513 | Day | $520.28 | $492.65 | $460.42 |
| W8005 | U1 | 51 | 513 | Day | $835.09 | $790.75 | $739.02 |
| TD & U1 |
| TE & U1 |
Respite—unlicensed out of home—15 minute W8010 | U1 | 51 | 513 | 15 min. | $2.49 | $2.36 | $2.20
| | W8011 | U1 | 51 | 513 | 15 min. | $3.26 | $3.09 | $2.88 |
| W8012 | U1 | 51 | 513 | 15 min. | $6.67 | $6.32 | $5.90 |
| W8013 | U1 | 51 | 513 | 15 min. | $10.54 | $9.98 | $9.33 |
| TD & U1 |
| TE & U1 |
| W8014 | U1 | 51 | 513 | 15 min. | $13.01 | $12.32 | $11.51 |
| W8015 | U1 | 51 | 513 | 15 min. | $20.88 | $19.77 | $18.48 |
| TD & U1 |
| TE & U1 |
Respite—licensed out of home—24 hour W7259 | U1 | 51 | 513 | Day | $128.51 | $121.69 | $113.73
| | U2 & U1 |
| W7260 | U1 | 51 | 513 | Day | $238.74 | $226.06 | $211.27 |
| U2 & U1 |
| W7262 | U1 | 51 | 513 | Day | $294.29 | $278.66 | $260.43 |
| U2 & U1 |
| W7263 | U1 | 51 | 513 | Day | $459.13 | $434.75 | $406.31 |
| TD & U1 |
| TE & U1 |
| U2 & U1 |
| TD & U2 & U1 |
| TE & U2 & U1 |
| W7299 | U1 | 51 | 513 | Day | $573.22 | $542.78 | $507.27 |
| U2 & U1 |
| W7300 | U1 | 51 | 513 | Day | $902.92 | $854.98 | $799.04 |
| TD & U1 |
| TE & U1 |
| U2 & U1 |
| TD & U2 & U1 |
| TE & U2 & U1 |
Respite—licensed out of home—15 minutes W7267 | U1 | 51 | 513 | 15 min. | $3.22 | $3.05 | $2.85
| | W7268 | U1 | 51 | 513 | 15 min. | $4.29 | $4.06 | $3.80 |
| W7270 | U1 | 51 | 513 | 15 min. | $7.36 | $6.97 | $6.51 |
| W7400 | U1 | 51 | 513 | 15 min. | $11.48 | $10.87 | $10.16 |
| TD & U1 |
| TE & U1 |
| W7401 | U1 | 51 | 513 | 15 min. | $14.33 | $13.57 | $12.68 |
| W7402 | U1 | 51 | 513 | 15 min. | $22.57 | $21.37 | $19.97 |
| TD & U1 |
| TE & U1 |
Department-Established Fees
| Service | Procedure Code | Modifier | Provider Type | Specialty Code | Unit | Area 1 | Area 2 | Area 3 |
|---|
| Licensed Community Homes—Ineligible | W6091 | | | | Day | $72.71 | $67.93 | $62.35 |
| W6093 | $38.64 | $35.67 | $32.20 |
| W6095 | $27.32 | $24.95 | $22.18 |
| W6097 | $21.22 | $19.17 | $16.78 |
| W6099 | $16.78 | $14.97 | $12.86 |
| Licensed Child Residential Services—Ineligible | W7011 | | | | Day | $72.71 | $67.93 | $62.35 |
| W7013 | $38.64 | $35.67 | $32.20 |
| W7015 | $27.32 | $24.95 | $22.18 |
| W7017 | $21.22 | $19.17 | $16.78 |
| W7019 | $16.78 | $14.97 | $12.86 |
| Licensed Community Residential Rehabilitation Services—Ineligible | W7021 | | | | Day | $72.71 | $67.93 | $62.35 |
| W7023 | $38.64 | $35.67 | $32.20 |
| W7025 | $27.32 | $24.95 | $22.18 |
| W7027 | $21.22 | $19.17 | $16.78 |
| W7029 | $16.78 | $14.97 | $12.86 |
| Unlicensed Residential Services—Ineligible | W7079 | | | | Day | $15.28 | $13.56 | $11.56 |
