1964 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 effective November 15, 2011, through ...

DEPARTMENT OF
PUBLIC WELFARE

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 Effective November 15, 2011, through June 30, 2012

[41 Pa.B. 6163]
[Saturday, November 12, 2011]

 This notice announces the Department of Public Welfare's (Department) payment 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 November 15, 2011, through June 30, 2012. These fee schedule payment 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 Mental Retardation Act of 1966 (50 P. S. §§ 4101—4704) and 55 Pa. Code Chapter 4300 (relating to county mental health and mental retardation fiscal manual).

 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 service definitions and a determination of allowable cost components which reflect costs that are reasonable, necessary, and related to the delivery of the service.

 In developing rates for each of the MA fee schedule services, the Department evaluated independent data sources such as a Commonwealth-specific compensation study and data from approved cost reports, as applicable, and considered the expected expenses for the delivery of services under the waivers for the major allowable cost categories:

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

 • Employee-related expenses related to 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 Statewide MA fee schedule rate for each service and adjusted each fee schedule rate by geographical area factors to reflect consideration for differences in wages observed across this Commonwealth.

 The fee schedule rates were established by the Department to fund the fee schedule services at a level sufficient to encourage provider participation and promote provider choice, while at the same time ensuring cost effectiveness 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, Excluding benefits and Agency with Choice Financial Management Services, Including Benefits.

 All services that were placed on the MA fee schedule from July 1, 2011, through November 14, 2011, will remain on the MA fee schedule for the remainder of the fiscal year (FY). These services include Companion, Behavior Support, Therapy (Physical, Occupational, Speech and Language, Individual Behavior, Group Behavior and Visual/Mobility) Nursing, Home Finding, Homemaker/Chore, Supports Broker, Older Adult Day, Supplemental Habilitation and Additional Individualized Staffing. The Department has identified a new service, Supports Coordination, to be placed on the MA Fee schedule effective November 15, 2011.

 There is no cost of living adjustment applied to any of the fee schedule rates for FY 2011-2012.

Geographic Areas:

Area 1:

 Bucks, Chester, Delaware, Lehigh, Montgomery, Northampton, Philadelphia

Area 2:

 Adams, Allegheny, Beaver, Berks, Carbon, Cumberland, Dauphin, Erie, Franklin, Fulton, Greene, Lancaster, Lawrence, Lebanon, Monroe, Perry, Pike, Schuylkill, Washington, York

Area 3:

 Armstrong, Bradford, Butler, Cameron, Centre, Clarion, Clinton, Columbia, Crawford, Elk, Forest, Indiana, Huntingdon, Juniata, Lackawanna, Luzerne, Lycoming, McKean, Mercer, Mifflin, Montour, Northumberland, Potter, Snyder, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Westmoreland, Wyoming

Area 4:

 Bedford, Blair, Cambria, Clearfield, Fayette, Jefferson, Somerset

Fee Schedule Rates Tables: Select Community-Based Services for FY 2011-2012

Select Community-Based Services*

 * Modifier ET must be used with applicable procedures codes when billing for temporary base-funded services.

 (PA) Prior authorization by Office of Developmental Programs (ODP) must be obtained for this service.

