updated with fy15-16 jbc increases dd fy 15-16... · rates effective july 1, 2015-june 30, 2016...

Colorado Choice Transitions FY15-16 Rate SchedulesUpdated with FY15-16 JBC Increases

WAIVER TYPE PERCENTAGE INCREASE MULTIPLIER

CCT EBD 0.50% 1.0050

CCT CMHS 0.50% 1.0050

CCT BI 0.50% 1.0050

CCT DD 1.70% 1.0170

CCT SLS 1.70% 1.0170

ADJUSTMENT TABLE

Colorado Choice Transitions: Elderly, Blind and Disabled (65+, 18-64)

Rates Effective July 1, 2015-June 30, 2016

Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Basic S5105 UC $ 24.06 $ 24.18 1/2 DayAn individual unit is 4-5

hours per day

Specialized S5105 UC TF $ 30.73 $ 30.88 1/2 DayAn individual unit is 3-5

hours per day

Assistive Technology-

ExtendedT2029 UC NR* NR* Per Purchase $1,000.00 Maximum

Caregiver Education S5110 UC $ 12.19 $ 12.19 15 Minutes

Coordinator T2038 UC NR* NR* Per Transition $2,000.00 Maximum

Service Items A9900 UC NR* NR* Per Purchase $1,500.00 Maximum

CDASS Homemaker T2025 U1 $ 3.43 $ 3.43 15 Minutes

CDASS Personal Care T2025 U1 $ 3.43 $ 3.43 15 Minutes

CDASS Health

MaintenanceT2025 U1 $ 6.49 $ 6.52 15 Minutes

Morning Star Financial

Services- FEAT2040 U1 $ 103.21 $ 103.21 Month

Public Partnerships, LLC-

FEAT2040 U1 $ 103.21 $ 103.21 Month

Northeast PA Center for

Independent Living- FEAT2040 U1 $ 85.00 $ 85.00 Month


Services- AwCT2040 U1 CG $ 111.11 $ 111.11 Month


AwCT2040 U1 CG $ 111.11 $ 111.11 Month


Independent Living- AwCT2040 U1 CG $ 100.00 $ 100.00 Month

Dental D2999 UC NR* NR* Per Procedure $8,000.00 Maximum

Enhanced Nursing

Services (RN)T1002 UC $ 8.87 $ 8.87 15 Minutes

Service is provided in the

first 30 days post

transition only. Maximum

50 units.

Home Delivered Meals S5170 UC $ 10.80 $ 10.80 Per

Delivery/Meal

Time limited for CCT

clients, may be provided

more often during initial

weeks after discharge

from an institution

Home Modification S5165 UC NR* NR* Per Mod$10,000.00 Lifetime

Maximum

Adult Day Services

Community Transition Services (CTS)

Combined Maximum of $3,500.00 for Coordinator and Items Purchased

Consumer Direct Attendant Support Services (CDASS)

CDASS Per Member Per Month, By FMS Vendor

Version: 2.0

Date: 06/18/2015 2



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Adult Day Services

Home Modification-

ExtendedS5165 UC KG NR* NR* Per Mod

$5,000.00 Lifetime

Maximum, can only be

accessed when Home

Modification limits have

been reached

Homemaker S5130 UC $ 3.84 $ 3.84 15 minutes

IHSS Health Maintenance H0038 UC $ 7.23 $ 7.27 15 minutes

IHSS Homemaker S5130 UC KX $ 3.84 $ 3.84 15 minutes

IHSS Personal Care T1019 UC KX $ 3.84 $ 3.84 15 minutes

IHSS Relative Personal

CareT1019 UC HR KX $ 3.84 $ 3.84 15 minutes

No limits on IHSS

benefits provided by

parents of adult children.

