1060 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
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 [41 Pa.B. 3292]
[Saturday, June 25, 2011]The Department of Public Welfare (Department) announces the proposed 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 July 1, 2011. These proposed 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. §§ 4104—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 following major allowable cost categories:
• Wages for direct care workers and other program staff, such as supervisors and program specialists, when 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, with benefits and excluding Benefits.
All services that were placed on the MA fee schedule in Fiscal Year (FY) 2010-2011 will remain on the MA fee schedule for FY 2011-2012. 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 the following new services to be placed on the MA fee schedule in FY 2011-2012, effective July 1, 2011: supports coordination, home and community habilitation unlicensed, licensed day habilitation (adult training), prevocational services, supported employment, transitional work and all waiver funded respite services, excluding respite camp which is a vendor service.
There is no cost of living adjustment applied to any of the proposed fee schedule rates for FY 2011-2012.
The proposed fee schedule rates are contingent on the final budget enacted by the General Assembly. The proposed fee schedule rates should be used to process claims submitted to the Provider Reimbursement and Operations Management Information System in electronic format (PROMISeTM) for services provided during FY 2011-2012 until a notice announcing final fee schedule rates is published.
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 * Modifier ET must be used with applicable procedure codes when billing for temporary Base-funded services.
** The Supports Coordination MA fee identified as follows for W7210 is also applicable to TSM and base funded supports coordination.
(PA) Prior authorization by the Office of Developmental Programs (ODP) must be obtained for this service.
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, Basic staff support W1724 51 363 15 min. $1.20 $1.12 $1.06 $0.97 ET Companion, level 1 W1725 51 363 15 min. $1.38 $1.29 $1.22 $1.11 ET Companion, level 2 W1726 51 363 15 min. $2.13 $1.99 $1.89 $1.72 ET Companion, level 3 W1727 51 363 15 min. $5.86 $5.48 $5.20 $4.73 ET 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 Supports Broker W7096 51 510 15 min. $8.20 $7.67 $7.27 $6.61 Licensed Day-Adult W7072 51 514 15 min. $2.16 $2.02 $1.92 $1.74 W7073 51 514 15 min. $2.63 $2.46 $2.33 $2.12 W7074 51 514 15 min. $4.22 $3.95 $3.74 $3.40 W7075 51 514 15 min. $9.66 $9.04 $8.57 $7.79 W7076 51 $14.06 $13.15 $12.47 $11.34 W7035 $18.66 $17.46 $16.55 $15.05 W7036 $27.46 $25.69 $24.36 $22.15 Prevocational W7087 $1.03 $0.96 $0.91 $0.83 W7088 $1.27 $1.19 $1.13 $1.02 W7089 $3.01 $2.82 $2.67 $2.43 W7090 $9.97 $9.33 $8.84 $8.04 W7091 $13.79 $12.90 $12.23 $11.12 W7092 $19.55 $18.29 $17.34 $15.77 W7093 $27.19 $25.44 $24.12 $21.93 **Supports Coordination W7210 21 218 15 min. $20.37 $19.08 $18.15 $16.48 Supported Employment W7235 53 530
53115 min. $12.88 $12.05 $11.43 $10.39 Transitional Work W7237 51 516 15 min. $1.22 $1.14 $1.08 $0.98 Transitional Work W7239 51 516 15 min. $2.03 $1.90 $1.80 $1.64 Transitional Work W7241 51 516 15 min. $3.98 $3.72 $3.53 $3.21 Transitional Work W7245 51 516 15 min. $10.12 $9.47 $8.98 $8.16 Unlicensed Home and Community Habilitation W7057 51 510 15 min. $1.64 $1.53 $1.45 $1.32 Unlicensed Home and Community Habilitation W7058 51 510 15 min. $2.05 $1.92 $1.82 $1.65 Unlicensed Home and Community Habilitation W7059 51 510 15 min. $3.47 $3.25 $3.08 $2.80 Unlicensed Home and Community Habilitation W7060 51 510 15 min. $8.49 $7.94 $7.53 $6.85 Unlicensed Home and Community Habilitation W7061 51 510 15 min. $12.89 $12.06 $11.43 $10.40 TD TE Unlicensed Home and Community Habilitation W7068 51 510 15 min. $16.70 $15.62 $14.81 $13.47 Unlicensed Home and Community Habilitation W7069 51 510 15 min. $25.51 $23.86 $22.63 $20.57 TD TE Home Finding Services W7277 51 571 15 min. $6.53 $6.11 $5.79 $5.27 In Home Respite—
24 hoursW7247 51 512 Day $107.73 $100.78 $95.57 $86.88 In Home Respite— 24 hours W7248 51 512 Day $139.06 $130.09 $123.36 $112.15 In Home Respite— 24 hours W7250 51 512 Day $389.72 $364.58 $345.72 $314.29 In Home Respite— 24 hours W7251 51 512 Day $750.46 $702.04 $665.73 $605.21 In Home Respite— 24 hours W7252 51 512 Day $765.70 $716.30 $679.25 $617.50 In Home Respite— 24 hours W7253 51 512 Day $1,487.19 $1,391.24 $1,319.28 $1,199.35 TD TE In Home Respite—