| W7081 | $6.14 | $4.90 | $3.47 |
| W7083 | $5.46 | $4.26 | $2.87 |
| Unlicensed Family Living Home—Ineligible | W7038 | | | | Day | $2.70 | $1.65 | $0.43 |
| W7040 | $1.31 | $0.34 | $0.00 |
| Licensed Adult Family Living Home—Ineligible | W7292 | | | | Day | $2.70 | $1.65 | $0.43 |
| W7294 | $1.31 | $0.34 | $0.00 |
| Licensed Child Family Living Home—Ineligible | W7296 | | | | Day | $2.70 | $1.65 | $0.43 |
| W7298 | $1.31 | $0.34 | $0.00 |
Agency with Choice Financial Management Services, Including Benefit Allowance**
**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 |
|---|
| Companion, level 3 | W1727 | | 54 | 540 | 15 min. | $3.76 | $3.56 | $3.33 |
| Supported Employment | W7235 | | 54 | 540 | 15 min. | $6.96 | $6.59 | $6.16 |
| Unlicensed Habilitation, level 3 | W7060 | | 54 | 540 | 15 min. | $5.66 | $5.36 | $5.01 |
| Unlicensed Habilitation, level 3, enhanced | W7061 | | 54 | 540 | 15 min. | $8.82 | $8.35 | $7.81 |
| TD |
| TE |
| Unlicensed Habilitation, level 4 | W7068 | | 54 | 540 | 15 min. | $11.34 | $10.74 | $10.04 |
| Unlicensed Habilitation, level 4, enhanced | W7069 | | 54 | 540 | 15 min. | $17.64 | $16.70 | $15.61 |
| TD |
| TE |
| Supports Broker | W7096 | | 54 | 540 | 15 min. | $6.41 | $6.07 | $5.67 |
| Respite—unlicensed, in home, level 2 | W7250 | | 54 | 540 | 1 day | $268.61 | $254.35 | $237.71 |
| W7258 | | 54 | 540 | 15 min. | $4.16 | $3.94 | $3.68 |
| Respite—unlicensed, in home, level 2, enhanced | W7251 | | 54 | 540 | 1 day | $513.63 | $486.36 | $454.54 |
| TD |
| TE |
| W7264 | | 54 | 540 | 15 min. | $7.95 | $7.53 | $7.04 |
| TD |
| TE |
| Respite—unlicensed, in home, level 3 | W7252 | | 54 | 540 | 1 day | $537.21 | $508.69 | $475.41 |
| W7265 | | 54 | 540 | 15 min. | $8.34 | $7.90 | $7.38 |
| Respite—unlicensed, in home, level 3, enhanced | W7253 | | 54 | 540 | 1 day | $1,027.25 | $972.71 | $909.07 |
| TD |
| TE |
| W7266 | | 54 | 540 | 15 min. | $15.92 | $15.07 | $14.09 |
| TD |
| TE |
| Homemaker/Chore | W7283 | | 54 | 540 | 1 hour | $16.18 | $15.32 | $14.32 |
| UA |
| Respite—unlicensed, out of home, level 2 | W8002 | | 54 | 540 | 1 day | $268.61 | $254.35 | $237.71 |
| W8012 | | 54 | 540 | 15 min. | $4.16 | $3.94 | $3.68 |
| Respite—unlicensed, out of home, level 2, enhanced | W8003 | | 54 | 540 | 1 day | $513.63 | $486.36 | $454.54 |
| TD |
| TE |
| W8013 | | 54 | 540 | 15 min. | $7.95 | $7.53 | $7.04 |
| TD |
| TE |
| Respite—unlicensed, out of home, level 3 | W8004 | | 54 | 540 | 1 day | $537.21 | $508.69 | $475.41 |
| W8014 | | 54 | 540 | 15 min. | $8.34 | $7.90 | $7.38 |