For all other relatives, the

limitations on payment to

family applies as set forth

in 10 C.C.R. 2505-10,

Section 8.485.200

Independent Living

Skills Training (ILST)H2014 UC $ 9.33 $ 9.33 15 Minutes

24 units per day

maximum

Intensive Case

Management T1016 UC $ 21.10 $ 21.10 15 Minutes

Install/Purchase T2029 UC TF NR* NR* Per Purchase 1 unit = 1 purchase

Monitoring S5185 UC NR* NR* Month 1 unit = 1 month

Peer Mentorship H2015 UC $ 5.36 $ 5.36 15 Minutes

Taxi A0100 UC PUC* PUC* 1 Way Trip

Mobility Van-Mileage

Band 1 (0-10 miles)A0120 UC $ 8.30 $ 8.34 1 Way Trip


Band 2 (11-20 miles)A0120 UC TT $ 15.28 $ 15.36 1 Way Trip


Band 3 (over 20 miles)A0120 UC TN $ 22.75 $ 22.86 1 Way Trip

Wheelchair Van-Mileage






Personal Care T1019 UC $ 3.84 $ 3.84 15 minutes

In Home Support Services

Medication Reminder

Non Medical Transportation

All types except Adult Day are limited to 208 trips, or 104 round trips per service plan year

Mobility Van

Wheelchair Van

Version: 2.0

Date: 06/18/2015 3



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Adult Day Services

Personal Care-Relative T1019 UC HR $ 3.84 $ 3.84 15 minutes

Maximum reimbursement

not to exceed 1776 units

per year

Install/Purchase S5160 UC NR* NR* Purchase 1 unit = 1 purchase


ACF S5151 UC $ 56.73 $ 57.01 Day

NF H0045 UC $ 126.51 $ 127.14 Day

In-Home S5150 UC $ 3.24 $ 3.24 15 minutesNot to exceed the ACF

per diem for respite care

Individual H0047 UC HF $ 72.94 $ 72.94 Hour

Group H0047 UC HQ HF $ 39.39 $ 39.39 Hour

Transitional Behavioral

Health ServicesH0025 UC $ 25.31 $ 25.31 30 Minutes

Transitional Specialized

Day RehabilitationS5101 UC $ 36.45 $ 36.45 1/2 Day

An individual unit is 4-5

hours per day

Vision Extended V2799 UC NR* NR* Per Procedure $1,000.00 Maximum

NR*

KX

HR

HB

HF

HQ

KG

TF

UC

Legend

Substance Abuse Counseling, Transitional

Personal Emergency Response System

Respite Care

Combined maximum of 30 days per calendar year for Respite Care provided in an ACF, In Home, or a Nursing Facility

Negotiated Rate, will vary by client

In Home Support Services (HCPCS Defn: Requirements specified in the medical policy have been met)

Relative providing care (HCPCS Defn: Family/Couple with client present)

Colorado Choice Transitions (HCPCS Defn: Medicaid Level of Care 12, as defined by each state)

To and From Adult Day (HCPSC Defn: Adult Program, non-geriatric)

Substance Abuse Program

Group Setting

Extended Demonstration Program (HCPCS Defn: DMEPOS item subject to DMEPOS competitive

Intermediate Level of Care

Version: 2.0

Date: 06/18/2015 4

Colorado Choice Transitions: Community Mental Health Supports (CMHS)


Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Basic S5105 UC $ 24.06 $ 24.18 1/2 DayAn individual unit is 4-5

hours per day

Specialized S5105 UC TF $ 30.73 $ 30.88 1/2 DayAn individual unit is 3-5

hours per day





Service Items A9900 UC NR* NR* Per Purchase $1,500.00 Maximum

CDASS Homemaker T2025 UA $ 3.43 $ 3.43 15 Minutes

CDASS Personal Care T2025 UA $ 3.43 $ 3.43 15 Minutes

CDASS Health

MaintenanceT2025 UA $ 6.49 $ 6.52 15 Minutes


Services- FEAT2040 UA $ 103.21 $ 103.21 Month


FEAT2040 UA $ 103.21 $ 103.21 Month


Independent Living- FEAT2040 UA $ 85.00 $ 85.00 Month


Services- AwCT2040 UA CG $ 111.11 $ 111.11 Month


AwCT2040 UA CG $ 111.11 $ 111.11 Month


Independent Living- AwCT2040 UA CG $ 100.00 $ 100.00 Month

Dental D2999 UC NR* NR* Per Procedure $8,000.00 Maximum

Enhanced Nursing


Service is provided in the

first 30 days post


50 units.

