IHCP bulletinprovider.indianamedicaid.com/ihcp/Bulletins/BT202020.pdf · U5=DD FSW CIH . 3/31/2020....
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IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT202020 MARCH 17, 2020 Page 1 of 2 FSSA will change rates and services for the FSW and CIH Waiver, pending CMS approval The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) has requested approval from the Centers of Medicare & Medicaid Services (CMS) for changes to rates and services for the Division of Disability and Rehabilitative Services (DDRS) Bureau of Developmental Disabilities Services (BDDS) Family Supports Waiver (FSW) and the Community Integration and Habilitation (CIH) Waiver. These changes will be effective for dates of service on or after April 17, 2020, pending CMS approval. The tables in this bulletin outline the changes, along with the effective dates, pending CMS approval: Table 1 introduces the new rate for Case Management. Table 2 lists the services added to the FSW: − Environmental Modification − Equipment – Assess/Inspect/Train − Remote Supports − Transportation Levels 2 and 3 Table 3 shows the services that the name/description is being changed for the CIH: − Remote Supports, formerly Electronic Monitoring Table 4 lists the services for CIH that are receiving an increase in their cap: − Community Transition Table 5 has the services for the FSW and the CIH that are receiving an increase in their cap: − Family & Caregiver Training, Family − Family & Caregiver Training, Non-Family Table 6 contains the services that have a name change for the FSW and CIH (these services are a combination of Community Habilitation and Facility Habilitation; some of these services have new procedure code and modifier combinations and some have the same procedure code and modifier combination of previous services): − Day Habilitation, Individual − Day Habilitation, Small Group, 2:1, 3:1, 4:1 − Day Habilitation, Medium Group, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1 − Day Habilitation, Large Group, 11:1, 12:1, 13:1, 14:1, 15:1, 16:1
Transcript of IHCP bulletinprovider.indianamedicaid.com/ihcp/Bulletins/BT202020.pdf · U5=DD FSW CIH . 3/31/2020....
IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT202020 MARCH 17, 2020
Page 1 of 2
FSSA will change rates and services for the FSW and CIH Waiver, pending CMS approval The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) has
requested approval from the Centers of Medicare & Medicaid Services (CMS) for changes to rates and services for the
Division of Disability and Rehabilitative Services (DDRS) Bureau of Developmental Disabilities Services (BDDS)
Family Supports Waiver (FSW) and the Community Integration and Habilitation (CIH) Waiver. These changes will be
effective for dates of service on or after April 17, 2020, pending CMS approval.
The tables in this bulletin outline the changes, along with the effective dates, pending
CMS approval:
Table 1 introduces the new rate for Case Management.
Table 2 lists the services added to the FSW:
− Environmental Modification
− Equipment – Assess/Inspect/Train
− Remote Supports
− Transportation Levels 2 and 3
Table 3 shows the services that the name/description is being changed for the
CIH:
− Remote Supports, formerly Electronic Monitoring
Table 4 lists the services for CIH that are receiving an increase in their cap:
− Community Transition
Table 5 has the services for the FSW and the CIH that are receiving an increase in their cap:
− Family & Caregiver Training, Family
− Family & Caregiver Training, Non-Family
Table 6 contains the services that have a name change for the FSW and CIH (these services are a combination
of Community Habilitation and Facility Habilitation; some of these services have new procedure code and
modifier combinations and some have the same procedure code and modifier combination of previous services):
− Day Habilitation, Individual
− Day Habilitation, Small Group, 2:1, 3:1, 4:1
− Day Habilitation, Medium Group, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1
− Day Habilitation, Large Group, 11:1, 12:1, 13:1, 14:1, 15:1, 16:1
IHCP bulletin BT202020 MARCH 17, 2020
Page 2 of 2
Table 7 encompasses the codes that will be end-dated:
− Case Management Annual PCISP Work – ending 3/31/2020
− Facility Habilitation, Group 2:1
− Facility Habilitation, Group 4:1
− Facility Habilitation, Group 6:1
− Facility Habilitation, Group 8:1
− Facility Habilitation, Group 10:1
− Facility Habilitation, Group 12:1
− Facility Habilitation, Group 14:1
− Facility Habilitation, Group 16:1
− Community Habilitation, Group 3:1
− Community Habilitation, Group 4:1
− Community Habilitation, Group 6:1
− Community Habilitation, Group 8:1
Table 8 contains all the services that are not changing for the FSW and the CIH Waiver.
