Eligibility Segment Code 0100866 SUPPORT COORDINATION (SC) 08 (Case Management/ Suppt Codination) Transition Service Community Transition, T2038 Transition Intensive Suppt Codination Suppt Codination Community Choices High Risk Case Management Community Choices Case Management Z0178 Z0195 $1,500.00 lifetime cap $157.00 per month $140.00 per month ENVIRONMENTAL ACCESSIBILITY ADAPTATION (EAA) Adaptation Basic Assessment and Approval Adaptation Basic Assessment and Approval Z0640 $600.00 15 (Environmental Accessibility Adaptation - EAA) Adaptation Final Inspection (1 visit only) Adaptation Final Inspection (2 me visits) Adaptation Ramp Adaptation Lift Adaptation Bathroom Adaptation Other Adaptations Adaptation Final Inspection Adaptation Final Inspection Adaptation Ramp Adaptation Lift Adaptation Bathroom Adaptation Other Adaptations Z0642 Z0641 Z0060 Z0061 Z0062 Z0063 $150.00 $250.00 Per service/ pay as approved PERSONAL ASSISTANCE SERVICES (PAS) 01 (Fiscal Agent); Agency); 82 (Personal Care Attendant); Services Services Self-Directed Overtime Services Shared by 2 Participants Services Shared by 2 Participants Self-Directed Overtime Attendant Care Services, per Attendant Care Services, per Attendant Care Services, per 15 minutes, 2 participants served Attendant Care Services, per 15 minutes, 2 participants served TU UN UN, TU $2.79 per $4.19 per $2.31 per $3.47 per Replaces December 28, 2016 Issuance Page 1 of 8
Eligibility Segment Code 0100866 01 (Fiscal Agent); Agency); 82 (Personal Care Attendant); Services Shared by 3 Participants Services Shared by 3 Participants Self-Directed Overtime Attendant Care Services, per 15 minutes, 3 participants served Attendant Care Services, per 15 minutes, 3 participants served UP UP, TU $2.02 per $3.04 per Agency); 82 (Personal Care Attendant); Services am/pm, provided in the mning Services am/pm, provided in the evening Attendant Care Services, provided in the mning Attendant Care Services, provided in the evening S5126 S5126 UF UH $30.00 ADULT DAY HEALTH CARE (ADHC) 85 (Adult Day Health Care ADHC) Adult Day Health Care (ADHC) Service Medical Rehabilitation Day Program S5100 $2.40 per plus provider specific transptation rate - Maximum of 40 units/day 200 units/week Replaces December 28, 2016 Issuance Page 2 of 8
Eligibility Segment Code 0100866 HOME DELIVERED MEALS AM (Home Delivered Meals) Home Delivered Meals Home Delivered Meals S5170 PERMANENT SUPPORTIVE HOUSING (PSH) Maximum of $7.00 per service/meal - Maximum of 2 meals per day AW (Permanent Supptive Housing Agency) Permanent Supptive Housing Permanent Supptive Housing Housing Stabilization Services Housing Transition/Crisis Intervention Services Z0648 Z0649 $15.11 per MONITORED IN-HOME CAREGIVING (MIHC) MI (Monited In Home Caregiving MIHC) Monited In-Home Caregiving Monited In-Home Caregiving Monited In-Home Caregiving, level 1 Monited In-Home Caregiving, level 2 S5140 TG $59.60 per day $89.40 per day Monited In-Home Caregiving Monited In-Home Caregiving, Intake and assessment T1028 $250.00 NURSING SERVICES Agency) Nursing Assessment by R.N. Nursing Assessment by L.P.N. Nursing Assessment by R.N. Nursing Assessment by L.P.N. T1001 Nursing Care by R.N. Nursing Care, in the home by R.N. T1030 Nursing Care by L.P.N. Nursing Care, in the home by L.P.N. T1031 TD TE $65.22 $58.00 $65.22 $58.00 Replaces December 28, 2016 Issuance Page 3 of 8
Eligibility Segment Code 0100866 SKILLED MAINTENANCE THERAPY (SMT) Physical Therapy S9131 Agency) Evaluation, Re-evaluation, Home Care Training, Family, Home Care Training, Non-Family, Occupational Therapy Physical Therapy Evaluation (20 minutes) Physical Therapy Evaluation (30 minutes) Physical Therapy Evaluation (45 minutes) Physical Therapy Re-evaluation, Physical Therapy Home Care Training, Family, per session, Physical Therapy Home Care Training, Non-Family, per session, Occupational Therapy 97161 97162 97163 97164 S5111 S5116 S9129 GP Occupational Therapy Evaluation (30 minutes) 97165 Occupational Therapy Evaluation, Occupational Therapy Evaluation (45 minutes) Occupational Therapy Evaluation (60 minutes) 97166 97167 GO Occupational Therapy Reevaluation, Occupational Therapy Re- Evaluation, 97168 Occupational Therapy Home Care Training, Family, Occupational Therapy- Home Care Training, Family, per session, S5111 Replaces December 28, 2016 Issuance Page 4 of 8