Home Delivered Meals S5170 UC $ 10.80 $ 10.80 Per Delivery





from an institution

Home Modification S5165 UC NR* NR* Per Mod $10,000.00 Maximum

Home Modification-


$5,000.00 Lifetime


accessed when Home


been reached

Adult Day Services


Combined Maximum of $3,500.00 for Coordinator and Items Purchased

Consumer Directed Attendant Services (CDASS)


Version: 2.0

Date: 06/18/2015 5



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Adult Day ServicesHomemaker S5130 UC $ 3.84 $ 3.84 15 Minutes

Independent Living

Skills TrainingH2014 UC $ 9.33 $ 9.33 15 Minutes

24 units per day

maximum

Intensive Case

Management T1016 UC $ 21.10 $ 21.10 15 Minutes

Install/Purchase T2029 UC TF NR* NR* Per Purchase 1 unit = 1 purchase















Peer Mentorship H2015 UC $ 5.36 $ 5.36 15 minutes

Personal Care T1019 UC $ 3.84 $ 3.84 15 minutes

Personal Care-Relative T1019 UC HR $ 3.84 $ 3.84 15 minutes



per year

Install/Purchase S5160 UC NR* NR* Per Purchase 1 unit = 1 purchase


ACF S5151 UC $ 56.73 $ 57.01 Day

NF H0045 UC $ 126.51 $ 127.14 Day

Individual H0047 UC HF $ 72.94 $ 72.94 1 Hour

Group H0047 UC HQ HF $ 39.39 $ 39.39 1 Hour

Transitional Behavioral

Health ServicesH0025 UC $ 25.31 $ 25.31 30 Minutes

Respite Care

Combined maximum of 30 days per calendar year for Respite Care provided in an ACF, In Home, or a Nursing Facility


Medication Reminder


All types except Adult Day are limited to 208 trips, or 104 round trips

Personal Emergency Response System (PERS)

Mobility Van

Wheelchair Van

Version: 2.0

Date: 06/18/2015 6



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Adult Day ServicesTransitional Specialized

Day Rehabilitation

Services

S5101 UC $ 36.45 $ 36.45 1/2 DayAn individual unit is 4-5

hours per day

Vision V2799 UC NR* NR* Per Procedure $1,000.00 Maximum

NR*

HR

HB

UA

HF

HQ

KG

TF

UC



To and From Adult Day (HCPCS Defn: Adult Program, non-geriatric)

Community Mental Health Supports (HCPCS Defn: Medicaid Level of Care 1, as defined by each state)

Legend


Group Setting

Extended Demonstration Program (HCPCS Defn: DMEPOS item subject to DMEPOS competitive



Version: 2.0

Date: 06/18/2015 7

Colorado Choice Transitions: Brain Injury


Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Adult Day Services S5102 UC $ 50.66 $ 50.91 Day

At least 2 or more hours

of attendance 1 or more

days per week

Assistive Technology T2029 UC HB NR* NR* Per Purchase

Behavioral

ProgrammingH0025 UC TF $ 14.29 $ 14.36 30 Minutes



Items Purchased A9900 UC NR* NR* Per Purchase $1,500.00 Maximum

CDASS Homemaker T2025 UC $ 3.43 $ 3.43 15 minutes

CDASS Personal Care T2025 UC $ 3.43 $ 3.43 15 Minutes

CDASS Health

Maintenance T2025 UC $ 6.45 $ 6.48 15 minutes


Services- FEAT2040 UC $ 103.21 $ 103.21 Month


FEAT2040 UC $ 103.21 $ 103.21 Month


Independent Living- FEAT2040 UC $ 85.00 $ 85.00 Month


Services- AwCT2040 UC CG $ 111.11 $ 111.11 Month


AwCT2040 UC CG $ 111.11 $ 111.11 Month


Independent Living- AwCT2040 UC CG $ 100.00 $ 100.00 Month

Day Treatment H2018 UC $ 80.37 $ 80.77 Day

At least 2 or more hours

of attendance 1 or more

days per week

Dental D2999 UC NR* NR* Per Procedure

10,000.00 Lifetime

Maximum, Demonstration

Service

Enhanced Nursing

Services (RN)T1002 UC $ 8.87 $ 8.87 15 minutes

Service is provided in first

30 days post transition

only. Maximum 50 units.

