NOTICES
DEPARTMENT OF HUMAN SERVICES
Rate Setting Methodology and Fee Schedule Rates for Services Funded Through the Office of Developmental Programs' Community Living Waiver
[48 Pa.B. 4358]
[Saturday, July 21, 2018]The purpose of this notice is to announce the Department of Human Services' (Department) final rate setting methodology and Fee Schedule Rates for select services funded through the Community Living Waiver effective January 1, 2018.
Fee Schedule Rates
The Department published its proposed Fee Schedule Rates at 47 Pa.B. 5112 (August 26, 2017). The Department received comments from 33 stakeholders regarding the rate setting methodology and Fee Schedule Rates. A summary of the comments received and the Department's responses are available at http://dhs.pa.gov/cs/groups/webcontent/documents/document/c_268077.pdf.
As a result of the comments received, the Department made changes to Agency with Choice/Financial Management Services rates for in-home and community support and respite (15-minute and day) services. In addition, the Department has corrected the following errors from the proposed Fee Schedule Rates:
• The rate for Enhanced Communication for Supports Coordination was removed.
• There was a typographical error in the proposed rate for Community Participation Support procedure code W5967. The proposed rate was listed as $5.59. The rate should have been $6.59.
Fee Schedule Rates for Community-Based Services through the Community Living Waiver Effective
January 1, 2018Modifier SE is used to identify the amount of units that are being billed when the individual spent time in the community during the provision of Community Participation Support services.
Modifier SE is used when billing for Benefits Counseling to identify that it is an Office of Developmental Program (ODP) service.
Modifier SE is used when billing for Music Therapy.
Modifier SE is used when billing for Consultative Nutritional Services to identify that it is an ODP service.
Modifier SE is used when billing for Family Caregiver Support Counseling to identify that it is an ODP service.
Modifier TD is used to identify services rendered by a Registered Nurse (RN).
Modifier TE is used to identify services rendered by a Licensed Practical Nurse (LPN).
Modifiers U5, U6, U7 and U8 are Support Intensity Scale Needs Group Modifiers.
Modifier UD is used when billing for Advanced Supported Employment.
Modifier GP is used to identify services rendered by a Physical Therapist.
Modifier GO is used to identify services rendered by an Occupational Therapist.
Modifier GN is used to identify services rendered by a Speech and Language Therapist.
Modifier UN is used to identify shift nursing at the 1:2 ratio.
Modifier UA is used to identify the Homemaker/Chore service when it is authorized as a temporary service.
Modifier U1 is utilized with the appropriate procedure code to allow providers, who are approved by the Department, to receive the Enhanced Communication Services Rate.
All rates in the table are per 15-minute unit unless otherwise noted.
Service Name Staffing Level Procedure Code Modifier 1 Modifier 2 Statewide Fee Enhanced Communication Statewide Fee (U1 modifier) Companion Services 1:3 W1724 $2.64 $3.03 1:2 W1725 $3.67 $4.25 1:1 W1726 $6.33 $7.43 Homemaker/Chore 1:1 W7283 $16.73
