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IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT202083 JUNE 30, 2020

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FSSA changes rates and services for the FSW and CIH Waiver Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) has

received approval from the Centers for Medicare & Medicaid Services (CMS) for changes to services for the Division of

Disability and Rehabilitative Services (DDRS) Bureau of Developmental Disabilities Services (BDDS) Family Supports

Waiver (FSW) and the Community Integration and Habilitation (CIH) Waiver.

IHCP Bulletin BT202020 previously announced these changes. However, due to the coronavirus disease 2019

(COVID-19) national public health emergency, these changes were put on hold. As a result, the implementation dates

have changed to July 16, 2020, with some services beginning on August 1, 2020.

The following tables outline the changes, along with the effective dates (be sure to make note of the effective dates for

billing purposes):

Table 1 introduces the new rate for Case

Management.

Table 2 lists the services added to the FSW:

− Environmental Modification

− Equipment – Assess/Inspect/Train

− Remote Supports

− Transportation Levels 2 and 3

Table 3 shows the services that the name/description is being changed for the CIH:

− Remote Supports, formerly Electronic Monitoring

Table 4 lists the services for CIH that are receiving an increase in their cap:

− Community Transition

Table 5 has the services for the FSW and the CIH that are receiving an increase in their cap:

− Family & Caregiver Training, Family

− Family & Caregiver Training, Non-Family

Table 6 contains the services that have a name change for the FSW and CIH (these services are a combination

of Community Habilitation and Facility Habilitation; some of these services have new procedure code and

modifier combinations and some have the same procedure code and modifier combination of previous

services):− Day Habilitation, Individual

− Day Habilitation, Small Group, 2:1, 3:1, 4:1

http://provider.indianamedicaid.com/ihcp/Bulletins/BT202020.pdf

IHCP bulletin BT202083 JUNE 30, 2020

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Day Habilitation, Medium Group, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1

Day Habilitation, Large Group, 11:1, 12:1, 13:1, 14:1, 15:1, 16:1

Table 7 encompasses the codes that will be end-dated:

− Case Management Annual PCISP Work– ending 6/30/2020

− Facility Habilitation, Group 2:1








− Community Habilitation, Group 3:1




Table 8 contains all the services that are not changing for the FSW and the CIH Waiver.

Questions or concerns should be directed to the FSSA Indiana Health Coverage Programs (IHCP) reimbursement

mailbox, ([email protected]). Please be sure to send communications containing

personal health information (PHI) to this mailbox via secure email.

If you have questions about this publication, please

contact Customer Assistance at 1-800-457-4584.

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FSW and CIH Waiver Service Table Updates 1 of 9

Table 1 – New rate for FSW and CIH Waiver service, effective for DOS on or after July 16, 2020

Service Code Mod 1

Mod 2

Mod 3

Dsc Proc Modified

FSW Old FSW New CIH Old CIH New Notes

Case Management T2022 U7 U5 U7=Waiver U5=DD

$131.25 $143.75 $131.25 $143.75 1/Month

Table 2 – Services added to FSW, effective for DOS on or after July 16, 2020

Service Code Mod 1

Mod 2

Mod 3

Dsc Proc Modified FSW Notes

Environmental Modification, Install

S5165 U7 U5 NU U7=Waiver U5=DD NU=New DME

Individual 1/Unit $15,0000 Lifetime

Environmental Modification, Maintain

S5165 U7 U5 U8 U7=Waiver U5=DD U8=Repair

Individual 1/Unit $500/Year

Equipment – Assess/Inspect/Train

T1028 U7 U5 U7=Waiver U5=DD

$17.99 15 Minutes

Remote Supports, Equipment

A9279 U7 U5 NU U7=Waiver U5=DD NU=New DME

Individual 1 Unit; $500 Lifetime Cap

Remote Supports, 1 Participant

A9279 U7 U5 UA U7=Waiver U5=DD UA=Agency

$13.62 Hour

Remote Supports, 2 Participants

A9279 U7 U5 U2 U7=Waiver U5=DD U2=Tier 2/Level 2

$6.81 Hour



$4.54 Hour



$3.41 Hour

Transportation, Level 2 T2002 U7 U5 U2 U7=Waiver U5=DD U2=Tier 2/Level 2

$21.00 Per Trip; 2 Trips/Day; $5,250/Year

Transportation, Level 3 T2002 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3