| Respite—unlicensed, out of home, level 3, enhanced | W8005 | | 54 | 540 | 1 day | $1,027.25 | $972.71 | $909.07 |
| TD |
| TE |
| W8015 | | 54 | 540 | 15 min. | $15.92 | $15.07 | $14.09 |
| TD |
| TE |
Enhanced Communication Agency with Choice Financial Management Services, Including Benefit Allowance, Consolidated Waiver Only—Requires ODP Approval**
**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 |
|---|
| Companion, level 3 | W1727 | U1 | 54 | 540 | 15 min. | $4.13 | $3.91 | $3.66 |
| Supported Employment | W7235 | U1 | 54 | 540 | 15 min. | $7.67 | $7.27 | $6.79 |
| Unlicensed Habilitation, level 3 | W7060 | U1 | 54 | 540 | 15 min. | $6.26 | $5.93 | $5.54 |
| Unlicensed Habilitation, level 3, enhanced | W7061 | U1 | 54 | 540 | 15 min. | $9.82 | $9.29 | $8.70 |
| TD & U1 |
| TE & U1 |
| Unlicensed Habilitation, level 4 | W7068 | U1 | 54 | 540 | 15 min. | $12.56 | $11.89 | $11.12 |
| Unlicensed Habilitation, level 4, enhanced | W7069 | U1 | 54 | 540 | 15 min. | $19.65 | $18.61 | $17.39 |
| TD & U1 |
| TE & U1 |
| Supports Broker | W7096 | U1 | 54 | 540 | 15 min. | $7.12 | $6.75 | $6.30 |
| Respite—unlicensed, in home, level 2 | W7250 | U1 | 54 | 540 | 1 day | $295.74 | $280.04 | $261.72 |
| W7258 | U1 | 54 | 540 | 15 min. | $4.58 | $4.34 | $4.05 |
| Respite—unlicensed, in home, level 2, enhanced | W7251 | U1 | 54 | 540 | 1 day | $571.16 | $540.83 | $505.45 |
| TD & U1 |
| TE & U1 |
| W7264 | U1 | 54 | 540 | 15 min. | $8.84 | $8.38 | $7.83 |
| TD & U1 |
| TE & U1 |
| Respite—unlicensed, in home, level 3 | W7252 | U1 | 54 | 540 | 1 day | $591.47 | $560.06 | $523.42 |
| W7265 | U1 | 54 | 540 | 15 min. | $9.19 | $8.70 | $8.13 |
| Respite—unlicensed, in home, level 3, enhanced | W7253 | U1 | 54 | 540 | 1 day | $1,142.31 | $1,081.66 | $1,010.90 |
| TD & U1 |
| TE & U1 |
| W7266 | U1 | 54 | 540 | 15 min. | $17.71 | $16.76 | $15.67 |
| TD & U1 |
| TE & U1 |
| Respite—unlicensed, out of home, level 2 | W8002 | U1 | 54 | 540 | 1 day | $295.74 | $280.04 | $261.72 |
| W8012 | U1 | 54 | 540 | 15 min. | $4.58 | $4.34 | $4.05 |
| Respite—unlicensed, out of home, level 2, enhanced | W8003 | U1 | 54 | 540 | 1 day | $571.16 | $540.83 | $505.45 |
| TD & U1 |
| TE & U1 |
| W8013 | U1 | 54 | 540 | 15 min. | $8.84 | $8.38 | $7.83 |
| TD & U1 |
| Respite—unlicensed, out of home, level 3 | W8004 | U1 | 54 | 540 | 1 day | $591.47 | $560.06 | $523.42 |
| W8014 | U1 | 54 | 540 | 15 min. | $9.19 | $8.70 | $8.13 |
| Respite—unlicensed, out of home, level 3, enhanced | W8005 | U1 | 54 | 540 | 1 day | $1,142.31 | $1,081.66 | $1,010.90 |