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

Service	Procedure Code	Modifier	Provider Type	Specialty Code	Unit	Area 1	Area 2	Area 3	Area 4
Nursing Services: LPN	T2025	TE	05	051	15 min.	$11.31	$10.58	$10.03	$9.12
		TE & ET
		TE	16	161
		TE & ET
Nursing Services: RN	T2025	TD	05	051	15 min.	$14.70	$13.75	$13.04	$11.85
		TD & ET
		TD	16	160
		TD & ET
Physical Therapy	T2025	GP	17	170	15 min.	$21.45	$20.07	$19.03	$17.30
		GP & ET
Occupational Therapy	T2025	GO	17	171	15 min.	$20.77	$19.43	$18.43	$16.75
		GO & ET
Speech and Language Therapy	T2025	GN	17	173	15 min.	$19.05	$17.82	$16.90	$15.36
		GN & ET
Individual Behavioral Therapy	T2025	HE	19	208	15 min.	$25.14	$23.52	$22.30	$20.27
		HE & ET
Group Behavioral Therapy	T2025	HE & HQ	19	208	15 min.	$7.88	$7.37	$6.99	$6.35
		HE, HQ & ET
Visual/Mobility Therapy	W7246		51	517	15 min.	$19.05	$17.82	$16.90	$15.36
		ET
Companion Services, Basic staff support	W1724		51	363	15 min.	$1.20	$1.12	$1.06	$0.97
		ET
Companion Services, level 1	W1725		51	363	15 min.	$1.38	$1.29	$1.22	$1.11
		ET
Companion Services, level 2	W1726		51	363	15 min.	$2.13	$1.99	$1.89	$1.72
		ET
Companion Services, level 3	W1727		51	363	15 min.	$5.86	$5.48	$5.20	$4.73
Supplemental Habilitation, 1:1 (PA)	W7070		52	456, 520, 521 or 522	15 min.	$5.24	$4.90	$4.65	$4.23
		ET
Supplemental Habilitation, 2:1 (PA)	W7084		52	456, 520, 521 or 522	15 min.	$10.49	$9.81	$9.31	$8.46
		ET
Additional Individualized Staffing, 1:1 (PA)	W7085		52	456, 520, 521 or 522	15 min.	$5.24	$4.90	$4.65	$4.23
Additional Individualized Staffing, 2:1 (PA)	W7086		52	456, 520, 521 or 522	15 min.	$10.49	$9.81	$9.31	$8.46
Older Adult Day Habilitation	W7094		51	410	15 min.	$2.12	$1.98	$1.88	$1.71
		ET
Behavioral Support	W7095		51	510	15 min.	$19.27	$18.03	$17.09	$15.54
	ET
Home Finding	W7277		51 or 55	571	15 min.	$6.53	$6.11	$5.79	$5.27
Supports Broker	W7096		51	510	15 min.	$8.20	$7.67	$7.27	$6.61
Homemaker/Chore (permanent)	W7283		43	430	1 hour	$18.93	$17.71	$16.79	$15.27
			51	430 or 431
			55	430 or 431
Homemaker/Chore (temporary)	W7283	UA	43	430	1 hour	$18.93	$17.71	$16.79	$15.27
		UA & ET
		UA	51	430 or 431
		UA & ET
		UA	45	430 or 431
		UA & ET
**Supports Coordination	W7210		21	218	15 min.	$20.37	$19.08	$18.15	$16.48

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	Area 4
Companion, level 3	W1727	U4	54	540	15 min.	$2.91	$2.73	$2.59	$2.35
Supported Employment	W7235					$5.81	$5.44	$5.16	$4.69
Unlicensed Habilitation, level 3	W7060	U4	54	540	15 min.	$4.81	$4.50	$4.27	$3.88
Unlicensed Habilitation, level 3, enhanced	W7061	U4	54	540	15 min.	$7.97	$7.45	$7.07	$6.42
		TD & U4
		TE & U4
Unlicensed Habilitation, level 4	W7068	U4	54	540	15 min.	$9.63	$9.01	$8.54	$7.77
Unlicensed Habilitation, level 4, enhanced	W7069	U4	54	540	15 min.	$15.93	$14.91	$14.13	$12.85
		TD & U4
		TE & U4
Supports Broker	W7096	U4	54	540	15 min.	$5.84	$5.47	$5.19	$4.71
Respite—unlicensed, in home, level 2	W7250	U4	54	540	1 day	$251.76	$235.52	$223.34	$203.03
	W7258	U4	54	540	15 min.	$3.31	$3.10	$2.94	$2.67
Respite—unlicensed, in home, level 2, enhanced	W7251	U4	54	540	1 day	$539.86	$505.03	$478.90	$435.37
		TD & U4
		TE & U4
	W7264	U4	54	540	15 min.	$7.10	$6.65	$6.30	$5.73
		TD & U4
		TE & U4
Respite—unlicensed in home, level 3	W7252	U4	54	540	1 day	$503.52	$471.04	$446.67	$406.07
	W7265	U4	54	540	15 min.	$6.63	$6.20	$5.88	$5.34
Respite—unlicensed, in home, level 3, enhanced	W7253	U4	54	540	1 day	$1,079.71	$1,010.05	$957.81	$870.73
		TD & U4
		TE & U4
	W7266	U4	54	540	15 min.	$14.21	$13.29	$12.60	$11.46
		TD & U4
		TE & U4
Homemaker/Chore	W7283	U4	54	540	1 hour	$12.76	$11.93	$11.32	$10.29
		UA & U4
Respite—unlicensed, out of home, level 2	W8002	U4	54	540	1 day	$251.76	$235.52	$223.34	$203.03
	W8012	U4	54	540	15 min.	$3.31	$3.10	$2.94	$2.67
Respite—unlicensed, out of home, level 2, enhanced	W8003	U4	54	540	1 day	$539.86	$505.03	$478.90	$435.37
		TD & U4
		TE & U4
	W8013	U4	54	540	15 min.	$7.10	$6.65	$6.30	$5.73
		TD & U4
		TE & U4
Respite—unlicensed, out of home, level 3	W8004	U4	54	540	1 day	$503.52	$471.04	$446.67	$406.07
	W8014	U4	54	540	15 min.	$6.63	$6.20	$5.88	$5.34
Respite—unlicensed, out of home, level 3, enhanced	W8005	U4	54	540	1 day	$1,079.71	$1,010.05	$957.81	$870.73
		TD & U4
		TE & U4
	W8015	U4	54	540	15 min.	$14.21	$13.29	$12.60	$11.46

