Reimbursement Rates for Medically Fragile Waiver Program
| Waiver Services | Unit of Service | Unit Rate | Service Code | Modifier 1 | Modifier 2 |
|---|---|---|---|---|---|
| Advanced Supportive/Restorative | 15 minutes | $7.06 | T1019 | TF | - |
| Case Management S | 15 minutes | $21.02 | T1016 | - | - |
| Case Management VR | 15 minutes | $30.10 | T1016 | TN | - |
| Institutional Transition Case Management S |
15 minutes | $21.02 | T1016 | U7 | - |
| Institutional Transition Case Management VR |
15 minutes | $30.10 | T1016 | U7 | TN |
| Transition Case Management S | 15 minutes | $21.02 | T1016 | U3 | - |
| Transition Case Management VR | 15 minutes | $30.10 | T1016 | U3 | TN |
| Environmental Modifications | As Billed | As Prior Authorized |
S5165 | - | - |
| Home Delivered Meals | 1 Meal | $6.44 | S5170 | - | - |
| Hospice Care | Per Diem | $154.75 | S9126 | - | - |
| In-home Extended Respite (8+hrs) | Per Diem | $241.38 | S9125 | - | - |
| In-home Respite (2-7 hours) | 15 minutes | $5.79 | T1005 | - | - |
| NF Extended Respite (8+ hours) | 1 day | Varies | UB120 | - | - |
| Personal Care | 15 minutes | $6.58 | T1019 | - | - |
| Personal Emergency Response Install |
1 Time | As Prior Authorized |
S5160 | - | - |
| Personal Emergency Response Monthly |
Monthly | As Prior Authorized |
S5161 | - | - |
| Prescriptions (maximum of 7 units only) |
As Ordered | Avg. $76.40 each |
W1111 | - | - |
| Private Duty Nursing | 15 minutes | $11.00 | T1000 | - | - |
| RN Assessment/Evaluation | 15 minutes | $21.45 | T1002 | - | - |
| RN Assessment/Evaluation -Transitional | 15 minutes | $19.50 | T1002 | U3 | - |
| Skilled Nursing – Home Health Setting (LPN) |
15 minutes | $20.02 | G0300 | - | - |
| Skilled Nursing – Home Health Setting (RN) |
15 minutes | $21.45 | G0299 | - | - |
| Specialized Medical Equipment and Supplies |
As Billed | As Prior Authorized |
HCPCS | - | - |
| Therapy Services | |||||
| Therapy – Occupational | 15 minutes | $26.00 | G0152 | - | - |
| Therapy – Physical | 15 minutes | $26.00 | G0151 | - | - |
| Therapy – Respiratory | 15 minutes | $18.60 | G0237 | - | - |
| Therapy – Speech/Language | 15 minutes | $24.43 | G0153 | - | - |
| Self-Directed Services | |||||
| Advanced Supportive/Restorative | 15 minutes | 7.06 | S5125 | TF | - |
| Personal Care | 15 minutes | 6.58 | S5125 | - | - |
| In-home Respite (2-7 hours) | 15 minutes | 5.26 | T1005 | U4 | - |
| In-home Extended Respite (8+hrs) | 1 day | 241.38 | S9125 | U4 | - |
| Incontinence Supplies | |||||
| Adult Small Brief | Each | 0.8 | T4521 | - | - |
| Adult Medium Brief | Each | 0.88 | T4522 | - | - |
| Adult Large Brief | Each | 0.99 | T4523 | - | - |
| Adult Extra Large Brief | Each | 1.16 | T4524 | - | - |
| Adult Small Underwear | Each | 0.89 | T4525 | - | - |
| Adult Medium Underwear | Each | 1.04 | T4526 | - | - |
| Adult Large Underwear | Each | 1.13 | T4527 | - | - |
| Adult Extra Large Underwear | Each | 1.29 | T4528 | - | - |
| Disposable/Guard Liner | Each | 0.61 | T4535 | - | - |
| Any Size Reusable Underpad | Each | 13.91 | T4537 | - | - |
| Chair Size Reusable Underpad | Each | 14.83 | T4540 | - | - |
| Large Disposable Underpad | Each | 0.6 | T4541 | - | - |
| Small Disposable Underpad | Each | 0.39 | T4542 | - | - |
Last Modified on
Nov 27, 2024
