Standard Rate Schedule: Medicaid 1915(c) Revised 11/01/22 Inv X
Invoice‐based: Provider submits actual costs to Vaya Health Finance department Appendix K retainer payments (XUCR modifier) available until end of federal State of Emergency
Electronic Visit Verification (EVV) and Direct Care Worker (DCW) adjustments included where applicable Service - Description
B4100BO ‐ Food thickener B4103BO ‐ Enteral Formulae ‐ Pediatric B4149BO ‐ Enteral Formulae ‐ Mfg Blend Natural Foods B4150BO ‐ Enteral Formulae B4152BO ‐ Ent Form Caloric Dense B4153BO ‐ Ent Form Hydrolyzed Proteins B4154BO ‐ Ent Form Special Met Needs, Excl Inherit Dis B4155BO ‐ Ent Form Incomplete/Modular B4157BO ‐ Ent Form Special Met Needs, Incl Inherit Dis B4158BO ‐ Ent Form Complete ‐ Pediatric B4159BO ‐ Ent Form Complete Soy‐based ‐ Pediatric B4160BO ‐ Ent Form Caloric Dense ‐ Pediatric B4161BO ‐ Ent Form Hydrolyzed Protiens ‐ Pediatric B4162BO ‐ Ent Form Special Metabolic ‐ Pediatric
Effective Date
Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv Inv
H2011HI ‐ Crisis Intervention and Stabilization Supports with Technical Amendment H2015 ‐ Community Networking Service ‐ Ind H2015 ‐ EOR Community Networking Service ‐ Ind H2015HQ ‐ Community Networking Group H2015HQ ‐ EOR Community Networking Group H2015U1 ‐ Community Networking ‐ Class & Conf H2015U2 ‐ Community Networking ‐ Transportation H2016 ‐ Level 1‐Residential Supports H2016U2 ‐ Level 1 AFL Residential Supports H2016HI ‐ Level 4‐Residential Supports H2016HIU2 ‐ Level 4 AFL‐Residential Supports H2025 ‐ Supported Employment ‐ Ind H2025 ‐ EOR Supported Employment ‐ Ind H2025HQ ‐ Supported Employment Group H2025HQ ‐ EOR Supported Employment Group H2025TS ‐ Supported Employment – Long Term Follow‐up H2025TS ‐ EOR Supported Employment – Long Term Follow‐up H2025TSHQ ‐ Supported Employment – Long Term Follow‐up ‐ Group H2025TSHQ ‐ EOR Supported Employment – Long Term Follow‐up ‐ Group S5110 ‐ Natural Supports Education: Individual S5111 ‐ Natural Supports Education: Conference S5150 ‐ Respite ‐ Non‐inst Individual S5150 ‐ EOR Respite ‐ Non‐inst Individual S5150HQ ‐ Respite ‐ Group S5150HQ ‐ EOR Respite ‐ Group S5150US ‐ Respite: Facility S5165 ‐ Home Modifications S5170 ‐ Home Delivered Meals, including preparation T1005TD ‐ Nursing Respite, RN T1005TD ‐ EOR ‐ Nursing Respite, RN T1005TD ‐ AWC ‐ Nursing Respite, RN T1005TE ‐ Nursing Respite, LPN T1005TE ‐ EOR ‐ Nursing Respite, LPN T1005TE ‐ AWC ‐ Nursing Respite, LPN
X X Inv Inv X X X X X X X X
Inv
Inv
Standard Rates
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
$ $ $ $ $ $ $ $ $ $ $ $ $ $
0.55 3.29 1.62 0.69 0.57 1.97 1.42 2.55 3.73 0.64 0.64 0.55 1.86 3.86
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 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022 12/1/2022
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
6.28 5.97 3.31 3.14 ‐ ‐ 119.07 124.07 192.89 197.89 8.27 7.86 2.95 2.80 8.27 7.86 2.80 2.66 8.96 ‐ 6.81 6.47 4.35 4.13 169.48 ‐ 6.99 15.60 14.82 15.60 15.60 14.82 15.60
Standard Rate Schedule: Medicaid 1915(c) Revised 11/01/22 Inv X
Invoice‐based: Provider submits actual costs to Vaya Health Finance department Appendix K retainer payments (XUCR modifier) available until end of federal State of Emergency
Electronic Visit Verification (EVV) and Direct Care Worker (DCW) adjustments included where applicable Service - Description
T1999 ‐ Individual Goods and Services T2012 ‐ Community Living and Supports, only in the community T2012GC ‐ Community Living and Supports, relative as provider lives in home T2012HQ ‐ Community Living and Supports ‐ Group, only in the community T2012GCHQ ‐ Community Living and Supports ‐ Group, relative as provider lives in home T2013TF ‐ Community Living and Supports T2013TF ‐ EOR Community Living and Supports T2013TFHQ ‐ Community Living and Supports‐ Group T2013TFHQ ‐ EOR Community Living and Supports‐Group T2014 ‐ Level 2 ‐ Residential Supports T2014U2 ‐ Level 2 AFL ‐ Residential Supports T2020 ‐ Level 3 ‐ Residential Supports T2020U2 ‐ Level 3 AFL ‐ Residential Supports T2021 ‐ Day Support ‐ Individual T2021HQ ‐ Day Support Group T2025 ‐ Specialized Consultative Service T2025HO ‐ Specialized Consultative Services: BCBA T2025U1 ‐ Financial Support Services T2025U2U1 ‐ Employer Supplies ‐ start‐up costs T2025U3 ‐ Crisis Services: Crisis Consultation T2027 ‐ Day Supports: Developmental Day T2029 ‐ Assistive Technology ‐ Equip & Supplies T2029MM ‐ ATES ‐ Monitoring / Connectivity and Nutritional Charges T2033 ‐ Supported Living – Level 1 T2033 ‐ EOR Supported Living – Level 1 T2033HI ‐ Supported Living – Level 2 T2033HI ‐ EOR Supported Living – Level 2 T2033TF ‐ Supported Living – Level 3 T2033TF ‐ EOR Supported Living – Level 3 T2033U1 ‐ Supported Living ‐ Periodic T2033U1 ‐ EOR Supported Living ‐ Periodic T2033U2 ‐ Supported Living ‐ Transition T2034 ‐ Crisis Services: Out of Home T2038 ‐ Community Transition T2039 ‐ Vehicle Modifications T2041 ‐ Community Navigator: Monthly T2041U1 ‐ Community Navigator: Periodic and Start Up Training T2041U1U6 ‐ Community Navigator: IFDS Orientation
Effective Date
Inv
X
X X X X X
X Inv Inv X X X X
Inv Inv
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 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
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
‐ 5.92 5.92 3.02 3.02 7.80 7.41 4.17 3.96 146.68 151.68 169.79 174.79 28.04 16.56 35.21 35.21 175.00 150.00 19.92 25.29 ‐ ‐ 228.71 217.27 276.14 262.33 322.76 306.62 6.61 6.28 6.06 249.69 ‐ ‐ 157.50 620.00 36.75