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	Area 4
Companion, level 3	W1727		54	540	15 min.	$3.84	$3.59	$3.41	$3.10
Supported Employment	W7235					$6.74	$6.30	$5.98	$5.44
Unlicensed Habilitation, level 3	W7060		54	540	15 min.	$5.74	$5.37	$5.09	$4.63
Unlicensed Habilitation, level 3, enhanced	W7061		54	540	15 min.	$8.89	$8.32	$7.89	$7.17
		TD
		TE
Unlicensed Habilitation, level 4	W7068		54	540	15 min.	$11.48	$10.74	$10.18	$9.26
Unlicensed Habilitation, level 4, enhanced	W7069		54	540	15 min.	$17.78	$16.64	$15.78	$14.34
		TD
		TE
Supports Broker	W7096		54	540	15 min.	$6.77	$6.33	$6.01	$5.46
Respite—unlicensed, in home, level 2	W7250		54	540	1 day	$322.08	$301.31	$285.72	$259.75
	W7258		54	540	15 min.	$4.24	$3.96	$3.76	$3.42
Respite—unlicensed, in home, level 2, enhanced	W7251		54	540	1 day	$610.18	$570.81	$541.29	492.08
		TD
		TE
	W7264		54	540	15 min.	$8.03	$7.51	$7.12	$6.47
		TD
		TE
Respite—unlicensed, in home, level 3	W7252		54	540	1 day	$644.17	$602.61	$571.44	$519.49
	W7265		54	540	15 min.	$8.48	$7.93	$7.52	$6.84
Respite—unlicensed, in home, level 3, enhanced	W7253		54	540	1 day	$1,220.36	$1,141.63	$1,082.58	$984.16
		TD
		TE
	W7266		54	540	15 min.	$16.06	$15.02	$14.24	$12.95
		TD
		TE
Homemaker/Chore	W7283		54	540	1 hour	$16.46	$15.40	$14.60	$13.27
		UA
Respite—unlicensed, out of home, level 2	W8002		54	540	1 day	$322.08	$301.31	$285.72	$259.75
	W8012		54	540	15 min.	$4.24	$3.96	$3.76	$3.42
Respite—unlicensed, out of home, level 2, enhanced	W8003		54	540	1 day	$610.18	$570.81	$541.29	$492.08
		TD
		TE
	W8013		54	540	15 min.	$8.03	$7.51	$7.12	$6.47
		TD
		TE
Respite—unlicensed, out of home, level 3	W8004		54	540	1 day	$644.17	$602.61	$571.44	$519.49
	W8014		54	540	15 min.	$8.48	$7.93	$7.52	$6.84
Respite—unlicensed, out of home, level 3, enhanced	W8005		54	540	1 day	$1,220.36	$1,141.63	$1,082.58	$984.16
		TD
		TE
	W8015		54	540	15 min.	$16.06	$15.02	$14.24	$12.95
		TD
		TE

Fiscal Impact

 It is anticipated there will be an approximate part-year savings of $7.565 million ($3.388 million State funds) in FY 2011-2012 and full-year savings of $12.666 million ($5.673 in State funds) in FY 2012-2013.

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 ODP in the corresponding regions:

 • Western region: Piatt Place, Room 4900, 301 5th Avenue, Pittsburgh, PA 15222, [phone]

 • Northeast region: Room 315, Scranton State Office Building, 100 Lackawanna Avenue, Scranton, PA 18503, [phone]

 • Southeast region: 801 Market Street, Suite 5071, Philadelphia, PA 19107, [phone] or [phone]

 • Central region: Room 430, Willow Oak Building, P. O. Box 2675, DGS Annex Complex, Harrisburg, PA 17105, [phone]

 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 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. E-mail should be sent to ODP's rate-setting mailbox at [e-mail] (use ''PN Fee Schedule'' in the subject line).

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at [phone] (TDD users) or [phone] (voice users).

GARY D. ALEXANDER, 
Secretary

 Fiscal Note: 14-NOT-730. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 11-1964. Filed for public inspection November 11, 2011, 9:00 a.m.]