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PA Bulletin, Doc. No. 12-1219

NOTICES

Medical Assistance Program Fee Schedule for Consolidated and Person/Family Directed Support Waiver-Funded Select Services, Targeted Service Management and Community Mental Retardation Base-Funded Program

[42 Pa.B. 3811]
[Saturday, June 30, 2012]

 The Department of Public Welfare (Department) announces the proposed fee schedule rates for select services funded through the Consolidated and Person/Family Directed Support waivers (waivers) and Targeted Service Management (TSM) to the Medical Assistance (MA) Program Fee Schedule effective July 1, 2012. These proposed fee schedule 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 Intellectual Disability Act of 1966 (50 P. S. §§ 4104—4704) and 55 Pa. Code Chapter 4300 (relating to county mental health and mental retardation fiscal manual) and 55 Pa. Code Chapter 51 (relating to Office of Developmental Program's home and community-based services).

 As part of the Department's efforts to continue to align rates and rate-setting methodology across all offices and programs, the Department used a market-based approach to develop the fee schedule rates. This process includes a review of the waiver service definitions and a determination of allowable cost components which reflect costs that are reasonable, necessary and related to the delivery of the service. The MA fee schedule rates were established by the Department to fund the fee schedule services at a level sufficient to provide access to services, encourage provider participation and promote provider choice, while at the same time ensuring participant health and welfare and fiscal accountability.

 The services selected for inclusion on the MA fee schedule are identified under the following categories: Select Community-Based Services and Agency with Choice/Financial Management Services, with benefits and excluding Benefits.

 The MA fee schedule services include: Companion, Behavior Support, Therapy (Physical, Occupational, Speech and Language, Individual Behavior, Group Behavior and Visual/Mobility) Nursing, Homemaker/Chore, Supports Broker, Supports Coordination, Older Adult Day, Supplemental Habilitation and Additional Individualized Staffing.

 In addition, the Department has identified the following new services to be placed on the MA Program Fee Schedule beginning July 1, 2012: Home and Community Habilitation Unlicensed, Licensed Day Habilitation (Adult Training), Prevocational Services, Supported Employment, Transitional Work and all waiver-funded Respite care Services, excluding Respite Camp which is a vendor service.

 Agency with Choice Financial Management Services (including and excluding benefits) include: Home and Community Habilitation (Unlicensed), Companion Services, Unlicensed In-Home and Out-of-Home Respite, Supported Employment, Supports Broker and Home- maker/Chore Services.

 In developing the proposed rates for each of the MA Program Fee Schedule services, the Department evaluated information from the United States Bureau of Labor Statistics, a Commonwealth-specific compensation study, data from approved cost reports and other independent data sources and considered the expected expenses for the delivery of services under the waivers for the major allowable cost categories listed as follows:

 • Wages for direct care workers and other program staff, such as supervisors and program specialists, when applicable.

 • Employee-related expenses for health insurance and other benefits, employer taxes, paid time off and training time.

 • Productivity related to the amount of time a direct care staff person is expected to be engaged in activities for which a claim can be submitted.

 • Program indirect expenses, including transportation-related costs.

 • Administration-related expenses.

 The Department established a single rate for each MA fee schedule service and adjusted each rate by area factors to reflect consideration for differences in costs observed across these geographic areas of this Commonwealth.

 The proposed MA Program Fee Schedule rates are contingent on the final budget enacted by the General Assembly. The proposed MA Program Fee Schedule rates should be used to process claims submitted to the Provider Reimbursement and Operations Management Information System (PROMISeTM) in electronic format for services provided until a notice announcing final fee schedule rates is published.

Geographic Areas:

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 Tables: Select Community-Based Services Effective July 1, 2012

 Modifier ET must be used with applicable procedure codes when billing for temporary Base-funded services.

 The Supports Coordination MA fee identified as follows for W7210 is also applicable to TSM and base funded supports coordination.

