Reimbursement Rates for Services Provided Through the
ADvantage & Medicaid State Plan Personal Care Programs
Effective 1/1/2011
ADvantage Medicaid Waiver Services |
| Waiver Services |
Unit of Service |
Unit Rate |
Service Code |
Mod 1 |
Mod 2 |
| Case Managerment - Standard |
15 min. |
$13.50 |
T1016 |
- |
- |
| Transitional Case Management - Standard |
15 min. |
$13.50 |
T1016 S |
U3 |
- |
| Case Management - Very Rural |
15 min. |
$18.80 |
T1016 |
TN |
- |
| Transitional Case Management - Very Rural |
15 min. |
$18.80 |
T1016 VR |
TN |
U3 |
| ADvantage Personal Care |
15 min. |
$3.63 |
T1019 |
- |
- |
| Advanced Supportive/Restorative |
15 min. |
$3.91 |
T1019 |
TF |
- |
| Skilled Nursing - Home Health Setting |
15 min. |
$13.50 |
G0154 |
- |
- |
| RN Assessment/Evaluation |
15 min. |
$13.50 |
T1002 |
- |
- |
| Occupational Therapy |
15 min. |
$13.75 |
G0152 |
- |
- |
| Physical Therapy |
15 min. |
$13.75 |
G0151 |
- |
- |
| Speech/Language Therapy |
15 min. |
$13.75 |
G0153 |
- |
- |
| Adult Day Health |
15 min. |
$1.88 |
S5100 |
- |
- |
| Personal Care In Adult Day Health |
1 session/ day |
$7.50 |
S5105 |
- |
- |
| Therapy in Adult Day Health |
1 session/ day |
$10.00 |
S5105 |
TG |
- |
| Home Delivered Meals |
1 meal |
$4.88 |
S5170 |
- |
- |
| NF Extended Respite (8+ hours) |
1 day |
As Billed |
UB120 |
- |
- |
| In-Home Respite (2-7 hours) |
15 min. |
3.63 |
T1005 |
- |
- |
|
In-Home Extended Respite (8+ hours) |
1 day |
165.88 |
S9125 |
- |
- |
| Environmental Modifications |
As Billed |
As Billed |
S5165 |
- |
- |
| Hospice |
1 day |
119.10 |
S9126 |
- |
- |
| Specialized Medical Equipment and Supplies |
As Billed |
As Prior Authorized |
HCPCS |
- |
- |
| Prescriptions (maximim of 7 prescriptions only) |
As Ordered |
Avg $76.40 each |
W1111 |
- |
- |
Assisted Living Services |
| Waiver Services |
Unit of Service |
Unit Rate |
Service Code |
Mod 1 |
Mod 2 |
| Standard Care Level |
Per day |
As Billed |
As Billed |
- |
- |
| Intermediate Care Level |
Per day |
As Billed |
As Billed |
- |
- |
| High Care Level |
Per day |
As Billed |
As Billed |
- |
- |
Incontinence Supplies |
| Waiver Services |
Unit of Service |
Unit Rate |
Service Code |
Mod 1 |
Mod 2 |
| Adult Small Brief |
Each |
$0.78 |
T4521 |
- |
- |
| Adult Medium Brief |
Each |
$0.85 |
T4522 |
- |
- |
| Adult Large Brief |
Each |
$0.96 |
T4523 |
- |
- |
| Adult Extra Large Brief |
Each |
$1.13 |
T4524 |
- |
- |
| Adult Small Underwear |
Each |
$0.86 |
T4525 |
- |
- |
| Adult Medium Underwear |
Each |
$1.01 |
T4526 |
- |
- |
| Adult Large Underwear |
Each |
$1.10 |
T4527 |
- |
- |
| Adult Extra Large Underwear |
Each |
$1.25 |
T4528 |
- |
- |
| Disposable Guard/Liner |
Each |
$0.59 |
T4535 |
- |
- |
| Any Size Reusable Underpad |
Each |
$13.50 |
T4537 |
- |
- |
| Chair Size Reusable Underpad |
Each |
$14.40 |
T4540 |
- |
- |
| Large Disposable Underpad |
Each |
$0.58 |
T4541 |
- |
- |
| Small Disposable Underpad |
Each |
$0.38 |
T4542 |
- |
- |
| Disposable Incontinence product, brief/diaper, bariatric |
Each |
As Billed |
T4543 |
- |
- |
Medicaid State Plan Personal Care Program |
| Waiver Services |
Unit of Service |
Unit Rate |
Service Code |
Mod 1 |
Mod 2 |
| Prescriptions (maximum of 6 prescriptions only) |
As Ordered |
Avg $76.40 each |
S1111 |
- |
- |
| Personal Care |
15 min. |
$3.63 |
T1019 |
- |
- |
| Individual Provider Personal Care |
15 min. |
$2.15 |
T1019 |
- |
- |
| Skilled Nursing |
15 min. |
$13.50 |
S9999 |
- |
- |
Medicare |
| Waiver Services |
Unit of Service |
Unit Rate |
Service Code |
Mod 1 |
Mod 2 |
| Medicare Part D Prescriptions |
As Ordered |
Avg $76.40 each |
M1111 |
- |
- |
|