(per hour)N/A 1:1 (temporary) W7283 UA $16.73
(per hour)N/A In-Home and Community Supports 1:3 W7058 $3.17 $3.67 1:2 W7059 $4.52 $5.27 1:1 W7060 $8.08 $9.48 1:1 enhanced W7061 TD and TE $11.44 $13.74 2:1 W7068 $15.72 $18.52 2:1 enhanced W7069 TD and TE $19.07 $22.77 Older Adult Daily Living Centers N/A W7094 $2.73 $3.08 Community Participation Support (CPS) <25% Community 1:2 or 1:3 and >75% Facility 1:11 to 1:15 W5945 SE $2.45 $2.75 <25% Community 1:2 or 1:3 and >75% Facility 1:7 to 1:10 W5946 SE $2.75 $3.10 <25% Community 1:2 or 1:3 and >75% Facility 1:2 to 1:6 W5947 SE $4.45 $5.10 <25% Community 1:1 and >75% Facility 1:7 to 1:15 W5948 SE $3.70 $4.23 <25% Community 1:1 and >75% Facility 1:2 to 1:6 W5950 SE $5.58 $6.44 <25% Community 1:1 and >75% Facility 1:1 W5951 SE $9.55 $11.17 <25% Community 1:1 Enhanced and >75% Facility 1:1 Enhanced W5952 SE TD and TE $13.28 $15.91 <25% Community 2:1 and >75% Facility 2:1 to 1:1 W5943 SE $18.32 $21.55 <25% Community 2:1 Enhanced and >75% Facility 2:1 Enhanced W5944 SE TD and TE $22.05 $26.29 <25% Community 2:3 and >75% Facility 1:11 to 1:15 W5940 SE $3.14 $3.57 <25% Community 2:3 and >75% Facility 1:7 to 1:10 W5941 SE $3.43 $3.92 <25% Community 2:3 and >75% Facility 1:2 to 1:6 W5942 SE $5.14 $5.92 Community Participation Support (continued) 25% Community 1:2 or 1:3 and 75% Facility 1:11 to 1:15 W5958 SE $2.93 $3.32 25% Community 1:2 or 1:3 and 75% Facility 1:7 to 1:10 W5959 SE $3.17 $3.60 25% Community 1:2 or 1:3 and 75% Facility 1:2 to 1:6 W5960 SE $4.57 $5.25 25% Community 1:1 and 75% Facility 1:7 to 1:15 W5961 SE $4.79 $5.53 25% Community 1:1 and 75% Facility 1:2 to 1:6 W5962 SE $6.33 $7.35 25% Community 1:1 and 75% Facility 1:1 W5963 SE $9.60 $11.23 25% Community 1:1 Enhanced and 75% Facility 1:1 Enhanced W5964 SE TD and TE $13.36 $16.00 25% Community 2:1 and 75% Facility 2:1 W5956 SE $18.43 $21.68 25% Community 2:1 Enhanced and 75% Facility 2:1 Enhanced W5957 SE TD and TE $22.18 $26.45 25% Community 2:3 and 75% Facility 1:11 to 1:15 W5953 SE $4.00 $4.60 25% Community 2:3 and 75% Facility 1:7 to 1:10 W5954 SE $4.25 $4.88 25% Community 2:3 and 75% Facility 1:2 to 1:6 W5955 SE $5.65 $6.53 50% Community 1:2 or 1:3 and 50% Facility 1:11 to 1:15 W5970 SE $3.81 $4.36 50% Community 1:2 or 1:3 and 50% Facility 1:7 to 1:10 W5971 SE $3.96 $4.53 50% Community 1:2 or 1:3 and 50% Facility 1:2 to 1:6 W5972 SE $4.80 $5.52 50% Community 1:1 and 50% Facility 1:7 to 1:15 W5973 SE $6.81 $7.92 50% Community 1:1 and 50% Facility 1:2 to 1:6 W5974 SE $7.74 $9.02 50% Community 1:1 and 50% Facility 1:1 W5975 SE $9.70 $11.35 Community Participation Support (continued) 50% Community 1:1 Enhanced and 50% Facility 1:1 Enhanced W5976 SE TD and TE $13.49 $16.16 50% Community 2:1 and 50% Facility 2:1 W5968 SE $18.63 $21.93 50% Community 2:1 Enhanced and 50% Facility 2:1 Enhanced W5969 SE TD and TE $22.42 $26.74 50% Community 2:3 and 50% Facility 1:11 to 1:15 W5965 SE $5.61 $6.50 50% Community 2:3 and 50% Facility 1:7 to 1:10 W5966 SE $5.75 $6.67 50% Community 2:3 and 50% Facility 1:2 to 1:6 W5967 SE $6.59 $7.66 75% Community 1:2 or 1:3 and 25% Facility 1:11 to 1:15 W5982 SE $4.70 $5.41 75% Community 1:2 or 1:3 and 25% Facility 1:7 to 1:10 W5983 SE $4.75 $5.46 75% Community 1:2 or 1:3 and 25% Facility 1:2 to 1:6 W5984 SE $5.03 $5.79 75% Community 1:1 