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

Service Procedure
Code 		Modifier Provider
Type 		Specialty
Code 		Unit Area 1 Area 2 Area 3
Nursing Services: LPN T2025 TE 05 051 15 min. $11.28 $10.68 $9.98
TE & ET
TE 16 161
TE & ET
Nursing Services: RN T2025 TD 05 051 15 min. $14.64 $13.86 $12.96
TD & ET
TD 16 160
TD & ET
Physical Therapy T2025 GP 17 170 15 min.$21.35 $20.22 $18.89
GP & ET
Occupational Therapy T2025 GO 17 171 15 min. $20.67 $19.57 $18.29
GO & ET
Speech and Language Therapy T2025 GN 17 173 15 min. $18.97 $17.96 $16.79
GN & ET
Individual Behavioral Therapy T2025 HE 19 208 15 min. $25.03 $23.70 $22.15
HE & ET
Group Behavioral Therapy T2025 HE & HQ 19 208 15 min. $7.85 $7.43 $6.95
HE, HQ & ET
Visual/Mobility Therapy W7246 51 517 15 min. $18.97 $17.96 $16.79
ET
Companion, Basic staff support W1724 51 363 15 min. $1.24 $1.17 $1.10
ET
Companion, level 1 W1725 51 363 15 min. $1.43 $1.35 $1.27
ET
Companion, level 2 W1726 51 363 15 min. $2.21 $2.09 $1.96
ET
Companion, level 3 W1727 51 363 15 min. $6.09 $5.77 $5.39
ET
Supplemental Habilitation, 1:1(PA) W7070 52 456, 520, 521 or 522 15 min. $5.39 $5.10 $4.77
ET
Supplemental Habilitation, 2:1(PA) W7084 52 456, 520, 521 or 522 15 min. $10.77 $10.20 $9.53
ET
Additional Individualized Staffing, 1:1(PA) W7085 52 456, 520, 521 or 522 15 min. $5.39 $5.10 $4.77
Additional Individualized Staffing, 2:1(PA) W708652 456, 520, 521 or 522 15 min. $10.77 $10.20 $9.53
Older Adult Day Habilitation W7094 51 410 15 min. $2.55 $2.41 $2.26
ET
Behavioral Support W7095 51 510 15 min. $19.16 $18.14 $16.96
ET
Supports Broker W7096 51 510 15 min. $8.59 $8.13 $7.60
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. $8.74 $8.28 $7.73
W7076 51 15 min. $12.78 $12.10 $11.31
W7035 15 min. $16.61 $15.73 $14.70
W7036 15 min. $24.97 $23.64 $22.10
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. $8.98 $8.50 $7.95
W7091 15 min. $12.51 $11.85 $11.07
W7092 15 min. $17.64 $16.70 $15.61
W7093 15 min. $24.71 $23.40 $21.87
Supports Coordination W7210 21 218 15 min. $20.96 $19.85 $18.55
Supported Employment W7235 53 530
531 		15 min. $14.07 $13.32 $12.45
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. $7.17 $6.79 $6.35
W7061 51 510 15 min. $11.05 $10.46 $9.78
TD
TE
W7068 51 510 15 min. $13.93 $13.19 $12.33
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 $241.15 $228.35 $213.41
W7251 51 512 Day $381.07 $360.84 $337.23
W7252 51 512 Day $475.06 $449.84 $420.41
W7253 51 512 Day $754.89 $714.81 $668.04
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. $6.03 $5.71 $5.34
W7264 51 512 15 min. $9.53 $9.02 $8.43
W7265 51 512 15 min. $11.88 $11.25 $10.51
W7266 51 512 15 min. $18.87 $17.87 $16.70
TD
TE
Respite—unlicensed out of home—24 hours W8000 51 513 Day $85.20 $80.68 $75.40
W8001 51 513 Day $110.80 $104.92 $98.05
W8002 51 513 Day $241.15 $228.35 $213.41
W8003 51 513 Day $381.07 $360.84 $337.23
W8004 51 513 Day $475.06 $449.84 $420.41
W8005 51 513 Day $754.89 $714.81 $668.04
TD
TE
Respite—unlicensed out of home—15 minutes 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. $6.03 $5.71 $5.34
W8013 51 513 15 min. $9.53 $9.02 $8.43
TD
TE
W8014 51 513 15 min. $11.88 $11.25 $10.51
W8015 51 513 15 min. $18.87 $17.87 $16.70
TD
TE
Respite—licensed out of home—24 hours W7259 51 513 Day $135.34 $128.15 $119.77
U2
W7260 51 513 Day $235.52 $223.01 $208.42
U2
W7262 51 513 Day $269.15 $254.86 $238.19
U2
W7263 51 513 Day $415.68 $393.61 $367.86
U2
W7299 51 513 Day $523.79 $495.98 $463.53
U2
W7300 51 513 Day $816.86 $773.49 $722.88
TD
TE
U2
Respite—licensed out of home—15 minutes W7267 51 513 15 min. $3.38 $3.20 $2.99
W7268 51 513 15 min. $3.68 $3.48 $3.26
W7270 51 513 15 min. $6.73 $6.37 $5.96
W7400 51 513 15 min. $10.39 $9.84 $9.19
TD
TE
W7401 51 513 15 min. $13.09 $12.39 $11.58
W7402 51 513 15 min. $20.42 $19.34 $18.07
TD
TE
Homemaker/Chore (permanent) W7283 43 430 1 hour $19.44 $18.41 $17.20
51 430 or 431
55 430 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
UA 45 430 or 431
UA & ET