$42.00 Per Trip; 2 Trips/Day; $7,875/Year



Table 3 – Service name changes for CIH Waiver, effective July 16, 2020

Service Code Mod 1

Mod 2

Mod 3

Dsc Proc Modified CIH Notes

Remote Supports, 1 Participant

A9279 U7 U5 UA U7=Waiver U5=DD UA=Agency

$13.62 Previously Electronic Monitoring










Table 4 – Cap increase for CIH Waiver service, effective for DOS on or after July 16, 2020

Service Code Mod 1

Mod 2

Mod 3

Dsc Proc Modified CIH Notes

Community Transition T2038 U7 U5 U7=Waiver U5=DD

Individual $2,500 Lifetime

Table 5 – Cap increases for FSW and CIH Waiver services, effective for DOS on or after July 16, 2020

Service Code Mod 1

Mod 2

Mod 3

Dsc Proc Modified

FSW CIH Notes

Family & Caregiver Training, Family

S5111 U7 U5 U7=Waiver U5=DD

Individual Individual $5,000/Year

Family & Caregiver Training, Non-Family


Individual Individual $5,000/Year



Table 6 – Service changes and name change for FSW and CIH Waiver services, effective for DOS on or after August 1, 2020

Service Code Mod 1

Mod 2

Mod 3

Dsc Proc Modified FSW CIH Notes

Day Habilitation, Individual


$24.85 $24.85 Hour

Day Habilitation, Small Group 2:1, 3:1, 4:1

T2020 U7 U5 U2 U7=Waiver U5=DD U2=Small Group

$8.90 $8.90 Hour

Day Habilitation, Medium Group 5:1, 6:1, 7:1, 8:1, 9:1, 10:1

T2020 U7 U5 UA U7=Waiver U5=DD UA=Medium Group

$4.96 $4.96 Hour

Day Habilitation, Large Group 11:1, 12:1, 13:1, 14:1, 15:1, 16:1**

T2020 U7 U5 UB U7=Waiver U5=DD UB=Large Group

$3.15 $3.15 Hour

**This code combination is new.

Table 7 – End-dated codes

Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified Waiver Program End Date

Case Management Annual PCISP Work


FSW CIH

6/30/2020

Facility Habilitation, Group 2:1

T2020 U7 U5 UA U2 U7=Waiver UA=Agency U5=DD U2=Tier 2/Level 2

FSW CIH

7/31/2020


T2020 U7 U5 UA U4 U7=Waiver UA=Agency U5=DD U4=Tier 4/Level 4

FSW CIH

7/31/2020


T2020 U7 U5 UA U6 U7=Waiver U5=DD UA=Agency U6=Tier 6/Level 6

FSW CIH

7/31/2020



FSW CIH

7/31/2020



Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified Waiver Program End Date


T2020 U7 U5 UA UB U7=Waiver U5=DD UA=Agency UB=Tier 10/Level 10

FSW CIH

7/31/2020


T2020 U7 U5 UA UC U7=Waiver U5=DD UA=Agency UC=Tier 12/Level 12

FSW CIH

7/31/2020


T2020 U7 U5 UA UD U7=Waiver U5=DD UA=Agency UD=Tier 14/Level 14

FSW CIH

7/31/2020



FSW CIH

7/31/2020

Community Habilitation, Group 3:1

T2020 U7 U5 U3 U7=Waiver U5=DD U3=Tier 3/Level 3

FSW CIH

7/31/2020



FSW CIH

7/31/2020



FSW CIH

7/31/2020



FSW CIH

7/31/2020

Table 8 – Unchanged services or codes for FSW and/or CIH Waiver

Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified

FSW Old

FSW New

CIH Old

CIH New

Notes

Adult Day Services, Level 1

S5101 U7 U5 U1 U7=Waiver U5=DD U1=Tier 1/Level 1

$23.05 $23.05 $23.05 $23.05 Half Day



$30.24 $30.24 $30.24 $30.24 Half Day



Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified

FSW Old

FSW New

CIH Old

CIH New

Notes



$36.00 $36.00 $36.00 $36.00 Half Day

Adult Day Services, ¼ hour, Level 1

S5100 U7 U5 U1 U7=Waiver U5=DD U1=Level 1

$1.45 $1.45 $1.45 $1.45 15 Minutes



$1.89 $1.89 $1.89 $1.89 15 Minutes



$2.25 $2.25 $2.25 $2.25 15 Minutes

Psychological Therapy, Individual

H0004 U7 U5 U3 U7=Waiver U5=DD U3=Level 3

$15.45 $15.45 $15.45 $15.45 15 Minutes

Psychological Therapy, Individual


$18.20 $18.20 $18.20 $18.20 15 Minutes

Behavior Management, Level 1


$18.20 $18.20 $18.20 $18.20 15 Minutes

Transitional Case Management Activities

T2038 U7 U5 UA U7=Waiver U5=DD UA=Agency

N/A N/A $131.25 $131.25 Monthly; 1 Unit/ Month up to 6 Units/Successful Transition

