1178 Medical Assistance Program fee schedule for select services in the Consolidated and Person/Family Directed Support Waivers and Community Mental Retardation Base Program?
Medical Assistance Program Fee Schedule for Select Services in the Consolidated and Person/Family Directed Support Waivers and Community Mental Retardation Base Program [40 Pa.B. 3621]
[Saturday, June 26, 2010]Purpose of Notice
This notice announces the Department of Public Welfare's (Department) proposed payment rates for select services provided in the Consolidated and Person/Family Directed Support (P/FDS) waivers (waivers) to the Medical Assistance (MA) Program Fee Schedule effective July 1, 2010. 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).
The services selected for inclusion on the MA fee schedule are listed as follows under the following categories: Select Community-Based Services; Unlicensed Out-of-Home Respite and Respite Camp ''Ineligible'' Services (Room and Board); Agency with Choice/Financial Management Services, Excluding Benefits; and Agency With Choice/Financial Management Services, Including Benefits.
In addition, three services are added to Select Community-Based services on the 2010-2011 MA Program Fee Schedule: supplemental habilitation, additional individualized staffing and older adult day habilitation. Supplemental habilitation and additional individualized staffing services will also require prior authorization from the Department.
The Department established proposed rates for each of the selected services on the MA Program Fee Schedule based on allowable cost components. Some of the Fiscal Year (FY) 2010-2011 (10-11) allowable cost components were adjusted from the FY 2009-2010 (09-10) rates. Specifically, for some of the FY 10-11 rates on the Select Community-Based Services table, the Department factored in a travel reimbursement rate obtained from actual FY 09-10 therapy providers in each of the four geographic areas. The Department also factored in a productivity time which reflects current practice Statewide for all therapy services. Similar adjustments for travel reimbursement and productivity time were made for the nursing and supports broker services in FY 10-11.
Once the proposed fee schedule rates were established, the Department adjusted the proposed rates based on wage differences for four geographic areas as identified as follows. These geographic area adjustments were not made to the proposed rates for unlicensed out-of-home respite and respite camp ineligible services. Proposed rates for those services were based on expected meal costs consistent with data published by the United States Department of Agriculture and do not vary by geographic area.
There is no Cost of Living Adjustment (COLA) applied to any of the proposed fee schedule rates in FY 10-11. The Governor's executive budget for FY 10-11 included a 1.0286% reduction in the appropriation for waiver services. The Department reduced all proposed fee schedule rates by 1.0286% to account for the proposed appropriation reduction.
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) during FY 10-11 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* * Modifier ET must be used with applicable procedures codes when billing for temporary base-funded services.