Questions or concerns should be directed to the FSSA Indiana Health Coverage Programs (IHCP) reimbursement
mailbox at [email protected]. Please be sure to use secure email to send communications
containing personal health information (PHI).
Pending CMS approval, these changes will go into effect on April 17, 2020 (with the exception of the end-dated
codes). Providers should make note of the effective dates for billing purposes. Providers should also make note of all
new procedure code and modifier combinations for services that are changing, along with any new rates. An
announcement will be made after the CMS approval has been received.
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IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 1 of 9
Table 1 – New rates for FSW and CIH Waiver service, effective for DOS on or after April 17, 2020
Service Code Mod 1
Mod 2
Mod 3
Dsc Proc Modified
FSW Old FSW New CIH Old CIH New Notes
Case Management T2022 U7 U5 U7=Waiver U5=DD
$131.25 $143.75 $131.25 $143.75 1/Month
Table 2 – Services added to FSW, effective for DOS on or after April 17, 2020
Service Code Mod 1
Mod 2
Mod 3
Dsc Proc Modified FSW Notes
Environmental Modification, Install
S5165 U7 U5 NU U7=Waiver U5=DD NU=New DME
Individual 1/Unit $15,0000 Lifetime
Environmental Modification, Maintain
S5165 U7 U5 U8 U7=Waiver U5=DD U8=Repair
Individual 1/Unit $500/Year
Equipment – Assess/Inspect/Train
T1028 U7 U5 U7=Waiver U5=DD
$17.99 15 Minutes
Remote Supports, Equipment
A9279 U7 U5 NU U7=Waiver U5=DD NU=New DME
Individual 1 Unit; $500 Lifetime Cap
Remote Supports, 1 Participant
A9279 U7 U5 UA U7=Waiver U5=DD UA=Agency
$13.62 Hour
Remote Supports, 2 Participants
A9279 U7 U5 U2 U7=Waiver U5=DD U2=Tier 2/Level 2
$6.81 Hour
Remote Supports, 3 Participants
A9279 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3
$4.54 Hour
Remote Supports, 4 Participants
A9279 U7 U5 U4 U7=Waiver U5=DD U4=Tier 4/Level 4
$3.41 Hour
Transportation, Level 2 T2002 U7 U5 U2 U7=Waiver U5=DD U2=Tier 2/Level 2
$21.00 Per Trip; 2 Trips/Day; $5,250/Year
Transportation, Level 3 T2002 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3
$42.00 Per Trip; 2 Trips/Day; $7,875/Year
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 2 of 9
Table 3 – Service name changes for CIH Waiver, effective April 17, 2020
Service Code Mod 1
Mod 2
Mod 3
Dsc Proc Modified CIH Notes
Remote Supports, 1 Participant
A9279 U7 U5 UA U7=Waiver U5=DD UA=Agency
$13.62 Previously Electronic Monitoring
Remote Supports, 2 Participants
A9279 U7 U5 U2 U7=Waiver U5=DD U2=Tier 2/Level 2
$6.81 Previously Electronic Monitoring
Remote Supports, 3 Participants
A9279 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3
$4.54 Previously Electronic Monitoring
Remote Supports, 4 Participants
A9279 U7 U5 U4 U7=Waiver U5=DD U4=Tier 4/Level 4
$3.41 Previously Electronic Monitoring