and 25% Facility 1:7 to 1:15 W5985 SE $8.83 $10.32 75% Community 1:1 and 25% Facility 1:2 to 1:6 W5990 SE $9.14 $10.69 75% Community 1:1 and 25% Facility 1:1 W5991 SE $9.79 $11.46 75% Community 1:1 Enhanced and 25% Facility 1:1 Enhanced W5992 SE TD and TE $13.62 $16.32 75% Community 2:1 and 25% Facility 2:1 W5980 SE $18.84 $22.18 75% Community 2:1 Enhanced and 25% Facility 2:1 Enhanced W5981 SE TD and TE $22.66 $27.03 75% Community 2:3 and 25% Facility 1:11 to 1:15 W5977 SE $7.21 $8.40 75% Community 2:3 and 25% Facility 1:7 to 1:10 W5978 SE $7.26 $8.46 75% Community 2:3 and 25% Facility 1:2 to 1:6 W5979 SE $7.54 $8.79 100% Community 1:2 or 1:3 W5995 $5.14 $5.93 Community Participation Support (continued) 100% Community 2:3 H2015 $8.01 $9.35 100% Community 1:1 W5996 $9.84 $11.52 100% Community 1:1 Enhanced W5997 TD and TE $13.68 $16.40 100% Community 2:1 W5993 $18.94 $22.30 100% Community 2:1 Enhanced W5994 TD and TE $22.78 $27.18 Small Group Employment 1:10 to 1:6 W7237 $2.21 $2.65 <1:6 to 1:3.5 W7239 $3.40 $4.09 <1:3.5 to >1:1 W7241 $6.60 $7.95 1:1 W7245 $12.05 $14.53 Benefits Counseling 1:1 W1740 SE $11.40 $13.57 Supported Employment—Career Assessment 1:1 W7235 $17.75 $21.12 Supported Employment—Job Finding and Development 1:1 H2023 $17.75 $21.12 Supported Employment—Job Coaching and Support 1:2 H2025 $10.45 $12.40 1:1 W9794 $17.75 $21.12 Advanced Supported Employment 1:1 (Discovery Profile Outcome) W7235 UD $3,810.00 $4,594.00 Advanced Supported Employment 1:1 (Job Acquisition Outcome) H2023 UD $3,810.00 $4,594.00 Advanced Supported Employment 1:1 (Job Retention Outcome) H2025 UD $9,144.00 $11,025.60 Shift Nursing—RN 1:2 T2025 TD UN $8.06 $9.90 1:1 T2025 TD $15.78 $19.46 Shift Nursing—LPN 1:2 T2025 TE UN $5.88 $7.13 1:1 T2025 TE $11.41 $13.92 Therapies—Physical 1:1 T2025 GP $21.29 $26.46 Therapies—Occupational 1:1 T2025 GO $19.71 $24.45 Therapies—Speech/Language 1:1 T2025 GN $19.12 $23.71 Therapies—Orientation, Mobility and Vision 1:1 W7246 $18.16 $22.48 Music Therapy 1:1 G0176 SE $15.34 $18.93 Art Therapy 1:1 G0176 $15.34 $18.93 Equine Assisted Therapy 1:1 S8940 $10.36 $12.30 Behavioral Supports—Level 1 1:1 W7095 $21.12 $25.44 Behavioral Supports—Level 2 1:1 W8996 $21.39 $26.42 Communication Specialist 1:1 T1013 $15.32 $18.90 Consultative Nutritional Services 1:1 S9470 SE $12.36 $15.15 Family Caregiver Support Counseling 1:1 without participant present 90846 SE $12.12 N/A 1:1 with participant present 90847 SE $12.12 $14.85 24 Hour Respite (In-Home Respite and Unlicensed Out-of-Home Respite Services) 1:4 W9795 $69.86
(per day)$83.12
(per day)1:3 W9796 $93.09
(per day)$110.78
(per day)1:2 W9797 $139.56
(per day)$166.10
(per day)1:1 W9798 $245.13
(per day)$291.75
(per day)1:1 Enhanced W9799 $416.93 (per day) $509.93
(per day)2:1 W9800 $490.11 (per day) $583.34
(per day)2:1 Enhanced W9801 $661.90 (per day) $801.53
(per day)15 Minute Respite (In-Home Respite and Unlicensed Out-of-Home Respite Services) 1:4 W8096 $1.75 $2.08 1:3 W9860 $2.33 $2.77 1:2 W9861 $3.49 $4.15 1:1 W9862 $6.13 $7.29 1:1 Enhanced W9863 $10.42 $12.75 2:1 W9864 $12.25 $14.58 2:1 Enhanced W8095 $16.55 $20.04 24 Hour Respite (Licensed Respite Group Homes) Needs Group 1-2 Person W9791 U5 $456.17 (per day) $543.52
(per day)Needs Group 1-3 Person W9792 U5 $331.94 (per day) $395.06