Home Delivered Meals S5170 UC $ 10.80 $ 10.80 Per Delivery/

Meal





from an institution

Home Modifications S5165 UC NR* NR* Per Mod$10,000.00 Lifetime

Maximum


Combined maximum of $3,500.00 for Coordinator and Items Purchased

Consumer Direct Attendant Supports and Services (CDASS)


Version: 2.0

Date: 06/18/2015 8



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Home Modifications-


$5,000.00 Lifetime


accessed when Home


been reached

Intensive Case

ManagementT1016 UC $ 21.10 $ 21.10 15 Minutes

Independent Living

Skills Training (ILST)T2013 UC $ 26.01 $ 26.14 Hour

Family H0004 UC HR $ 14.76 $ 14.83 15 minutes

Group H0004 UC HQ $ 8.27 $ 8.31 15 minutes

Individual H0004 UC $ 14.76 $ 14.83 15 minutes















Personal Care T1019 UC TG $ 3.90 $ 3.90 15 minutesNot to exceed 10 hours

per day

Personal Care-Relative T1019 UC HR TG $ 3.90 $ 3.90 15 minutes



per year

Installation S5160 UC NR* NR* Per Purchase 1 unit = 1 purchase


NF H0045 UC TF $ 119.70 $ 120.30 Day

In Home S5150 UC $ 3.24 $ 3.24 15 minutesAll inclusive of client's

needs

Family T1006 UC HR HF $ 59.11 $ 59.41 Hour

Respite Care

Combined maximum of 30 days per calendar year for Respite Care provided In Home or a Nursing Facility

Substance Abuse Counseling

Mental Health Counseling

Must obtain Department approval over 30 cumulative visits of counseling

Non-Medical Transportation

All types except Adult Day are limited to 204 trips, or 104 round trips

Personal Emergency Response System (PERS)

Mobility Van

Wheelchair Van

Version: 2.0

Date: 06/18/2015 9



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Group H0047 UC HQ TF HF $ 33.11 $ 33.28 Hour

Individual H0047 UC TF HF $ 59.11 $ 59.41 Hour

Supported Living

ProgramT2033 UC FS* FS* Day

Per diem rate set by

HCPF using acuity levels

of client population

Transitional Living -

Acuity Tier 1T2016 UC KX $ 347.09 $ 348.83 1 Day


Acuity Tier 2T2016 UC HB $ 371.89 $ 373.75 1 Day


Acuity Tier 3T2016 UC HE $ 397.70 $ 399.69 1 Day


Acuity Tier 4T2016 UC HK $ 425.10 $ 427.23 1 Day


Acuity Tier 5T2016 UC HB HE $ 450.44 $ 452.69 1 Day

Transitional Specialized

Day Rehabilitation

Services

S5101 UC $ 36.45 $ 36.45 1/2 DayAn individual unit is 4-5

hours per day

Vision V2799 UC NR* NR* Per Procedure $1,000.00 Maximum

NR*

FS*

KX

HR

HB

U6

HF

HQ

UC

Legend

Transitional Living Program (TLP) Tiered Rates


Facility Specific rate determined using acuity scores by the Dept.

In Home Support Services (HCPCS Defn: Requirements specified in the medical policy have been met)



To and From Adult Day (HCPCS Defn: Adult Program, non-geriatric)

Brain Injury (HCPCS Defn: Medicaid Level of Care 1, as defined by each state)


Group Setting

Version: 2.0

Date: 06/18/2015 10

Colorado Choice Transitions: Developmentally Disabled


Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments



Behavioral Line Staff H2019 UC $ 6.52 $ 6.63 15 MinutesMaximum of 960 units per

Service Plan year.

Behavioral Consultation H2019 UC HI TG $ 24.52 $ 24.94 15 MinutesMaximum of 80 units per

service plan year

Behavioral Counseling-

Individual H2019 UC TF TG $ 24.52 $ 24.94 15 Minutes

Behavioral Counseling

Group H2019 UC TF HQ $ 8.26 $ 8.40 15 Minutes

Behavioral Plan

Assessment T2024 UC HI $ 24.52 $ 24.94 15 Minutes

Maximum of 40 units per

Service Plan year.