Table 4 – Cap increase for CIH Waiver service, effective for DOS on or after April 17, 2020
Service Code Mod 1
Mod 2
Mod 3
Dsc Proc Modified CIH Notes
Community Transition T2038 U7 U5 U7=Waiver U5=DD
Individual $2,500 Lifetime
Table 5 – Cap increases for FSW and CIH Waiver services, effective for DOS on or after April 17, 2020
Service Code Mod 1
Mod 2
Mod 3
Dsc Proc Modified
FSW CIH Notes
Family & Caregiver Training, Family
S5111 U7 U5 U7=Waiver U5=DD
Individual Individual $5,000/Year
Family & Caregiver Training, Non-Family
S5116 U7 U5 U7=Waiver U5=DD
Individual Individual $5,000/Year
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 3 of 9
Table 6 – Service changes and name change for FSW and CIH Waiver services, effective for DOS on or after April 17, 2020
Service Code Mod 1
Mod 2
Mod 3
Dsc Proc Modified FSW CIH Notes
Day Habilitation, Individual
T2020 U7 U5 U7=Waiver U5=DD
$24.85 $24.85 Hour
Day Habilitation, Small Group 2:1, 3:1, 4:1
T2020 U7 U5 U2 U7=Waiver U5=DD U2=Small Group
$8.90 $8.90 Hour
Day Habilitation, Medium Group 5:1, 6:1, 7:1, 8:1, 9:1, 10:1
T2020 U7 U5 UA U7=Waiver U5=DD UA=Medium Group
$4.96 $4.96 Hour
Day Habilitation, Large Group 11:1, 12:1, 13:1, 14:1, 15:1, 16:1
T2020 U7 U5 UB U7=Waiver U5=DD UB=Large Group
$3.15 $3.15 Hour
Table 7 – End-dated codes
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified Waiver Program End Date
Case Management Annual PCISP Work
T2024 U7 U5 U7=Waiver U5=DD
FSW CIH
3/31/2020
Facility Habilitation, Group 2:1
T2020 U7 U5 UA U2 U7=Waiver UA=Agency U5=DD U2=Tier 2/Level 2
FSW CIH
4/30/2020
Facility Habilitation, Group 4:1
T2020 U7 U5 UA U4 U7=Waiver UA=Agency U5=DD U4=Tier 4/Level 4
FSW CIH
4/30/2020
Facility Habilitation, Group 6:1
T2020 U7 U5 UA U6 U7=Waiver U5=DD UA=Agency U6=Tier 6/Level 6
FSW CIH
4/30/2020
Facility Habilitation, Group 8:1
T2020 U7 U5 UA U8 U7=Waiver U5=DD UA=Agency U8=Tier 8/Level 8
FSW CIH
4/30/2020
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 4 of 9
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified Waiver Program End Date
Facility Habilitation, Group 10:1
T2020 U7 U5 UA UB U7=Waiver U5=DD UA=Agency UB=Tier 10/Level 10
FSW CIH
4/30/2020
Facility Habilitation, Group 12:1
T2020 U7 U5 UA UC U7=Waiver U5=DD UA=Agency UC=Tier 12/Level 12
FSW CIH
4/30/2020
Facility Habilitation, Group 14:1
T2020 U7 U5 UA UD U7=Waiver U5=DD UA=Agency UD=Tier 14/Level 14
FSW CIH
4/30/2020
Facility Habilitation, Group 16:1
T2020 U7 U5 UA U9 U7=Waiver U5=DD UA=Agency U9=Tier 16/Level 16
FSW CIH
4/30/2020
Community Habilitation, Group 3:1
T2020 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3
FSW CIH
4/30/2020
Community Habilitation, Group 4:1
T2020 U7 U5 U4 U7=Waiver U5=DD U4=Tier 4/Level 4
FSW CIH
4/30/2020
Community Habilitation, Group 6:1
T2020 U7 U5 U6 U7=Waiver U5=DD U6=Tier 6/Level 6
FSW CIH
4/30/2020
Community Habilitation, Group 8:1
