Standard Rate Schedule: Non-Clinician Medicaid 1915(b) and (b)(3) Revised 03/22/23 Electronic Visit Verification (EVV) and Direct Care Worker (DCW) adjustments included where applicable Q - Requires LQASP (Licensed Qualified Autism Services Practitioner) Service - Description
Effective Date
Standard Rates
96138 - PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING
12/1/2022
$
32.64
96139 - add on PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING
12/1/2022
$
32.64
12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
1.74 26.56 53.65 18.29 9.88 28.00 30.00 10.00 341.86 163.60 253.90 22.31 140.30 393.47 267.81 219.98 357.42 17.43 141.82 16.50 3.02 430.19 0.01 3.94 3.94 5.29 5.29 86.25 94.50
12/1/2022
$
9.00
12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
33.70 3.31 38.00 38.00 38.00 38.00 38.00 6.28 192.89 197.89 119.07 124.07 3.69 146.45 13.67 7.49 268.00 45.52 2.95 11.21 25.17 2.95 2.80 8.27 8.30
96146 - PSYCH OR NEUROPSYCH AUTOMATED TESTING AND RESULT 97151 - Behavior identification assessment 97152 - Behavior identification supporting assessment, tech 97153 - Adaptive behavior treatment by protocol, tech 97154 - Group adaptive behavior treatment by protocol, tech 97155 - Adaptive behavior treatment with protocol modification, QHP 97156 - Family adaptive behavior treatment guidance 97157 - Multiple-family group adaptive behavior treatment guidance H0010 - DETOX-NON-HSP-MED H0012HB - Community Residential Tx-Adult H0013 - SA Med Mon Community Residential Tx H0014 - AMBULATORY DETOX H0015 - SA IOP H0019HK - HRI L4, BH LT Res H0019HQ - HRI L3, <=4 beds, BH LT Res H0019TJ - HRI L3, 5+ beds, BH LT Res H0019UR - Residential Level IV (5+ Beds) H0020 - Outpatient Opioid Treatment H0035 - MH PARTIAL HOSP, < 24 HR H0038 - Peer Support Services (PSS) - individual H0038HQ - Peer Support Services (PSS) - group H0040 - ACTT H004022 - ACTT > 4 events per month H0045HQU4HA - (B3) Child Group Respite H0045HQU4HB - (B3) Adult Group Respite H0045U4HA - (B3) Child Individual Respite H0045U4HB - (B3) Adult Individual Respite H0046 - High Risk Res L1 H2011 - CRISIS SERVICES H2011U4HI - DI Crisis Intervention and Stabilization Supports with Technical Amendment H2012HA - DAY TREATMENT CHILD H2015HQU4 - DI Community Networking - Group H2015HTHF - CST - SA Professional - Community Support Team H2015HTHM - CST - Paraprofessional - Community Support Team H2015HTHN - CST - QP/AP - Community Support Team H2015HTHO - CST - Team Lead - Community Support Team H2015HTU1 - CST - PSS - Community Support Team H2015U4 - DI Community Networking - Individual H2016HIU4 - DI Level 4-Residential Supports H2016HIU4U2 - DI Level 4 AFL-Residential Supports H2016U4 - DI Level 1-Residential Supports H2016U4U2 - DI Level 1 AFL Residential Supports H2017 - PSYCHOSOCIAL REHAB H2020 - Child Residential Level II – Program Type H2021 - Outpatient Plus H2021HQ - Group Outpatient Plus H2022 - INTENSIVE-IN-HOME H2022U4 - (b)(3) Transitional Living H2023HQU4 - IDD non-DI Initial Group Supported Employment H2023U4 - IDD non-DI Initial Individual Supported Employment H2023U4HH - MHSA Initial Individual Supported Employment H2025HQU4 - DI Group - Supported Employment H2025TSHQU4 - DI Supported Employment – Long Term Follow-up - Group H2025TSU4 - DI Supported Employment – Long Term Follow-up H2025U4 - DI Individual Supported Employment