(PA) Prior authorization by 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 minutes $10.91 $10.20 $9.68 $8.80 TE & ET TE 16 161 TE & ET Nursing Services: RN T2025 TD 05 051 15 minutes $16.38 $15.32 $14.53 $13.21 TD & ET TD 16 160 TD & ET Physical Therapy T2025 GP 17 170 15 minutes $19.99 $18.70 $17.74 $16.12 GP & ET Occupational Therapy T2025 GO 17 171 15 minutes $21.07 $19.71 $18.69 $16.99 GO & ET Speech and Language Therapy T2025 GN 17 173 15 minutes $21.50 $20.11 $19.07 $17.34 GN & ET Individual Behavioral Therapy T2025 HE 19 208 15 minutes $20.58 $19.25 $18.25 $16.59 HE & ET Group Behavioral Therapy T2025 HE & HQ 19 208 15 minutes $5.15 $4.81 $4.57 $4.15 HE, HQ & ET Visual/ Mobility Therapy W7246 51 517 15 minutes $21.51 $20.12 $19.08 $17.34 ET Companion Services,
Basic staff supportW1724 51 363 15 minutes $ .77 $ .72 $ .68 $ .62 ET Companion Services,
level 1W1725 51 363 15 minutes $ .97 $ .91 $ .86 $ .78 ET Companion Services,
level 2W1726 51 363 15 minutes $2.05 $1.92 $1.82 $1.65 ET Companion Services,
level 3W1727 51 363 15 minutes $4.60 $4.31 $4.08 $3.71 ET Supplemental Habilitation, 1:1(PA) W7070 52 456, 520, 521 or 522 15 minutes $4.82 $4.51 $4.28 $3.89 ET Supplemental Habilitation, 2:1(PA) W7084 52 456, 520, 521 or 522 15 minutes $9.65 $9.03 $8.56 $7.78 ET Additional Individualized Staffing, 1:1(PA) W7085 52 456, 520, 521 or 522 15 minutes $4.82 $4.51 $4.28 $3.89 Additional Individualized Staffing, 2:1(PA) W7086 52 456, 520, 521 or 522 15 minutes $9.65 $9.03 $8.56 $7.78 Older Adult Day Habilitation W7094 51 410 15 minutes $2.85 $2.67 $2.53 $2.30 ET Behavioral Support W7095 51 510 15 minutes $21.30 $19.92 $18.89 $17.18 ET Supports Broker W7096 51 510 15 minutes $10.74 $10.05 $9.53 $8.66 Homemaker/ Chore (permanent) W7283 43 430 51 430 or 431 55 430 or 431 Homemaker/ Chore (temporary) W7283 UA 43 430 UA & ET UA 51 430 or 431 UA & ET UA 45 430 or 431 UA & ET Unlicensed Out-of-Home Respite and Respite Camp Ineligible Services (Room and Board) Service Procedure Code Provider Type Specialty Code Unit Areas 1 through 4 Respite—unlicensed, out of home, ineligible W6060 51 513 W6061 51 513 W6062 51 513 54 540 or 541 W6063 51 513 54 540 or 541 W6064 51 513 54 540 or 541 W6065 51 513 54 540 or 541 W6066 51 513 W6067 51 513 W6068 51 513 54 540 or 541 W6069 51 513 54 540 or 541 W6070 51 513 54 540 or 541 W6071 51 513 54 540 or 541 Respite—camp, ineligible W8400 55 555 15 minutes $4.00/unit, max of 3 ineligible units per day 54 540 or 541 W8401 55 554 1 day $12.00/unit, max of 1 ineligible unit per day 54 540 or 541 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 minutes $3.03 $2.84 $2.69 $2.45 Unlicensed Habilitation, level 3 W7060 U4 54 540 15 minutes $5.02 $4.70 $4.45 $4.05 Unlicensed Habilitation, level 3, enhanced W7061 U4 54 540 15 minutes $8.30 $7.77 $7.36 $6.70 TD & U4 TE & U4 Unlicensed Habilitation, level 4 W7068 U4 54 540 15 minutes $10.03 $9.38 $8.90 $8.09 Unlicensed Habilitation, level 4, enhanced W7069 U4 54 540 15 minutes $16.60 $15.53 $14.72 $13.38 TD & U4 TE & U4 Supports Broker W7096 U4 54 540 15 minutes $6.09 $5.70 $5.40 $4.91 Respite— unlicensed, in home, level 2 W7250 U4 54 540 1 day $220.84 $206.59 $195.91 $178.10 W7258 U4 54 540 15 minutes $3.45 $3.23 $3.06 $2.78 Respite— unlicensed, in home, level 2, enhanced W7251 U4 54 540 1 day $473.73 $443.17 $420.25 $382.04 TD & U4 TE & U4 W7264 U4 54 540 15 minutes $7.40 $6.93 $6.57 $5.97 TD & U4 TE & U4 Respite— unlicensed in home, level 3 W7252 U4 54 540 1 day $441.68 $413.19 $391.81 $356.19 W7265 U4 54 540 15 minutes $6.90 $6.46 $6.12 $5.57 Respite— unlicensed, in home, level 3, enhanced W7253 U4 54 540 1 day $947.46 $886.34 $840.49 $764.08 TD & U4 TE & U4 W7266 U4 54 540 15 minutes $14.80 $13.84 $13.13 $11.93 TD & U4 TE & U4 Homemaker/ Chore W7283 U4 54 540 1 hour $13.28 $12.43 $11.78 $10.71 UA & U4 Respite— unlicensed, out of home, level 2 W8002 U4 54 540 1day $220.84 $206.59 $195.91 $178.10 W8012 U4 54 540 15 minutes $3.45 $3.23 $3.06 $2.78 Respite— unlicensed, out of home, level 2, enhanced W8003 U4 54 540 1 day $473.73 $443.17 $420.25 $382.04 TD & U4 TE & U4 W8013 U4 54 540 15 minutes $7.40 $6.93 $6.57 $5.97 TD & U4 TE & U4 Respite— unlicensed, out of home, level 3 W8004 U4 54 540 1 day $441.68 $413.19 $391.81 $356.19 W8014 U4 54 540 15 minutes $6.90 $6.46 $6.12 $5.57 Respite— unlicensed, out of home, level 3, enhanced W8005 U4 54 540 1 day $947.46 $886.34 $840.49 $764.08 TD & U4 TE & U4 W8015 U4 54 540 15 minutes $14.80 $13.84 $13.13 $11.93 TD & U4 TE & U4 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 minutes $3.84 $3.59 $3.41 $3.10 Unlicensed Habilitation, level 3 W7060 54 540 15 minutes $6.35 $5.94 $5.64 $5.12 Unlicensed Habilitation, level 3, enhanced W7061 54 540 15 minutes $10.51 $9.83 $9.32 $8.48 TD TE Unlicensed Habilitation, level 4 W7068 54 540 15 minutes $12.70 $11.88 $11.26 $10.24 Unlicensed Habilitation, level 4, enhanced W7069 54 540 15 minutes $21.01 $19.66 $18.64 $16.94 TD TE Supports Broker W7096 54 540 15 minutes $7.71 $7.21 $6.84 $6.22 Respite— unlicensed, in home, level 2 W7250 54 540 1 day $279.58 $261.55 $248.02 $225.47 W7258 54 540 15 minutes $4.36 $4.08 $3.87 $3.52 Respite— unlicensed, in home, level 2, enhanced W7251 54 540 1 day $599.74 $561.05 $532.03 $483.66 TD TE W7264 54 540 15 minutes $9.37 $8.77 $8.31 $7.56 TD TE Respite— unlicensed, in home, level 3 W7252 54 540 1 day $559.17 $523.09 $496.04 $450.94 W7265 54 540 15 minutes $8.74 $8.18 $7.75 $7.05 Respite— unlicensed, in home, level 3, enhanced W7253 54 540 1 day $1,199.49 $1,122.10 $1,064.06 $967.33 TD TE W7266 54 540 15 minutes $18.74 $17.53 $16.62 $15.11 TD TE Homemaker/ Chore W7283 54 540 1 hour $16.82 $15.73 $14.92 $13.56 UA Respite— unlicensed, out of home, level 2 W8002 54 540 1 day $279.58 $261.55 $248.02 $225.47 W8012 54 540 15 minutes $4.36 $4.08 $3.87 $3.52 Respite— unlicensed, out of home, level 2, enhanced W8003 54 540 1 day $599.74 $561.05 $532.03 $483.66 TD TE W8013 54 540 15 minutes $9.37 $8.77 $8.31 $7.56 TD TE Respite— unlicensed, out of home, level 3 W8004 54 540 1 day $559.17 $523.09 $496.04 $450.94 W8014 54 540 15 minutes $8.74 $8.18 $7.75 $7.05 Respite— unlicensed, out of home, level 3, enhanced W8005 54 540 1 day $1,199.49 $1,122.10 $1,064.06 $967.33 TD TE W8015 54 540 15 minutes $18.74 $17.53 $16.62 $15.11 TD TE Fiscal Impact
It is estimated that implementation of the Medical Assistance Program Fee Schedule rates included in this Public Notice will result in decreased State fund costs totaling approximately $0.318 million.
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 Office of Developmental Programs (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 through a link on the Internet at: https://www.hcsis.state.pa.us/hcsis-ssd/pgm/asp/PRCNT.ASP, or contact the previously referenced ODP regional office.
Interested persons are invited to submit written comments regarding this notice to the Department at the following addresses:
By E-mail:
Use subject header ''PN Fee Schedule'' to the Office of Developmental Programs' rate-setting mailbox at: ra-ratesetting@state.pa.us.
By postal mail:
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 17120Persons 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).
HARRIET DICHTER,
SecretaryFiscal Note: 14-NOT-645. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 10-1178. Filed for public inspection June 25, 2010, 9:00 a.m.]