T2020 U7 U5 U8 U7=Waiver U5=DD U8=Tier 8/Level 8
FSW CIH
4/30/2020
Table 8 – Unchanged services or codes for FSW and/or CIH Waiver
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified
FSW Old
FSW New
CIH Old
CIH New
Notes
Adult Day Services, Level 1
S5101 U7 U5 U1 U7=Waiver U5=DD U1=Tier 1/Level 1
$23.05 $23.05 $23.05 $23.05 Half Day
Adult Day Services, Level 2
S5101 U7 U5 U2 U7=Waiver U5=DD U2=Tier 2/Level 2
$30.24 $30.24 $30.24 $30.24 Half Day
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 5 of 9
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified
FSW Old
FSW New
CIH Old
CIH New
Notes
Adult Day Services, Level 3
S5101 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3
$36.00 $36.00 $36.00 $36.00 Half Day
Adult Day Services, ¼ hour, Level 1
S5100 U7 U5 U1 U7=Waiver U5=DD U1=Level 1
$1.45 $1.45 $1.45 $1.45 15 Minutes
Adult Day Services, ¼ hour, Level 2
S5100 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
$1.89 $1.89 $1.89 $1.89 15 Minutes
Adult Day Services, ¼ hour, Level 3
S5100 U7 U5 U3 U7=Waiver U5=DD U3=Level 3
$2.25 $2.25 $2.25 $2.25 15 Minutes
Psychological Therapy, Individual
H0004 U7 U5 U3 U7=Waiver U5=DD U3=Level 3
$15.45 $15.45 $15.45 $15.45 15 Minutes
Psychological Therapy, Individual
H0004 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
$18.20 $18.20 $18.20 $18.20 15 Minutes
Behavior Mgmt, Level 1 H0004 U7 U5 U1 U7=Waiver U5=DD U1=Level 1
$18.20 $18.20 $18.20 $18.20 15 Minutes
Transitional Case Management Activities
T2038 U7 U5 UA U7=Waiver U5=DD UA=Agency
N/A N/A $131.25 $131.25 Monthly; 1 Unit/ Month up to 6 Units/Successful Transition
Extended Services T2025 U7 U5 UA U7=Waiver U5=DD UA=Agency
$36.96 $36.96 $36.96 $36.96 Hour
Rent & Food for Unrelated Live-In Caregiver
T2025 U7 U5 U7=Waiver U5=DD
N/A N/A $545.00 $545.00 Month
Equipment – Assess/Inspect/Train
T1028 U7 U5 U7=Waiver U5=DD
N/A N/A $36.96 $36.96 15 Minutes
Intensive Behavioral Intervention, Level 1
H2020 U7 U5 U1 U7=Waiver U5=DD U1=Level 1
$104.60 $104.60 $104.60 $104.60 Hour
Intensive Behavioral Intervention, Level 2
H2020 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
$25.00 $25.00 $25.00 $25.00 Hour
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 6 of 9
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified
FSW Old
FSW New
CIH Old
CIH New
Notes
Music Therapy H2032 U7 U5 U1 U7=Waiver U5=DD U1=Level 1
$10.78 $10.78 $10.78 $10.78 15 Minutes
Recreational Therapy H2032 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
$10.78 $10.78 $10.78 $10.78 15 Minutes
Occupational Therapy G0152 U7 U5 UA U7=Waiver U5=DD UA=Agency
$17.99 $17.99 $17.99 $17.99 15 Minutes
Participant Assistance and Care
T2033 U7 U5 U7=Waiver U5=DD UA=Agency
$24.40 $24.40 N/A N/A Hour
Structured Family Caregiving, Level 1
T2033 U7 U5 U1 U7=Waiver U5=DD U1=Level 1
N/A N/A $51.87 $51.87 1 Unit/Day
Structured Family Caregiving, Level 2
