Code Mod 1 Mod 2 Description Unit Def Annual Max ARTC RATES Description

Prior Authorization Required (Yes

or No)

ARTC Fee Schedule Reference

Rate per Hour

H2016 *Supportive Living- CurrentBudgeted Approved Rate Yes

H2016 UF Supportive Living – one on one staffing – level 1

Per 15 minutes $5.25/15 Min units Base Level ­one on one

staffing Yes Labeled Level 3 $21/Hour

H2016 UH Supportive Living – one on one

staffing – level 2 Per 15 minutes $5.75/15 Min units

Advanced Level - one

on one staffing

Yes Labeled Level 4 $23/Hour

H2016 U5 Supportive Living – one on one

staffing – level 5 Per 15 minutes Custom Yes

H2016 U1 UQ Supportive Living – shared staffing –

up to 4 members level 1 Per 15 minutes $3.50/15 Min units Yes Labeled Level 1 $14/Hour

H2016 U2 UR Supportive Living – shared staffing –

5 – 8 members level 2 Per 15 minutes $1.75/15 Min units Yes $7/Hour

H2016 U3 UQ Supportive Living – shared staffing

(custom)– level 3 Per 15 minutes $4.00/15 Min units Yes Labeled Level 2 $16/Hour

H2016 UK Supportive Living – Community

(camps, activities, Camp Aldersgate etc. – alternate supportive

supervision)

Pass-thru Cost

Custom Rate for each Camp or other

Activity approved byAuth

Yes

H2016 UD Supportive Living – non medical transportation – one on one

Per mile $.52/Mile Yes

H2016 UD US Supportive Living – non medical transportation – Multi-member

transport Per mile $.26/Mile Yes

H2016 UC Supportive Living – Companion and Activity Therapy

Pass-thru Cost

Custom Rate for Hippo Therapy or

other Activity approved by Auth

Yes

H2023 *Supported Employment -Currentbudgeted Approved Rate

Per 15 minutes $3.59 Yes

H2023 UA UB Supported Employment – Job

Coaching Per 15 minutes Allowed maximum of 40 hours per week $3.59 Yes

H2023 U1 UA Supported Employment – Discovery

and career planning Per 15 minutes

Allowed 50 hours maximum over a six-week period

$3.59 Yes

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Code Mod 1 Mod 2 Description Unit Def Annual Max ARTC RATES Description

Prior Authorization Required (Yes

or No)

ARTC Fee Schedule Reference

Rate per Hour

H2023 U2 UA Supported Employment – Job

Development

This is outcome-based reimbursement, payable in stages to incentivize retention of the job.

The total outcome payment is $3000.00. The payment schedule is as follows: A. 60%

at the end of the beneficiary’s first pay period. B. 25% when the beneficiary has

completed four (4) weeks on the job. C. 15% when the beneficiary has completed eight

(8) weeks on the job.

$3.59

Yes

H2023 U3 UA Supported Employment –

Employment Path Per 15 minutes

Allowed maximum is 25 hours per week alone or combined with Employment Supports in

small group $3.59 Yes

H2023 UK Supported Employment – Extended

Services Per 15 minutes

Allowed maximum of 20% of the beneficiary’s weekly scheduled work hours.

$3.59 Yes

H2023 UQ Supported Employment – Job

Coaching Shared Staffing (up to 4 members)

Per 15 minutes Allowed maximum of 40 hours per week $1.80 Yes

S5151 *Respite Services - Current Budgeted

Approved Rate Yes

S5151 Respite Services – one on one Per 15 minutes $4.00/15 Min units Yes Labeled Respite

Care $16/Hour

S5151 UN Respite Services – shared staffing Per 15 minutes $2.00/15 Min units Yes $8/Hour

T2020 UA Supplemental Support Services

(unforeseen events – guardianship, snow days, bedbugs)

Pass-thru Cost $ 3,690.00 annual combined max with

T2028 and T2020 (CTS)

Custom Rate for each Activity approved by

Auth Yes

T2025 *Consultation Services Yes

T2025 UK Consultation Services – Treatment Planning/Participation in PCSP

Per Hour Annual max $1320.00 inclusive of all

consultation requests No

$100/hour, two hours Max for

PCSP Participation and

Treatment Planning

T2025 U1 Consultation Services –Behavior Support Plans/Training

Per Hour Annual max $1320.00 inclusive of all

consultation requests $136.40 Yes

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Code Mod 1 Mod 2 Description Unit Def Annual Max ARTC RATES Description

Prior Authorization Required (Yes

or No)

ARTC Fee Schedule

Reference Rate per Hour

T2025 U2 Consultation Services – Eligibility

Paperwork Per Occurrence

Annual max $1320.00 inclusive of all consultation requests

No $50 for Medicaid

Eligibility Paperwork once

per year.

T2025 U3

Consultation Services – Providing updated psychological and adaptive

behavior assessments by licensed psychological examiner

Per Hour Annual max $1320.00 inclusive of all

consultation requests $114.43 Same as

90791 U4

Yes

T2025 U4

Consultation Services – Training of direct service staff and/or family by professionals to support member in

goals of PCSP

Per Hour Annual max $1320.00 inclusive of all

consultation requests $136.40 Yes

T2028 **Specialized Medical Supplies Pass-thru Cost $ 3,690.00 annual combined max with

T2028 and T2020 (CTS) Yes

T2020 UA U1 **Community Transition Services Pass-thru Cost $ 3,690.00 annual combined max with

T2028 and T2020 (CTS) Yes

T2034 UA U1 Crisis Intervention Services Per Hour Annual max $2,640.00 $124.00 - 24 $127.10 - 85 Yes

K0108 UB **Environmental Modifications (K0108 w/o/ modifier used for

wheelchair reimbursement) Pass-thru Cost $ 7,687.50 annual combined max Yes

S5160 **Adaptive equipment, personal

emergency response system (PERS), installation and testing,

Pass-thru Cost $ 7,687.50 annual combined max Yes

S5161 **Adaptive equipment, personal

emergency response system (PERS), service fee, per month, excludes installation and testing

Pass-thru Cost $ 7,687.50 annual combined max Yes

S5162

**Adaptive equipment, personal emergency response system

(PERS), purchase only Pass-thru Cost $ 7,687.50 annual combined max Yes

S5165 U1 **CES adaptive equipment, perservice Pass-thru Cost $ 7,687.50 annual combined max Yes

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