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PA Bulletin, Doc. No. 11-1964

NOTICES

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, (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 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 ra-ratesetting@pa.gov (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 (800) 654-5984 (TDD users) or (800) 654-5988 (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.]



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