(per day)Needs Group 1-4 Person W9793 U5 $263.76 (per day) $313.54
(per day)Needs Group 2-2 Person W9791 U6 $538.09 (per day) $643.36
(per day)Needs Group 2-3 Person W9792 U6 $365.87 (per day) $436.50
(per day)Needs Group 2-4 Person W9793 U6 $292.42 (per day) $348.59
(per day)Needs Group 3-1 Person W9790 U7 $787.76 (per day) $940.81
(per day)Needs Group 3-2 Person W9791 U7 $644.77 (per day) $774.54
(per day)Needs Group 3-3 Person W9792 U7 $457.38 (per day) $548.81
(per day)Needs Group 3-4 Person W9793 U7 $360.12 (per day) $431.68
(per day)Needs Group 4-1 Person W9790 U8 $861.70 (per day) $1,034.28
(per day)Needs Group 4-2 Person W9791 U8 $702.24 (per day) $847.32
(per day)Needs Group 4-3 Person W9792 U8 $499.39 (per day) $601.96
(per day)Needs Group 4-4 Person W9793 U8 $393.36 (per day) $473.69
(per day)24 Hour Respite (Respite Only Home) Needs Group 1-2 Person W9865 U5 $520.58 (per day) $620.26
(per day)Needs Group 1-3 Person W9866 U5 $378.80 (per day) $450.83
(per day)Needs Group 1-4 Person W9871 U5 $300.98 (per day) $357.79
(per day)Needs Group 2-2 Person W9865 U6 $614.06 (per day) $734.20
(per day)Needs Group 2-3 Person W9866 U6 $417.52 (per day) $498.13
(per day)Needs Group 2-4 Person W9871 U6 $333.70 (per day) $397.80
(per day)Needs Group 3-2 Person W9865 U7 $735.80 (per day) $883.89
(per day)Needs Group 3-3 Person W9866 U7 $521.94 (per day) $626.29
(per day)Needs Group 3-4 Person W9871 U7 $410.95 (per day) $492.62
(per day)Needs Group 4-2 Person W9865 U8 $801.39 (per day) $966.95
(per day)Needs Group 4-3 Person W9866 U8 $569.89 (per day) $686.95
(per day)Needs Group 4-4 Person W9871 U8 $448.88 (per day) $540.56
(per day)Supports Broker Services 1:1 W7096 $16.88 $19.66 Supports Coordination 1:1 W7210 $23.62 N/A Housing Transition and Tenancy Sustaining 1:1 H0043 $10.48 $12.50 Supplemental Habilitation 1:1 W7070 $5.46 $6.67 2:1 W7084 $10.93 $13.32
Service Group Needs Group Procedure Code Modifier 1 Modifier 2 Approved Program Capacity or Staffing Level Statewide Fee Enhanced Communication Statewide Fee Supported Living Needs Group 1 W9872 U5 1 Person $133.10 $156.12 W9873 U5 2 People $93.17 $109.29 W9874 U5 3 People $66.55 $78.06 Needs Group 2 W9872 U6 1 Person $208.26 $244.33 W9873 U6 2 People $166.61 $195.47 W9874 U6 3 People $110.79 $129.97 Life Sharing—over 30 hours per week on average Needs Group 1 W8593 U5 SE (provided by relative) 1 Person $144.22 $180.99 W8595 U5 SE (provided by relative) 2 People $102.45 $128.80 Needs Group 2 W8593 U6 SE (provided by relative) 1 Person $171.82 $215.60 W8595 U6 SE (provided by relative) 2 People $122.88 $154.54 Life Sharing—under 30 hours per week on average N/A W7037 SE (provided by relative) TD and TE 1 Person $142.23 $178.45 W7039 SE (provided by relative) TD and TE 2 People $100.72 $126.60
Agency with Choice Financial Management Services, Including Benefit Allowance** Effective January 1, 2018
**No modifier is needed to indicate the benefit allowance is included. Modifier TD is used to identify services rendered by an RN.
Modifier TE is used to identify services rendered by an LPN.
Modifier U1 is utilized with the appropriate procedure code to allow providers, who are approved by the Department, to receive the Enhanced Communication Services Rate.
All rates in the table are per 15 minute unit unless otherwise noted.