| TD & U1 |
| TE & U1 |
| W8015 | U1 | 54 | 540 | 15 min. | $17.71 | $16.76 | $15.67 |
| TD & U1 |
| TE & U1 |
Agency with Choice Financial Management Services, Excluding Benefit Allowance **
**Modifier U4 must be used with all procedures codes when billing for services excluding benefit allowance.
| Service | Procedure code | Modifier** | Provider Type | Specialty Code | Unit | Area 1 | Area 2 | Area 3 |
|---|
| Companion, level 3 | W1727 | U4 | 54 | 540 | 15 min. | $3.14 | $2.97 | $2.78 |
| Supported Employment | W7235 | U4 | 54 | 540 | 15 min. | $6.34 | $6.00 | $5.61 |
| Unlicensed Habilitation, level 3 | W7060 | U4 | 54 | 540 | 15 min. | $5.04 | $4.77 | $4.46 |
| Unlicensed Habilitation, level 3, enhanced | W7061 | U4 | 54 | 540 | 15 min. | $8.20 | $7.76 | $7.26 |
| TD & U4 |
| TE & U4 |
| Unlicensed Habilitation, level 4 | W7068 | U4 | 54 | 540 | 15 min. | $10.10 | $9.56 | $8.94 |
| Unlicensed Habilitation, level 4, enhanced | W7069 | U4 | 54 | 540 | 15 min. | $16.40 | $15.53 | $14.51 |
| TD & U4 |
| TE & U4 |
| Supports Broker | W7096 | U4 | 54 | 540 | 15 min. | $5.79 | $5.48 | $5.12 |
| Respite—unlicensed, in home, level 2 | W7250 | U4 | 54 | 540 | 1 day | $228.95 | $216.79 | $202.61 |
| W7258 | U4 | 54 | 540 | 15 min. | $3.54 | $3.35 | $3.13 |
| Respite—unlicensed, in home, level 2, enhanced | W7251 | U4 | 54 | 540 | 1 day | $473.97 | $448.80 | $419.44 |
| TD & U4 |
| TE & U4 |
| W7264 | U4 | 54 | 540 | 15 min. | $7.33 | $6.94 | $6.49 |
| TD & U4 |
| TE & U4 |
| Respite—unlicensed in home, level 3 | W7252 | U4 | 54 | 540 | 1 day | $457.89 | $433.58 | $405.21 |
| W7265 | U4 | 54 | 540 | 15 min. | $7.10 | $6.72 | $6.28 |
| Respite—unlicensed, in home, level 3, enhanced | W7253 | U4 | 54 | 540 | 1 day | $947.93 | $897.60 | $838.88 |
| TD & U4 |
| TE & U4 |
| W7266 | U4 | 54 | 540 | 15 min. | $14.68 | $13.90 | $12.99 |
| TD & U4 |
| TE & U4 |
| Homemaker/Chore | W7283 | U4 | 54 | 540 | 1 hour | $13.70 | $12.97 | $12.12 |
| UA & U4 |
| Respite—unlicensed, out of home, level 2 | W8002 | U4 | 54 | 540 | 1 day | $228.95 | $216.79 | $202.61 |
| W8012 | U4 | 54 | 540 | 15 min. | $3.54 | $3.35 | $3.13 |
| Respite—unlicensed, out of home, level 2, enhanced | W8003 | U4 | 54 | 540 | 1 day | $473.97 | $448.80 | $419.44 |
| TD & U4 |
| TE & U4 |
| W8013 | U4 | 54 | 540 | 15 min. | $7.33 | $6.94 | $6.49 |
| TD & U4 |
| TE & U4 |
| Respite—unlicensed, out of home, level 3 | W8004 | U4 | 54 | 540 | 1 day | $457.89 | $433.58 | $405.21 |
| W8014 | U4 | 54 | 540 | 15 min. | $7.10 | $6.72 | $6.28 |
| Respite—unlicensed, out of home, level 3, enhanced | W8005 | U4 | 54 | 540 | 1 day | $947.93 | $897.60 | $838.88 |
| TD & U4 |
| TE & U4 |
| W8015 | U4 | 54 | 540 | 15 min. | $14.68 | $13.90 | $12.99 |
Enhanced Communication Agency with Choice Financial Management Services, Excluding Benefit Allowance, Consolidated Waiver Only—Requires ODP Approval**