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
Companion, level 3 W1727 U4 54 540 15 min. $2.91 $2.76 $2.58
Supported Employment W7235 U4 54 540 15 min. $5.56 $5.26 $4.92
Unlicensed Habilitation, level 3 W7060 U4 54 540 15 min. $4.81 $4.55 $4.26
Unlicensed Habilitation, level 3, enhanced W7061 U4 54 540 15 min. $7.97 $7.55 $7.05
TD & U4
TE & U4
Unlicensed Habilitation, level 4 W7068 U4 54 540 15 min. $9.63 $9.12 $8.52
Unlicensed Habilitation, level 4, enhanced W7069 U4 54 540 15 min. $15.93 $15.08 $14.10
TD & U4
TE & U4
Supports Broker W7096 U4 54 540 15 min. $5.56 $5.26 $4.92
Respite—unlicensed, in home, level 2 W7250 U4 54 540 1 day $213.97 $202.61 $189.35
W7258 U4 54 540 15 min. $3.31 $3.13 $2.93
Respite—unlicensed, in home, level 2, enhanced W7251 U4 54 540 1 day $458.99 $434.62 $406.19
TD & U4
TE & U4
W7264 U4 54 540 15 min. $7.10 $6.72 $6.28
TD & U4
TE & U4
Respite—unlicensed in home, level 3 W7252 U4 54 540 1 day $427.93 $405.21 $378.70
W7265 U4 54 540 15 min. $6.63 $6.28 $5.87
Respite—unlicensed, in home, level 3, enhanced W7253 U4 54 540 1 day $917.97 $869.23 $812.36
TD & U4
TE & U4
W7266 U4 54 540 15 min. $14.21 $13.46 $12.58
TD & U4
TE & U4
Homemaker/ Chore W7283 U4 54 540 1 hour $12.76 $12.08 $11.29
UA & U4
Respite—unlicensed, out of home, level 2 W8002 U4 54 540 1 day $213.97 $202.61 $189.35
W8012 U4 54 540 15 min. $3.31 $3.13 $2.93
Respite—unlicensed, out of home, level 2, enhanced W8003 U4 54 540 1 day $458.99 $434.62 $406.19
TD & U4
TE & U4
W8013 U4 54 540 15 min. $7.10 $6.72 $6.28
TD & U4
TE & U4
Respite—unlicensed, out of home, level 3 W8004 U4 54 540 1 day $427.93 $405.21 $378.70
W8014 U4 54 540 15 min. $6.63 $6.28 $5.87
Respite—unlicensed, out of home, level 3, enhanced W8005 U4 54 540 1 day $917.97 $869.23 $812.36
TD & U4
TE & U4
W8015 U4 54 540 15 min. $14.21 $13.46 $12.58