Specialized Habilitation

Level 1T2021 UC HQ $ 2.32 $ 2.36 15 Minutes Maximum 4,800 units


Level 2T2021 UC HI HQ $ 2.55 $ 2.59 15 Minutes Maximum 4,800 units


Level 3T2021 UC TF HQ $ 2.84 $ 2.89 15 Minutes Maximum 4,800 units


Level 4T2021 UC TF HI HQ $ 3.34 $ 3.40 15 Minutes Maximum 4,800 units


Level 5T2021 UC TG HQ $ 4.14 $ 4.21 15 Minutes Maximum 4,800 units


Level 6T2021 UC TG HI HQ $ 5.95 $ 6.05 15 Minutes Maximum 4,800 units


Level 7T2021 UC SC HQ $ 9.36 $ 9.52 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 1T2021 UC $ 2.82 $ 2.87 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 2T2021 UC HI $ 3.09 $ 3.14 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 3T2021 UC TF $ 3.48 $ 3.54 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 4T2021 UC TF HI $ 4.00 $ 4.07 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 5T2021 UC TG $ 4.82 $ 4.90 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 6T2021 UC TG HI $ 6.33 $ 6.44 15 Minutes Maximum 4,800 units

Supported Community

Connections Level 7T2021 UC SC $ 9.36 $ 9.52 15 Minutes Maximum 4,800 units

Behavioral Services

Day Rehabilitation

Maximum units of Specialized Habilitation, Supported Community Connections, Prevocational Services, and Supported Employment

is 7112 units per service plan year; Maximum combined units of Specialized Habilitation, Supported Community Connections,

Prevocational Services and Supported Employment is 4800 units per service plan year.

Dental Services

Maximum of 208 units

combined Individual and

Group, per Service Plan

year.


Combined Maximum of $3,500.00 for Coordinator and Items Purchased.

Version: 2.0

Date: 06/18/2015 11



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Basic D2999 UC HI $ 1.00 $ -

Major D2999 UC TF $ 1.00 $ -

Enhanced Nursing


Services is provided in

the first 30 days post


50 units.

Home Accessibility

Adaptations-ExtendedS5165 UC KG NR* NR* Per Mod $5,000 Lifetime Maximum

Intensive Case


Transportation Mileage

Band 1 (0-10 Miles)T2003 UC $ 5.69 $ 5.79 1 Trip


Band 2 (11-20 Miles)T2003 UC HI $ 11.93 $ 12.13 1 Trip


Band 3 (over 20 miles)T2003 UC TF $ 18.16 $ 18.47 1 Trip

Other (public

conveyance)T2004 UC $ 1.00 $ 1.00 Dollar

A dollar per unit for the

cost of a bus pass or

other public conveyance

may only be used when it

is more cost effective

than or equivalent to the

applicable mileage band.


Prevocational Services

Level 1T2015 UC HQ $ 2.32 $ 2.36 15 Minutes Maximum 4,800 units


Level 2T2015 UC HI HQ $ 2.55 $ 2.59 15 Minutes Maximum 4,800 units


Level 3T2015 UC TF HQ $ 2.84 $ 2.89 15 Minutes Maximum 4,800 units


Level 4T2015 UC TF HI HQ $ 3.34 $ 3.40 15 Minutes Maximum 4,800 units


Level 5T2015 UC TG HQ $ 4.14 $ 4.21 15 Minutes Maximum 4,800 units


Level 6T2015 UC TG HI HQ $ 5.95 $ 6.05 15 Minutes Maximum 4,800 units

Group Home Level 1 T2016 UC HQ $ 86.79 $ 88.27 Day

Group Home Level 2 T2016 UC HI HQ $ 114.24 $ 116.18 Day

Group Home Level 3 T2016 UC TF HQ $ 134.58 $ 136.87 Day

Group Home Level 4 T2016 UC TF HI HQ $ 158.99 $ 161.69 Day


Maximum of 508 trips (all mileage bands) per Service Plan year.