15 MinutesW7255 51 512 15 min. $1.68 $1.57 $1.49 $1.35 In Home Respite—
15 MinutesW7256 51 512 15 min. $2.17 $2.03 $1.93 $1.75 In Home Respite—
15 MinutesW7258 51 512 15 min. $6.09 $5.70 $5.40 $4.91 In Home Respite—
15 MinutesW7264 51 512 15 min. $11.73 $10.97 $10.41 $9.46 In Home Respite—
15 MinutesW7265 51 512 15 min. $11.96 $11.19 $10.61 $9.65 In Home Respite—
15 MinutesW7266 51 512 15 min. $23.24 $21.74 $20.62 $18.74 TD TE Respite—unlicensed out of home—
24 hourW8000 51 513 Day $107.73 $100.78 $95.57 $86.88 Respite—unlicensed out of home—
24 hourW8001 51 513 Day $139.06 $130.09 $123.36 $112.15 Respite—unlicensed out of home—
24 hourW8002 51 513 Day $389.72 $364.58 $345.72 $314.29 Respite—unlicensed out of home—
24 hourW8003 51 513 Day $750.46 $702.04 $665.73 $605.21 Respite—unlicensed out of home—
24 hourW8005 51 513 Day $1,487.19 $1,391.24 $1,319.28 $1,199.35 TD TE Respite—unlicensed out of home—
15 minuteW8010 51 513 15 min. $1.68 $1.57 $1.49 $1.35 Respite—unlicensed out of home—
15 minuteW8011 51 513 15 min. $2.17 $2.03 $1.93 $1.75 Respite—unlicensed out of home—
15 minuteW8012 51 513 15 min. $6.09 $5.70 $5.40 $4.91 Respite—unlicensed out of home—
15 minuteW8013 51 513 15 min. $11.73 $10.97 $10.41 $9.46 TD TE Respite—unlicensed out of home—
15 minuteW8014 51 513 15 min. $11.96 $11.19 $10.61 $9.65 Respite—unlicensed out of home—
15 minuteW8015 51 513 15 min. $23.24 $21.74 $20.62 $18.74 TD TE Respite—licensed out of home—
24 hourW7259 51 513 Day $141.25 $132.14 $125.30 $113.91 U2 Respite—licensed out of home—
24 hourW7260 51 513 Day $205.93 $192.64 $182.68 $166.07 U2 Respite—licensed out of home—
24 hourW7262 51 513 Day $478.54 $447.67 $424.51 $385.92 U2 Respite—licensed out of home—
24 hourW7263 51 513 Day $826.31 $773.00 $733.02 $666.38 U2 Respite—licensed out of home—
24 hourW7299 51 513 Day $901.31 $843.16 $799.55 $726.86 U2 Respite—licensed out of home—
24 hourW7300 51 513 Day $1,596.83 $1,493.81 $1,416.54 $1,287.77 TD TE U2 Respite—licensed out of home—
15 minutesW7267 51 513 15 min. $2.21 $2.07 $1.96 $1.78 Respite—licensed out of home—
15 minutesW7268 51 513 15 min. $3.22 $3.01 $2.86 $2.60 Respite—licensed out of home—
15 minutesW7270 51 513 15 min. $7.48 $7.00 $6.64 $6.03 Respite—licensed out of home—
15 minutesW7400 51 513 15 min. $12.91 $12.08 $11.45 $10.41 TD TE Respite—licensed out of home—
15 minutesW7401 51 513 15 min. $14.08 $13.17 $12.49 $11.35 Respite—licensed out of home—
15 minutesW7402 51 513 15 min. $24.95 $23.34 $22.13 $20.12 TD TE 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 $4.73 $4.42 $4.20 $3.81 UA & ET UA 51 430 or 431 UA & ET UA 45 430 or 431 UA & ET 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 3W8004 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, enhancedW8005 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 savings of $20.386 million ($9.130 million State funds) to the Commonwealth. The amount of funding available for this program is dependent upon the funds appropriated by the General Assembly in the forthcoming fiscal year. Therefore, until a budget bill is passed and enacted, any estimated fiscal impact associated with this notice is solely based on the funding levels as proposed in the Governor's Executive Budget.
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 (412) 565-5144
• Northeast region: Room 315, Scranton State Office Building, 100 Lackawanna Avenue, Scranton, PA 18503 (570) 963-4749
• Southeast region: 801 Market Street, Suite 5071, Philadelphia, PA 19107 (215) 560-2242 or (215) 560-2245
• Central region: Room 430, Willow Oak Building, P. O. Box 2675, DGS Annex Complex, Harrisburg, PA 17105 (717) 772-6507
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 at the Office of Developmental Programs' rate-setting mailbox at ra-ratesetting@state.pa.us, use subject header ''PN Fee Schedule,'' or 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.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
GARY D. ALEXANDER,
Acting SecretaryFiscal Note: 14-NOT-702. The amount of funding available for this program is dependent upon the funds appropriated by the General Assembly for the forthcoming fiscal year; therefore, until a budget bill is passed and enacted, any estimated fiscal impact associated with this notice is solely based on funding levels as proposed in the Governor's Executive Budget. Based on the proposed budget, this action will not result in a loss of revenue or an increase in program costs to the Commonwealth or its political subdivisions. (8) recommends adoption.
[Pa.B. Doc. No. 11-1060. Filed for public inspection June 24, 2011, 9:00 a.m.]