T2033 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
N/A N/A $75.67 $75.67 1 Unit/Day
Structured Family Caregiving, Level 3
T2033 U7 U5 U3 U7=Waiver U5=DD U3=Level 3
N/A N/A $102.87 $102.87 1 Unit/Day
Personal Response System, Install
S5160 U7 U5 U7=Waiver U5=DD
$52.07 $52.07 $52.07 $52.07 1 Unit
Personal Response System, Maintain
S5161 U7 U5 U7=Waiver U5=DD
$52.07 $52.07 $52.07 $52.07 1 Unit/Month
Physical Therapy G0151 U7 U5 UA U7=Waiver U5=DD UA=Agency
$18.12 $18.12 $18.12 $18.12 15 Minutes
Prevocational 2:1 T2015 U7 U5 U2 U7=Waiver U5=DD Oasis U2=Level 2
$8.90 $8.90 $8.90 $8.90 Hour
Prevocational 4:1 T2015 U7 U5 U4 U7=Waiver U5=DD U4=Level 4
$8.90 $8.90 $8.90 $8.90 Hour
Prevocational 6:1 T2015 U7 U5 U6 U7=Waiver U5=DD U6=Level 6
$4.96 $4.96 $4.96 $4.96 Hour
Prevocational 8:1 T2015 U7 U5 U8 U7=Waiver U5=DD U8=Level 8
$4.96 $4.96 $4.96 $4.96 Hour
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 7 of 9
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified
FSW Old
FSW New
CIH Old
CIH New
Notes
Prevocational 10:1 T2015 U7 U5 UB U7=Waiver U5=DD UB=Level 10
$4.96 $4.96 $4.96 $4.96 Hour
Prevocational 12:1 T2015 U7 U5 UC U7=Waiver U5=DD UC=Level 12
$3.15 $3.15 $3.15 $3.15 Hour
Prevocational 14:1 T2015 U7 U5 UD U7=Waiver U5=DD UD=Level 14
$3.15 $3.15 $3.15 $3.15 Hour
Prevocational 16:1 T2015 U7 U5 U9 U7=Waiver U5=DD U9=Level 16
$3.15 $3.15 $3.15 $3.15 Hour
Psychological Therapy, Family
90846 U7 U5 U7=Waiver U5=DD
$17.27 $17.27 $17.27 $17.27 15 Minutes
Psychological Therapy, Group
90853 U7 U5 U7=Waiver U5=DD
$4.81 $4.81 $4.81 $4.81 15 Minutes
Residential Habilitation Services, Level 1 (35 or Less Hours/Week)
T2016 U7 U5 UA U7=Waiver U5=DD UA=Agency
N/A N/A $26.15 $26.15 Hour
Residential Habilitation Services, Level 2 (Over 35 Hours/Week)
T2016 U7 U5 U7=Waiver U5=DD
N/A N/A $21.97 $21.97 Hour
RHS Daily Level 1 (2 Person Setting, Algo Level 3)
T2016 U7 U5 UN UA U7=Waiver U5=DD UN=2 Patients UA=Agency
N/A N/A $171.33 $171.33 1 Unit/Day
RHS Daily Level 2 (2 Person Setting, Algo Level 4)
T2016 U7 U5 UN UB U7=Waiver U5=DD UN=2 Patients UB=Face 2 Face
N/A N/A $241.63 $241.63 1 Unit/Day
RHS Daily Level 3 (2 Person Setting, Algo Level 5)
T2016 U7 U5 UN UC U7=Waiver U5=DD UN=2 Patients UC=Case Mgmt
N/A N/A $263.59 $263.59 1 Unit/Day
RHS Daily Level 4 (3 Person Setting, Algo Level 3)
T2016 U7 U5 UP UA U7=Waiver U5=DD UP=3 Patients UA=Agency
N/A N/A $171.33 $171.33 1 Unit/Day
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 8 of 9
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified
FSW Old
FSW New
CIH Old
CIH New
Notes
RHS Daily Level 5 (3 Person Setting, Algo Level 4)
T2016 U7 U5 UP UB U7=Waiver U5=DD UP=3 Patients UB=Face 2 Face
N/A N/A $221.85 $221.85 1 Unit/Day
RHS Daily Level 6 (3 Person Setting, Algo Level 5)
T2016 U7 U5 UP UC U7=Waiver U5=DD UP=3 Patients UC=Case Mgmt
N/A N/A $241.63 $241.63 1 Unit/Day