Extended Services T2025 U7 U5 UA U7=Waiver U5=DD UA=Agency

$36.96 $36.96 $36.96 $36.96 Hour

Rent & Food for Unrelated Live-In Caregiver


N/A N/A $545.00 $545.00 Month

Equipment – Assess/Inspect/Train


N/A N/A $36.96 $36.96 15 Minutes

Intensive Behavioral Intervention, Level 1


$104.60 $104.60 $104.60 $104.60 Hour

Intensive Behavioral Intervention, Level 2


$25.00 $25.00 $25.00 $25.00 Hour



Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified

FSW Old

FSW New

CIH Old

CIH New

Notes

Music Therapy H2032 U7 U5 U1 U7=Waiver U5=DD U1=Level 1

$10.78 $10.78 $10.78 $10.78 15 Minutes

Recreational Therapy H2032 U7 U5 U2 U7=Waiver U5=DD U2=Level 2

$10.78 $10.78 $10.78 $10.78 15 Minutes

Occupational Therapy G0152 U7 U5 UA U7=Waiver U5=DD UA=Agency

$17.99 $17.99 $17.99 $17.99 15 Minutes

Participant Assistance and Care

T2033 U7 U5 U7=Waiver U5=DD UA=Agency

$24.40 $24.40 N/A N/A Hour

Structured Family Caregiving, Level 1

T2033 U7 U5 U1 U7=Waiver U5=DD U1=Level 1

N/A N/A $51.87 $51.87 1 Unit/Day



N/A N/A $75.67 $75.67 1 Unit/Day



N/A N/A $102.87 $102.87 1 Unit/Day

Personal Response System, Install


$52.07 $52.07 $52.07 $52.07 1 Unit

Personal Response System, Maintain


$52.07 $52.07 $52.07 $52.07 1 Unit/Month

Physical Therapy G0151 U7 U5 UA U7=Waiver U5=DD UA=Agency

$18.12 $18.12 $18.12 $18.12 15 Minutes

Prevocational 2:1 T2015 U7 U5 U2 U7=Waiver U5=DD Oasis U2=Level 2

$8.90 $8.90 $8.90 $8.90 Hour

Prevocational 4:1 T2015 U7 U5 U4 U7=Waiver U5=DD U4=Level 4

$8.90 $8.90 $8.90 $8.90 Hour


$4.96 $4.96 $4.96 $4.96 Hour


$4.96 $4.96 $4.96 $4.96 Hour



Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified

FSW Old

FSW New

CIH Old

CIH New

Notes

Prevocational 10:1 T2015 U7 U5 UB U7=Waiver U5=DD UB=Level 10

$4.96 $4.96 $4.96 $4.96 Hour

Prevocational 12:1 T2015 U7 U5 UC U7=Waiver U5=DD UC=Level 12

$3.15 $3.15 $3.15 $3.15 Hour

Prevocational 14:1 T2015 U7 U5 UD U7=Waiver U5=DD UD=Level 14

$3.15 $3.15 $3.15 $3.15 Hour


$3.15 $3.15 $3.15 $3.15 Hour

Psychological Therapy, Family

90846 U7 U5 U7=Waiver U5=DD

$17.27 $17.27 $17.27 $17.27 15 Minutes

Psychological Therapy, Group

90853 U7 U5 U7=Waiver U5=DD

$4.81 $4.81 $4.81 $4.81 15 Minutes

Residential Habilitation Services, Level 1 (35 or Less Hours/Week)

T2016 U7 U5 UA U7=Waiver U5=DD UA=Agency

N/A N/A $26.15 $26.15 Hour

Residential Habilitation Services, Level 2 (Over 35 Hours/Week)


N/A N/A $21.97 $21.97 Hour

RHS Daily Level 1 (2 Person Setting, Algo Level 3)