Prevocational Services and Supported Employment is 4800 units per service plan year

Please refer to DIDD

Dental Fee Schedule for

rates

Residential Services

Version: 2.0

Date: 06/18/2015 12



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Group Home Level 5 T2016 UC TG HQ $ 175.63 $ 178.62 Day

Group Home Level 6 T2016 UC TG HI HQ $ 207.83 $ 211.36 Day

Group Home Level 7 T2016 UC SC HQ NR* NR* Day

Personal Care Alternative

Level 1T2016 UC $ 63.81 $ 64.89 Day


Level 2T2016 UC HI $ 103.11 $ 104.86 Day


Level 3T2016 UC TF $ 125.98 $ 128.12 Day


Level 4T2016 UC TF HI $ 153.38 $ 155.99 Day


Level 5T2016 UC TG $ 176.25 $ 179.25 Day


Level 6T2016 UC TG HI $ 221.50 $ 225.27 Day


Level 7T2016 UC SC NR* NR* Day

Host Home Level 1 T2016 UC TT $ 59.18 $ 60.19 Day

Host Home Level 2 T2016 UC HI TT $ 95.62 $ 97.25 Day

Host Home Level 3 T2016 UC TF TT $ 116.82 $ 118.81 Day

Host Home Level 4 T2016 UC TF HI TT $ 142.25 $ 144.67 Day

Host Home Level 5 T2016 UC TG TT $ 163.45 $ 166.23 Day

Host Home Level 6 T2016 UC TG HI TT $ 205.44 $ 208.93 Day

Host Home Level 7 T2016 UC SC TT NR* NR* Day

Supported Employment

Group Level 1T2019 UC HQ $ 3.11 $ 3.16 15 Minutes


Group Level 2T2019 UC HI HQ $ 3.40 $ 3.46 15 Minutes


Group Level 3T2019 UC TF HQ $ 3.79 $ 3.85 15 Minutes


Group Level 4T2019 UC TF HI HQ $ 4.38 $ 4.45 15 Minutes


Group Level 5T2019 UC TG HQ $ 5.23 $ 5.32 15 Minutes


Group Level 6T2019 UC TG HI HQ $ 6.82 $ 6.94 15 Minutes


Individual-All LevelsT2019 UC SC $ 12.80 $ 13.02 15 Minutes

Job Development Group-

All LevelsH2023 UC HQ $ 4.08 $ 4.15 15 Minutes

Job Development Levels

1-2H2023 UC $ 12.80 $ 13.02 15 Minutes


3-4H2023 UC HI $ 12.80 $ 13.02 15 Minutes


5-6H2023 UC TF $ 12.80 $ 13.02 15 Minutes

Job Placement H2024 UC $ 1.00 $ 1.00 Dollar

Job Placement Group H2024 UC HQ $ 1.00 $ 1.00 Dollar





Prevocational Services and Supported Employment is 4800 units per service plan year

Version: 2.0

Date: 06/18/2015 13



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments



Disposable T2028 UC $ 1.00 $ 1.00 Dollar

Equipment T2029 UC TF $ 1.00 $ 1.00 Dollar

Vision V2799 UC HI $ 1.00 $ 1.00 Dollar $1,000.00 Maximum

22

HQ

SC

TF

TG

TT

U3

Specialized Medical Equipment and Supplies

Services may be

authorized by a CCB up

the DDD pre-established

thresholds, beyond which

DDD prior authorization is

required.

Legend

Individualized service provided to more one patient in the same setting

Developmentally Disabled (HCPCS Defn: Medicaid Level of Care 1, as defined by each state)

(CPT Defn: Increased procedural services)

Group Setting

Medically Necessary Service or Supply


Complex/High Tech Level of Care

Version: 2.0

Date: 06/18/2015 14

Colorado Choice Transitions: Supported Living Services


Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Assistive Technology T2035 UC $ 1.00 $ 1.00 Dollar

Maximum of $10,000 of

Assistive Technology,

Home Accessibility

Adaptations, and Vehicle

Modifications combined

per Waiver Renewal

Period (7/1/14 - 6/30/19).

Behavioral Line Staff H2019 UC $ 6.52 $ 6.63 15 MinutesMaximum of 960 units per

Service Plan year.

Behavioral Consultation H2019 UC HI TG $ 24.52 $ 24.94 15 MinutesMaximum of 80 units per

service plan year


IndividualH2019 UC TF TG $ 24.52 $ 24.94 15 Minutes


Group H2019 UC TF HQ $ 8.26 $ 8.40 15 Minutes

Behavioral Plan

Assessment T2024 UC HI $ 24.52 $ 24.94 15 Minutes

Maximum of 40 units per

Service Plan year.