**Modifier U4 must be used with all procedures codes when billing for services excluding benefit allowance.
| Service | Procedure Code | Modifier** | Provider Type | Specialty Code | Unit | Area 1 | Area 2 | Area 3 |
|---|
| Companion, level 3 | W1727 | U4 & U1 | 54 | 540 | 15 min. | $3.50 | $3.32 | $3.10 |
| Supported Employment | W7235 | U4 & U1 | 54 | 540 | 15 min. | $7.04 | $6.66 | $6.23 |
| Unlicensed Habilitation, level 3 | W7060 | U4 & U1 | 54 | 540 | 15 min. | $5.65 | $5.35 | $5.00 |
| Unlicensed Habilitation, level 3, enhanced | W7061 | U4 & U1 | 54 | 540 | 15 min. | $9.20 | $8.70 | $8.14 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| Unlicensed Habilitation, level 4 | W7068 | U4 & U1 | 54 | 540 | 15 min. | $11.31 | $10.70 | $10.01 |
| Unlicensed Habilitation, level 4, enhanced | W7069 | U4 & U1 | 54 | 540 | 15 min. | $18.40 | $17.42 | $16.28 |
| TD & U4 & U1 |
| Supports Broker | W7096 | U4 & U1 | 54 | 540 | 15 min. | $6.49 | $6.15 | $5.74 |
| Respite—unlicensed, in home, level 2 | W7250 | U4 & U1 | 54 | 540 | 1 day | $256.05 | $242.45 | $226.59 |
| W7258 | U4 & U1 | 54 | 540 | 15 min. | $3.96 | $3.75 | $3.51 |
| Respite—unlicensed, in home, level 2, enhanced | W7251 | U4 & U1 | 54 | 540 | 1 day | $531.47 | $503.24 | $470.32 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| W7264 | U4 & U1 | 54 | 540 | 15 min. | $8.22 | $7.79 | $7.28 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| Respite—unlicensed in home, level 3 | W7252 | U4 & U1 | 54 | 540 | 1 day | $512.09 | $484.90 | $453.17 |
| W7265 | U4 & U1 | 54 | 540 | 15 min. | $7.94 | $7.52 | $7.02 |
| Respite—unlicensed, in home, level 3, enhanced | W7253 | U4 & U1 | 54 | 540 | 1 day | $1,062.91 | $1,006.47 | $940.63 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| W7266 | U4 & U1 | 54 | 540 | 15 min. | $16.46 | $15.59 | $14.57 |
| TE & U4 & U1 |
| Respite—unlicensed, out of home, level 2 | W8002 | U4 & U1 | 54 | 540 | 1 day | $256.05 | $242.45 | $226.59 |
| W8012 | U4 & U1 | 54 | 540 | 15 min. | $3.96 | $3.75 | $3.51 |
| Respite—unlicensed, out of home, level 2, enhanced | W8003 | U4 & U1 | 54 | 540 | 1 day | $531.47 | $503.24 | $470.32 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| W8013 | U4 & U1 | 54 | 540 | 15 min. | $8.22 | $7.79 | $7.28 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| Respite—unlicensed, out of home, level 3 | W8004 | U4 & U1 | 54 | 540 | 1 day | $512.09 | $484.90 | $453.17 |
| W8014 | U4 & U1 | 54 | 540 | 15 min. | $7.94 | $7.52 | $7.02 |
| Respite—unlicensed, out of home, level 3, enhanced | W8005 | U4 & U1 | 54 | 540 | 1 day | $1,062.91 | $1,006.47 | $940.63 |
| TD & U4 & U1 |
| TE & U4 & U1 |
| W8015 | U4 & U1 | 54 | 540 | 15 min. | $16.46 | $15.59 | $14.57 |
| TD & U4 & U1 |
| TE & U4 & U1 |
Fiscal Impact
There is no additional cost to the Commonwealth anticipated in FY 2016-2017 and subsequent years as a result of this notice.
Public Comment
Copies of this notice may be obtained at the local Mental Health/Intellectual Disability (MH/ID) 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/ID County Program or AE may be found at 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 of Human Services, Office of Developmental Programs, Division of Provider Assistance and Rate Setting, 4th Floor, Health and Welfare Building, 625 Forster Street, Harrisburg, PA 17120. Comments can also be sent to ra-ratesetting@pa.gov or ra-ratesetting@state.pa.us. Use subject header ''PN Fee Schedule.''
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service by dialing 711 or by using one of the following toll free numbers:
(800) 654-5984 (TDD users)
(800) 654-5988 (voice users)
(844) 308-9292 (Speech-to-Speech)
(844) 308-9291 (Spanish)
THEODORE DALLAS,
Secretary
Fiscal Note: 14-NOT-1047. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 16-1099. Filed for public inspection June 24, 2016, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official
Pennsylvania Bulletin full text database.
Due to the limitations of HTML or differences in display capabilities
of different browsers, this version may differ slightly from the
official printed version.