T2016 U7 U5 UN UA U7=Waiver U5=DD UN=2 Patients UA=Agency

N/A N/A $171.33 $171.33 1 Unit/Day


T2016 U7 U5 UN UB U7=Waiver U5=DD UN=2 Patients UB=Face 2 Face

N/A N/A $241.63 $241.63 1 Unit/Day


T2016 U7 U5 UN UC U7=Waiver U5=DD UN=2 Patients UC=Case Mgmt

N/A N/A $263.59 $263.59 1 Unit/Day


T2016 U7 U5 UP UA U7=Waiver U5=DD UP=3 Patients UA=Agency

N/A N/A $171.33 $171.33 1 Unit/Day



Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified

FSW Old

FSW New

CIH Old

CIH New

Notes


T2016 U7 U5 UP UB U7=Waiver U5=DD UP=3 Patients UB=Face 2 Face

N/A N/A $221.85 $221.85 1 Unit/Day


T2016 U7 U5 UP UC U7=Waiver U5=DD UP=3 Patients UC=Case Mgmt

N/A N/A $241.63 $241.63 1 Unit/Day


T2016 U7 U5 UQ UA U7=Waiver U5=DD UQ=4 Patients UA=Agency

N/A N/A $160.35 $160.35 1 Unit/Day


T2016 U7 U5 UQ UB U7=Waiver U5=DD UQ=4 Patients UB=Face 2 Face

N/A N/A $206.47 $206.47 1 Unit/Day


T2016 U7 U5 UQ UC U7=Waiver U5=DD UQ=4 Patients UC=Case Mgmt

N/A N/A $219.66 $219.66 1 Unit/Day

Respite S5151 U7 U5 U7=Waiver U5=DD

$26.15 $26.15 $26.15 $26.15 Hour

Respite T1005 U7 U5 TD U7=Waiver U5=DD TD=RN

$7.79 $7.79 $7.79 $7.79 15 minutes

Respite T1005 U7 U5 TE U7=Waiver U5=DD TE=LPN

$5.91 $5.91 $5.91 $5.91 15 minutes

Specialized Medical Equip/Supply, Install

T2029 U7 U5 NU U7=Waiver U5=DD NU=New DME

Individual Individual N/A N/A $7,500 Lifetime

Specialized Medical Equip/Supply, Install

T2029 U7 U5 NU U7=Waiver U5=DD NU=New DME

N/A N/A Individual Individual

Specialized Medical Equip/Supply, Maintain

T2029 U7 U5 U8 U7=Waiver U5=DD U8=Repair

Individual Individual Individual Individual $500/Year

Speech Therapy 92507 U7 U5 UA U7=Waiver U5=DD UA=Agency

$18.12 $18.12 $18.12 $18.12 15 Minutes



Service Code Mod 1

Mod 2

Mod 3

Mod 4

Dsc Proc Modified

FSW Old

FSW New

CIH Old

CIH New

Notes

Transportation, Level 1 T2002 U7 U5 U7=Waiver U5=DD

$5.25 $5.25 N/A N/A 2 Trips/Day

Transportation, Level 1 T2002 U7 U5 U7=Waiver U5=DD

N/A N/A $5.25 $5.25 Per Trip; 2 Trips/Day; $2,625/Year

Transportation, Level 2 T2002 U7 U5 U2 U7=Waiver U5=DD U2=Level 2

N/A Added $21.00 $21.00 Per Trip; 2 Trips/Day; $5,250/Year

Transportation, Level 3 T2002 U7 U5 U3 U7=Waiver U5=DD U3=Level 3

N/A Added $42.00 $42.00 Per Trip; 2 Trips/Day; $7,875/Year

Vehicle Modification, Install


Individual Individual N/A N/A $7,500 Lifetime

Vehicle Modification, Install


N/A N/A Individual Individual $15,000 Lifetime

Vehicle Modification, Maintain

T2039 U7 U5 U8 U7=Waiver U5=DD U8=Repair

Individual Individual Individual Individual $500/Year

Wellness Coordination, Tier 1


N/A N/A $52.77 $52.77 1 Unit/Month



N/A N/A $111.96 $111.96 1 Unit/Month



N/A N/A $223.92 $223.92 1 Unit/Month

Workplace Assistance T1020 U7 U5 U7=Waiver U5=DD

$27.69 $27.69 $27.69 $27.69 Hour

Facility-Based Support T1020 U7 U5 UA U7=Waiver U5=DD UA=Agency

$1.94 $1.94 $1.94 $1.94 Hour

Environmental Modification, Install

S5165 U7 U5 NU U7=Waiver U5=DD NU=New DME

N/A Added Individual Individual 1 Unit/$15,000 Lifetime Cap

Environmental Modification, Maintain

S5165 U7 U5 U8 U7=Waiver U5=DD U8=Repair

N/A Added Individual Individual 1 Unit/$500 per Year

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