Service Name Staffing Level Procedure Code Modifier 1 Modifier 2 Statewide Fee Enhanced Communication Statewide Fee In-Home and Community supports 1:1 W7060 $5.74 $6.97 2:1 W7068 $11.48 $13.95 In-Home and Community supports—Enhanced 1:1 (Enhanced) W7061 TD and TE $7.55 $9.34 2:1 (Enhanced) W7069 TD and TE $11.31 $13.86 Companion Services 1:1 W1726 $4.54 $5.51 In-Home Respite and Unlicensed Out-of-Home Respite Services 1:1 W9862 $4.15 $4.84 2:1 W9864 $8.29 $9.66 1:1 W9798 $315.10 (per day) $367.42
(per day)2:1 W9800 $529.51 (per day) $634.14
(per day)In-Home Respite and Unlicensed Out-of-Home Respite Services—Enhanced 1:1 W9863 $7.50 $9.28 2:1 W8095 $10.99 $13.45 1:1 W9799 $570.23 (per day) $705.01
(per day)2:1 W9801 $834.98 (per day) $1,022.08
(per day)Supported Employment—Career Assessment 1:1 W7235 $6.96 $7.67 Supported Employment—Job Finding and Development 1:1 H2023 $6.96 $7.67 Supported Employment—Job Coaching and Support 1:1 W9794 $6.96 $7.67 Supports Broker 1:1 W7096 $5.42 $6.63 Homemaker/Chore 1:1 W7283 $13.78
(per hour)N/A AWC FMS Monthly Administrative Fee Per Person
Per MonthW7319 $231.21 N/A
Agency with Choice Financial Management Services, Excluding Benefit Allowance Effective January 1, 2018
**Modifier U4 must be used with all procedures codes when billing for services excluding benefit allowance. Modifier TD is used to identify services rendered by an RN.
Modifier TE is used to identify services rendered by an LPN.
Modifier U1 is utilized with the appropriate procedure code to allow providers, who are approved by the Department, to receive the Enhanced Communication Services Rate.
All rates in the table are per 15-minute unit unless otherwise noted.
Service Name Staffing Level Procedure Code Modifier 1 Modifier 2 Statewide Fee Enhanced Communication Statewide Fee (U1 modifier) In-Home and Community supports 1:1 W7060 U4 $5.11 $6.34 2:1 W7068 U4 $10.22 $12.69 Companion Services 1:1 W1726 U4 $3.92 $4.89 In-Home Respite and Unlicensed Out-of-Home Respite Services 1:1 W9862 U4 $3.52 $4.27 2:1 W9864 U4 $7.03 $8.40 1:1 W9798 U4 $267.22 (per day) $319.54
(per day)2:1 W9800 U4 $445.36 (per day) $549.99
(per day)In-Home and Community supports—Enhanced 1:1 W7061 U4 TD and TE $6.93 $8.72 2:1 W7069 U4 TD and TE $10.07 $12.61 In-Home Respite and Unlicensed Out-of-Home Respite Services—Enhanced 1:1 W9863 U4 $6.88 $8.66 2:1 W8095 U4 $9.75 $12.21 1:1 W9799 U4 $523.05 (per day) $657.84
(per day)2:1 W9801 U4 $740.63 (per day) $927.74
(per day)Supported Employment—Career Assessment 1:1 W7235 U4 $6.34 $7.04 Supported Employment—Job Finding and Development 1:1 H2023 U4 $6.34 $7.04 Supported Employment—Job Coaching and Support 1:1 W9794 U4 $6.34 $7.04 Supports Broker 1:1 W7096 U4 $4.80 $6.00 Homemaker/Chore 1:1 W7283 U4 $11.29
(per hour)N/A AWC FMS Monthly Administrative Fee Per Person
Per MonthW7319 $231.21 N/A Rate-Setting Methodology for Transportation (per trip) Services
The Department published notice of the methodology used to develop rates for transportation trip services funded through the Community Living Waiver at 47 Pa.B. 5112. The Department will implement the methodology described in the proposed notice. The Department received two comments from stakeholders regarding the methodology used to develop transportation trip rates. A summary of the comments received and the Department's responses is available at http://dhs.pa.gov/cs/groups/webcontent/documents/document/c_268077.pdf.
Fiscal Impact
It is anticipated that there will be an additional cost of approximately $32.000 million ($15.418 million in State Funds) to the Commonwealth in Fiscal Year (FY) 2017-2018 and an annualized cost of $64.000 million ($30.629 million in State Funds) in FY 2018-2019 and subsequent years.
Copies of this notice may be obtained at the local Mental Health/Intellectual Disability (MH/ID) County Program, Administrative Entity (AE) or regional Office of Developmental Programs 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: P.O. Box 2675, 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.
TERESA D. MILLER,
SecretaryFiscal Note: 14-NOT-1249. (1) General Fund; (2) Implementing Year 2017-18 is $15,418,000; (3) 1st Succeeding Year 2018-19 through 5th Succeeding Year 2022-23 are $30,629,000; (4) 2016-17 Program—$1,349,000; 2015-16 Program—$1,203,000; 2014-15 Program—$1,075,000; (7) ID—Community Waiver Program; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 18-1134. Filed for public inspection July 20, 2018, 9:00 a.m.]
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