Level 1T2021 UC HQ $ 2.32 $ 2.36 15 Minutes


Level 2T2021 UC HI HQ $ 2.55 $ 2.59 15 Minutes


Level 3T2021 UC TF HQ $ 2.84 $ 2.89 15 Minutes


Level 4T2021 UC TF HI HQ $ 3.34 $ 3.40 15 Minutes


Level 5T2021 UC TG HQ $ 4.14 $ 4.21 15 Minutes


Level 6T2021 UC TG HI HQ $ 5.95 $ 6.05 15 Minutes

Supported Community

Connections Level 1T2021 UC $ 2.82 $ 2.87 15 Minutes

Supported Community

Connections Level 2T2021 UC HI $ 3.09 $ 3.14 15 Minutes

Supported Community

Connections Level 3T2021 UC TF $ 3.48 $ 3.54 15 Minutes

Supported Community

Connections Level 4T2021 UC TF HI $ 4.00 $ 4.07 15 Minutes

Supported Community

Connections Level 5T2021 UC TG $ 4.82 $ 4.90 15 Minutes

Supported Community

Connections Level 6T2021 UC TG HI $ 6.33 $ 6.44 15 Minutes


Combined Maximum of $3,500.00 for Coordinator and Items Purchased.

Behavioral Services

Day Habilitation

Maximum of 7,112 combined units of Specialized Habilitation, Supported Community Connections, Prevocational Services, and

Supported Employment per Service Plan year.

Maximum of 208 units

combined Individual and

Group, per Service Plan

year.

Version: 2.0

Date: 06/18/2015 15



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Basic/Preventative D2999 UC HI $ 1.00 $ -

Major D2999 UC TF $ 1.00 $ -

Enhanced Nursing


Services provided in first

30 days post-transition

only. Maximum 50 units.

Home Accessibility

AdaptationsS5165 UC $ 1.00 $ 1.00 Dollar

Maximum $10,000.00 for

combination of Assistive

Technology, Vehicle

Modifications and Home

Accessibility Adaptations

combined per waiver

renewal period

(07/01/2014-06/30/2019)

Home Accessibility

Adaptations-ExtendedS5165 UC KG $ 1.00 $ 1.00 Dollar

$5,000.00 Lifetime

Maximum

Basic S5130 UC HI $ 3.73 $ 3.73 15 Minutes

Enhanced S5130 UC TF $ 6.02 $ 6.12 15 Minutes

Requires a habilitative

plan as described in the

waiver or extraordinary

cleaning due to the

individual behavioral or

medical needs.

Independent Living

Skills Training (ILST)H2014 UC $ 9.33 $ 9.33 15 Minutes

24 units per day

maximum

Intensive Case


Mentorship H2021 UC $ 9.83 $ 10.00 15 MinutesMaximum of 192

units/year.

Mileage Band 1 (0-10

Miles)T2003 UC $ 5.69 $ 5.79 1 Trip

Mileage Band 2 (11-20

Miles)T2003 UC HI $ 11.93 $ 12.13 1 Trip

Mileage Band 3 (Over 20

Miles)T2003 UC TF $ 18.16 $ 18.47 1 Trip

Mileage not in Day

ProgramT2003 UC HB $ 5.69 $ 5.79

4 Trips per

week

4 Trips Per Week

(Mileage band 1)


Maximum of 208 trips (all mileage bands) per Service Plan year.

Dental Services

Homemaker

Please refer to DIDD

Dental Fee Schedule for

rates

Version: 2.0

Date: 06/18/2015 16



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Other (public

conveyance)T2004 UC $ 1.00 $ 1.00 Dollar

A dollar per unit for the

cost of a bus pass or

other public conveyance

may only be used when it

is more cost effective

than or equivalent to the

applicable mileage band.