Eligibility Segment Code 0100866 Occupational Therapy Home Care Training, Non- Family, Occupational Therapy- Home care training, Non-Family, per session, S5116 Agency) Speech/Language Swallowing Function Evaluation, Hearing Evaluation-Speech Fluency, Hearing Evaluation-Speech Sound Production, Hearing Evaluation- Speech Sound Production with Language Comprehension and Expression, Swallowing Function Evaluation, Evaluation-Speech Fluency, Evaluation - Speech Sound Production, Evaluation - Speech Sound Production with Language Comprehension and Expression, 92610 92521 92522 92523 GN Hearing Evaluation- Behavial and Qualitative Analysis of Voice and Resonance, Evaluation-Behavial and Qualitative Analysis of Voice and Resonance, 92524 GN Hearing Therapy, Therapy, 92507 Therapy-Speech/Language Oral Function Therapy, Oral Function Therapy, 92526 Replaces December 28, 2016 Issuance Page 5 of 8
Eligibility Segment Code 0100866 PERSONAL EMERGENCY REONSE SYSTEM (PERS) 16 (Personal Emergency Response System PERS) Personal Emergency Response (PERS) (Assistive Devices & Medical Supplies) Installation Personal Emergency Response (PERS) (Assistive Devices & Medical Supplies) Monthly Personal Emergency Response (PERS), Installation Personal Emergency Response (PERS), Monthly Z0058 Z0059 $30.00 Initial installation $27.00 monthly maintenance ASSISTIVE DEVICES AND MEDICAL SUPPLIES Telecare Activity and Sens Moniting Equipment Installation and Removal Emergency Response System, Installation & Testing S5160 $200.00 one time at installation 17 (Assistive Devices) Telecare Activity and Sens Moniting Moniting, Routine Maintenance and Rental Telecare - Health Status Moniting -Equipment Installation & Removal Telecare - Health Status Moniting - Moniting, Routine Maintenance & Rental Emergency Response system, Per Month (Excludes installation & testing) Telecare - Health Status Moniting -Equipment Installation & Removal Telecare - Health Status Moniting - Moniting, Routine Maintenance & Rental S5161 Z0643 Z06 $130.00 monthly $200.00 one time at installation $165.00 monthly Telecare - Medication Dispensing & Moniting - Equipment Installation & Removal Telecare - Medication Dispensing & Moniting - Equipment Installation & Removal Z0647 $25.00 one time at Installation Telecare - Medication Dispensing & Moniting Medication Reminder Service, Non-Face-To-Face; Per Month S5185 $40.00 monthly Replaces December 28, 2016 Issuance Page 6 of 8
Eligibility Segment Code 0100866 17 (Assistive Devices), (Organzied Health Assistive Device/Equipment Rental including Routine Repair and Maintenance Assistive Device/ Equipment Repair Specialized Medical Equipment, Not Otherwise Specified, T2029 RR Pay as approved Equipment Repair Z0646 Pay as approved 08 (Case Management/ Suppt Codination) 17 (Assistive Devices), Assistive Device/Equipment Purchase Medical Supply Purchase - Recurring Specialized Medical Equipment/Other Supply Purchase - Recurring Z0624 Z0645 Per service/ pay as approved (Organzied Health 17 (Assistive Devices) Assistive Devices & Medical Supplies Procurement Services, NOS T2025 Per service/ pay as approved: $0 - $300 - $0 $301 - $600 - $50; $601 - $900 - $75; $901 - $1,200 - $100; $1,201 & over - $125 Replaces December 28, 2016 Issuance Page 7 of 8
Eligibility Segment Code 0100866 CAREGIVER TEMPORARY SUPPORT 82 (Personal Care Attendant PCA); AN (Caregiver Tempary Suppt); Caregiver Tempary Suppt Service, in home Respite Care Services T1005 $2.79 per AN (Caregiver Tempary Suppt) 83 (Center-Based Respite) System/ Super Caregiver Tempary Suppt Service, Center Based, Overnight (assisted living facility) Caregiver Tempary Suppt Service, Center Based, Not Overnight (ADHC) Caregiver Tempary Suppt Service, Center Based, Overnight (nursing facility) Caregiver Tempary Suppt Service, Center Based, Overnight (respite care center) Respite Care Services, not in the home Respite Care Services, group setting Respite Care Services, not in the home, group setting Respite Care Services, not in the home, group setting, services provided at night H0045 T1005 H0045 H0045 HQ HQ, UJ $95.00 daily with overnight stay $2.62 per and Maximum of 40 units per day $141.36 daily with overnight stay $141.36 daily with overnight stay Replaces December 28, 2016 Issuance Page 8 of 8