RHS Daily Level 7 (4 Person Setting, Algo Level 3)
T2016 U7 U5 UQ UA U7=Waiver U5=DD UQ=4 Patients UA=Agency
N/A N/A $160.35 $160.35 1 Unit/Day
RHS Daily Level 8 (4 Person Setting, Algo Level 4)
T2016 U7 U5 UQ UB U7=Waiver U5=DD UQ=4 Patients UB=Face 2 Face
N/A N/A $206.47 $206.47 1 Unit/Day
RHS Daily Level 9 (4 Person Setting, Algo Level 5)
T2016 U7 U5 UQ UC U7=Waiver U5=DD UQ=4 Patients UC=Case Mgmt
N/A N/A $219.66 $219.66 1 Unit/Day
Respite S5151 U7 U5 U7=Waiver U5=DD
$26.15 $26.15 $26.15 $26.15 Hour
Respite T1005 U7 U5 TD U7=Waiver U5=DD TD=RN
$7.79 $7.79 $7.79 $7.79 15 minutes
Respite T1005 U7 U5 TE U7=Waiver U5=DD TE=LPN
$5.91 $5.91 $5.91 $5.91 15 minutes
Specialized Medical Equip/Supply, Install
T2029 U7 U5 NU U7=Waiver U5=DD NU=New DME
Individual Individual N/A N/A $7,500 Lifetime
Specialized Medical Equip/Supply, Install
T2029 U7 U5 NU U7=Waiver U5=DD NU=New DME
N/A N/A Individual Individual
Specialized Medical Equip/Supply, Maintain
T2029 U7 U5 U8 U7=Waiver U5=DD U8=Repair
Individual Individual Individual Individual $500/Year
Speech Therapy 92507 U7 U5 UA U7=Waiver U5=DD UA=Agency
$18.12 $18.12 $18.12 $18.12 15 Minutes
IHCP bulletin BT202020 MARCH 17, 2020
FSW and CIH Waiver Service Table Updates 9 of 9
Service Code Mod 1
Mod 2
Mod 3
Mod 4
Dsc Proc Modified
FSW Old
FSW New
CIH Old
CIH New
Notes
Transportation, Level 1 T2002 U7 U5 U7=Waiver U5=DD
$5.25 $5.25 N/A N/A 2 Trips/Day
Transportation, Level 1 T2002 U7 U5 U7=Waiver U5=DD
N/A N/A $5.25 $5.25 Per Trip; 2 Trips/Day; $2,625/Year
Transportation, Level 2 T2002 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
N/A Added $21.00 $21.00 Per Trip; 2 Trips/Day; $5,250/Year
Transportation, Level 3 T2002 U7 U5 U3 U7=Waiver U5=DD U3=Level 3
N/A Added $42.00 $42.00 Per Trip; 2 Trips/Day; $7,875/Year
Vehicle Modification, Install
T2039 U7 U5 U7=Waiver U5=DD
Individual Individual N/A N/A $7,500 Lifetime
Vehicle Modification, Install
T2039 U7 U5 U7=Waiver U5=DD
N/A N/A Individual Individual $15,000 Lifetime
Vehicle Modification, Maintain
T2039 U7 U5 U8 U7=Waiver U5=DD U8=Repair
Individual Individual Individual Individual $500/Year
Wellness Coordination, Tier 1
T2022 U7 U5 U1 U7=Waiver U5=DD U1=Level 1
N/A N/A $52.77 $52.77 1 Unit/Month
Wellness Coordination, Tier 2
T2022 U7 U5 U2 U7=Waiver U5=DD U2=Level 2
N/A N/A $111.96 $111.96 1 Unit/Month
Wellness Coordination, Tier 3
T2022 U7 U5 U3 U7=Waiver U5=DD U3=Level 3
N/A N/A $223.92 $223.92 1 Unit/Month
Workplace Assistance T1020 U7 U5 U7=Waiver U5=DD
$27.69 $27.69 $27.69 $27.69 Hour
Facility Based Support T1020 U7 U5 UA U7=Waiver U5=DD UA=Agency
$1.94 $1.94 $1.94 $1.94 Hour
Environmental Modification, Install
S5165 U7 U5 NU U7=Waiver U5=DD NU=New DME
N/A Added Individual Individual 1 Unit/$15,000 Lifetime Cap
Environmental Modification, Maintain
S5165 U7 U5 U8 U7=Waiver U5=DD U8=Repair
N/A Added Individual Individual 1 Unit/$500 per Year