Q Q Q Q Q Q Q
Standard Rate Schedule: Non-Clinician Medicaid 1915(b) and (b)(3) Revised 03/22/23 Electronic Visit Verification (EVV) and Direct Care Worker (DCW) adjustments included where applicable Q - Requires LQASP (Licensed Qualified Autism Services Practitioner) Service - Description
Effective Date
H2026HQU4 - IDD non-DI Maint Group Supported Employment H2026U4 - IDD non-DI Maint Individual Supported Employment H2033 - MULTI-SYSTEMIC-THER H2035 - SA Comprehensive Outpatient Trt Prog Q3014GT - TELEHEALTH ORIG SITE FEE S5110U4 - DI Natural Supports Education - Individual S5145 - CTSP Residential II S5145HA - CTSP FAM TYPE RES II IAFT S5145HK - Enh Rate Therapeutic Foster Care S5145U5 - Enhanced Therapeutic Foster Care S5150HQU4 - DI Respite - Group S5150U4 - DI Respite - Individual S5150USU4 - DI Respite - Facility S9484 - FAC BASED CRISIS HR S9484HA - FAC BASED CRISIS HR - Child & Adol T1005TDU4 - AWC - DI Respite - Nursing RN T1005TDU4 - DI Respite - Nursing RN T1005TEU4 - AWC - DI Respite - Nursing LPN T1005TEU4 - DI Respite - Nursing LPN T1019U4 - Individual Support T1019U4TS - Individual Support - non-EVV, only in the community T1023 - DIAGNOSTIC-ASSESSMENT T2012GCHQU4 - DI Community Living and Supports - Group, relative as provider lives in home
12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Standard Rates
2.80 11.21 39.19 48.34 21.25 8.96 175.00 248.40 175.00 175.00 4.35 6.81 169.48 30.00 31.50 15.60 15.60 14.85 14.85 13.20 12.00 242.47
12/1/2022
$
3.02
T2012GCU4 - DI Community Living and Supports, relative as provider lives in home
12/1/2022
$
5.92
T2012HQU4 - DI Community Living and Supports - Group, only in the community T2012U4 - DI Community Living and Supports, only in the community T2013TFHQU4 - DI Community Living and Supports- Group T2013TFU4 - DI Community Living and Supports T2013U4 - B3 non-DI In Home Skill Building T2014U4 - DI Level 2 - Residential Supports T2014U4U2 - DI Level 2 AFL - Residential Supports T2016U5 - Behavioral Health Crisis Risk Assessment and Intervention (BH-CAI) T2016U5U1 - L1 Long-term Community Supports T2016U5U2 - L2 Long-term Community Supports T2016U5U3 - L3 Long-term Community Supports T2016U5U4 - L4 Long-term Community Supports T2016U5U5 - L5 Long-term Community Supports T2020U4 - DI Level 3 - Residential Supports T2020U4U2 - DI Level 3 AFL - Residential Supports T2021HQU4 - DI Day Supports - Group T2021U4 - DI Day Supports - Individual T2025HOU4 - DI Specialized Consultative Services - BCBA T2025U3U4 - DI Crisis Services: Crisis Consultation T2025U4 - DI Specialized Consultative Services T2027U4 - DI Developmental Day T2033HIU4 - DI Supported Living – Level 2 T2033TFU4 - DI Supported Living – Level 3 T2033U1U4 - DI Supported Living - Periodic T2033U2U4 - DI Supported Living - Transition T2033U4 - DI Supported Living – Level 1 T2034U4 - DI Crisis Services - Out of Home T2041U1U4 - B-3 DI Community Navigator: Periodic and Start up Training T2041U4 - B-3 DI Community Navigator - Monthly T2041U4U5 - B-3 Community Guide - Monthly
12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
3.02 5.92 4.17 7.80 7.80 146.68 151.68 450.00 101.28 125.28 135.70 141.82 138.21 169.79 174.79 16.56 28.04 39.90 19.92 39.90 25.29 276.14 322.76 6.61 6.61 228.71 249.69 620.00 157.50 157.50