Personal Emergency

Response System

(PERS)

S5161 UC $ 1.00 $ 1.00 Dollar

Personal Care T1019 UC TF $ 4.87 $ 4.95 15 Minutes


Level 1T2015 UC HQ $ 2.32 $ 2.36 15 Minutes


Level 2T2015 UC HI HQ $ 2.55 $ 2.59 15 Minutes


Level 3T2015 UC TF HQ $ 2.84 $ 2.89 15 Minutes


Level 4T2015 UC TF HI HQ $ 3.34 $ 3.40 15 Minutes


Level 5T2015 UC TG HQ $ 4.14 $ 4.21 15 Minutes


Level 6T2015 UC TG HI HQ $ 5.95 $ 6.05 15 Minutes

Massage Therapy 97124 UC $ 18.34 $ 18.65 15 Minutes

Movement Therapy

BachelorsG0176 UC HN $ 15.29 $ 15.29 15 Minutes

Movement Therapy

MastersG0176 UC $ 22.41 $ 22.79 15 Minutes

Hippotherapy Individual S8940 UC $ 20.37 $ 20.72 15 Minutes

Hippotherapy Group S8940 UC HQ $ 8.66 $ 8.66 15 Minutes

Rec Pass Access Fee S5199 UC $ 1.00 $ 1.00 Dollar

Individual S5150 UC TG $ 4.87 $ 4.87 15 Minutes

Individual Day S5151 UC TG $ 194.60 $ 197.91 1 Day

Group S5151 UC HQ TG $ 1.00 $ 1.00 Dollar

Camp T2036 UC $ 1.00 $ 1.00 Dollar

Disposable T2028 UC $ 1.00 $ 1.00 Dollar


Maximum combined units of Specialized Habilitation, Supported Community Connections and Supported Employment is 7,112 units

per year.

Professional Services

Respite Care

Specialized Medical Equipment and Supplies

Group Respite rates may

not exceed the rate paid

for Individual Respite.

Use Individual Day rate

when Respite services

exceed 40 units (10

hours) in a 24 hour

period.

Version: 2.0

Date: 06/18/2015 17



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

Equipment T2029 UC TF $ 1.00 $ 1.00 Dollar


Group Level 1T2019 UC HQ $ 3.11 $ 3.11 15 Minutes


Group Level 2T2019 UC HI HQ $ 3.40 $ 3.46 15 Minutes


Group Level 3T2019 UC TF HQ $ 3.79 $ 3.85 15 Minutes


Group Level 4T2019 UC TF HI HQ $ 4.38 $ 4.45 15 Minutes


Group Level 5T2019 UC TG HQ $ 5.23 $ 5.23 15 Minutes


Group Level 6T2019 UC TG HI HQ $ 6.82 $ 6.82 15 Minutes


Individual-All LevelsT2019 UC HI $ 12.80 $ 13.02 15 Minutes

Job Development Group-

All LevelsH2023 UC HQ $ 4.08 $ 4.15 15 Minutes


1-2H2023 UC $ 12.80 $ 13.02 15 Minutes


3-4H2023 UC HI $ 12.80 $ 13.02 15 Minutes


5-6H2023 UC TF $ 12.80 $ 13.02 15 Minutes

Job Placement H2024 UC $ 1.00 $ 1.00 Dollar

Job Placement Group H2024 UC HQ $ 1.00 $ 1.00 Dollar



Vehicle Modifications T2039 UC NR* NR* Per Mod

Maximum $10,000.00 for

combination of Assistive

Technology, Vehicle

Modifications and Home

Accessibility Adaptations

combined per waiver

renewal period

(07/01/2014-06/30/2019)

Vision V2799 UC HI $ 1.00 $ 1.00 Dollar

22

HQ

SC

TF


The maximum Supported Employment units per Service Plan year are limited to 7,112 minus the combined total units for Specialized

Habilitation, Supported Community Connections and Prevocational Services, which are limited to a maximum of 4,800 units.



Legend

(CPT Defn: Increased procedural services)

Group Setting

Medically Necessary Service or Supply

Version: 2.0

Date: 06/18/2015 18



Service TypeProc

Code

Mod

#1

Mod

#2

Mod

#3

Mod

#4

Rate

Effective

7/1/2014-

6/30/2015

New Rate

Effective

7/1/2015-

6/30/2016

Unit Value Comments

TG

TT

U8

Complex/High Tech Level of Care

Individualized service provided to more one patient in the same setting

Supported Living Services (HCPCS Defn: Medicaid Level of Care 1, as defined by each state)

Version: 2.0

Date: 06/18/2015 19

updated with fy15-16 jbc increases dd fy 15-16... · rates effective july 1, 2015-june 30, 2016...

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