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
Companion, level 3 W1727 54 540 15 min. $3.83 $3.63 $3.39
Supported Employment W7235 54 540 15 min. $6.45 $6.11 $5.71
Unlicensed Habilitation, level 3 W7060 54 540 15 min. $5.74 $5.44 $5.08
Unlicensed Habilitation, level 3, enhanced W7061 54 540 15 min. $8.89 $8.42 $7.87
TD
TE
Unlicensed Habilitation, level 4 W7068 54 540 15 min. $11.48 $10.87 $10.16
Unlicensed Habilitation, level 4, enhanced W7069 54 540 15 min. $17.78 $16.84 $15.73
TD
TE
Supports Broker W7096 54 540 15 min. $6.45 $6.11 $5.71
Respite-unlicensed, in home, level 2 W7250 54 540 1 day $270.77 $256.39 $239.62
W7258 54 540 15 min. $4.23 $4.01 $3.74
Respite—unlicensed, in home, level 2, enhanced W7251 54 540 1 day $515.79 $488.40 $456.45
TD
TE
W7264 54 540 15 min. $8.03 $7.60 $7.11
TD
TE
Respite—unlicensed, in home, level 3 W7252 54 540 1 day $541.54 $512.79 $479.24
W7265 54 540 15 min. $8.46 $8.01 $7.49
Respite—unlicensed, in home, level 3, enhanced W7253 54 540 1 day $1,031.58 $976.81 $912.90
TD
TE
W7266 54 540 15 min. $16.06 $15.21 $14.21
TD
TE
Homemaker/ Chore W7283 54 540 1 hour $16.43 $15.56 $14.54
UA
Respite—unlicensed, out of home, level 2 W8002 54 540 1 day $270.77 $256.39 $239.62
W8012 54 540 15 min. $4.23 $4.01 $3.74
Respite—unlicensed, out of home, level 2, enhanced W8003 54 540 1 day $515.79 $488.40 $456.45
TD
TE
W801354 540 15 min. $8.03 $7.60 $7.11
TD
TE
Respite—unlicensed, out of home, level 3 W8004 54 540 1 day $541.54 $512.79 $479.24
W8014 54 540 15 min. $8.46 $8.01 $7.49
Respite—unlicensed, out of home, level 3, enhanced W8005 54 540 1 day $1,031.58 $976.81 $912.90
TD
TE
W8015 54 540 15 min. $16.06 $15.21 $14.21
TD
TE

Fiscal Impact

 It is anticipated there will be an approximate cost to the Commonwealth of $15.694 million ($7.144 million State funds) in Fiscal Year (FY) 2012-2013 and subsequent fiscal years.

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 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 at the Office of Developmental Programs' rate-setting mailbox at ra-ratesetting@state.pa.us, use subject header ''PN Fee Schedule,'' or 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).

GARY D. ALEXANDER, 
Secretary

 Fiscal Note: 14-NOT-772. (1) General Fund:

(2) Implementing Year 2012-13 is $7,144,000
(3) 1st Succeeding Year 2013-14 is $7,144,000
2nd Succeeding Year 2014-15 is $7,144,000
3rd Succeeding Year 2015-16 is $7,144,000
4th Succeeding Year 2016-17 is $7,144,000
5th Succeeding Year 2017-18 is $7,144,000
ID—Community
Waiver Program		ID—Community
Base Program		Human Services
Development Fund
(4) 2011-12 Program—$854,863,000 $166,520,000
$14,956,000
2010-11 Program—$672,376,000 $155,958,000
$23,243,000
2009-10 Program—$622,849,000 $156,619,000
$33,346,000
Prior to FY 2012-2013, ID—Community Base Services were provided through the ID—Community Base Program appropriation. Beginning in FY 2012-2013, ID—Community Base Services are provided through the Human Services Development Fund.
(7) ID—Community Waiver Program; (8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 12-1219. Filed for public inspection June 29, 2012, 9:00 a.m.]


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