Transcription of Developmental Disabilities Waiver Services & Rates
1 Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate Employment and Day Options Individual Supported Employment H2023 N/A Hour NOVA DARS ROS DARS Group Supported Employment 2 or fewer members per staff H2024 UA Hour NOVA $ ROS $ Group Supported Employment More than 2, up to 4 members per staff H2024 U2 Hour NOVA $ ROS $ Group Supported Employment More than 4 members per staff H2024 U3 Hour NOVA $ ROS $ Workplace Assistance Services H2025 N/A Hour NOVA $ ROS $ community Engagement Tier 1 T2021 N/A Hour NOVA $ ROS $ community Engagement Tier 2 T2021 N/A Hour NOVA $ ROS $ community Engagement Tier 3 T2021 N/A Hour NOVA $ ROS $ community Engagement Tier 4 T2021 N/A Hour NOVA $ ROS $ community Coaching (Code Effective 1/1/2020)
2 T2013 N/A Hour NOVA $ ROS $ Group Day Support Tier 1 97150 N/A Hour NOVA $ ROS $ Group Day Support Tier 2 97150 N/A Hour NOVA $ ROS $ Group Day Support Tier 3 97150 N/A Hour NOVA $ ROS $ Group Day Support Tier 4 97150 N/A Hour NOVA $ ROS $ Peer Mentoring (Effective 7/1/2018) H0038 N/A Hour NOVA $ ROS $ community Guide (Effective 7/1/2018) H2015 N/A Hour NOVA $ ROS $ Personal Care and Related Services Personal Assistance T1019 N/A Hour NOVA $ ROS $ Respite Care T1005 N/A Hour NOVA $ ROS $ Companion Care S5135 N/A Hour NOVA $ ROS $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate CD Personal Assistance S5126 N/A Hour NOVA $ ROS $ CD Respite Care S5150 N/A Hour NOVA $ ROS $ CD Companion Care S5136 N/A Hour NOVA $ ROS $ CD Routine Visit 99509 N/A Hour NOVA $ ROS $ CD Initial Comprehensive Visit H2000 N/A Hour NOVA $ ROS $ CD Employee Management Training / Consumer Training S5109 N/A Hour NOVA $ ROS $ Individual & Family Caregiver Training S5111 N/A **Year NOVA IC ROS IC CD Management Training S5116 N/A Hour NOVA $ ROS $ CD Reassessment Visit T1028 N/A Hour NOVA $ ROS $ Residential Options Independent Living Supports Tier 1 T2032 N/A Month NOVA $1, ROS $1, Independent Living Supports Tier 2-4 T2032 N/A Month NOVA $2, ROS $2.
3 Independent Living Supports- Partial Month Tier 1 T2032 U1 Partial Month NOVA $ ROS $ Independent Living Supports- Partial Month Tier 2-4 T2032 U1 Partial Month NOVA $1, ROS $1, Shared Living T1020 N/A Month NOVA IC ROS IC Shared Living T1020 N/A Partial Month NOVA IC ROS IC Supported Living Residential Tier 1 H0043 N/A 344 billing days Per Diem NOVA $ ROS $ Supported Living Residential Tier 2 H0043 N/A 344 billing days Per Diem NOVA $ ROS $ Supported Living Residential Tier 3 H0043 N/A 344 billing days Per Diem NOVA $ ROS $ Supported Living Residential Tier 4 H0043 N/A 344 billing days Per Diem NOVA $ ROS $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate In-Home Support Services Size 1 H2014 UA Hour NOVA $ ROS $ In-Home Support Services Size 2 H2014 U2 Hour NOVA $ ROS $ In-Home Support Services Size 3 H2014 U3 Hour NOVA $ ROS $ Sponsored Residential Tier 1 (Rate Effective 1/1/17) T2033 N/A 344 billing days Per Diem NOVA $ ROS $ Sponsored Residential Tier 2 (Rate Effective 1/1/17) T2033 N/A 344 billing days Per Diem NOVA $ ROS $ Sponsored Residential Tier 3 (Rate Effective 1/1/17) T2033 N/A 344 billing days Per Diem NOVA $ ROS $ Sponsored Residential Tier 4 (Rate Effective 1/1/17) T2033 N/A 344 billing days Per Diem NOVA $ ROS $ Sponsored Residential (Rate Effective 07/01/2016 thru 12/31/2016) T2033 N/A Hour NOVA $ ROS $ Sponsored Residential- Exceptional Supports (Rate Effective 07/01/2016 thru 12/31/2016)
4 T2033 U1 Hour NOVA $ ROS $ Group Home Residential- Tier 1 4 or fewer person homes H2022 UA 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 4 or fewer person homes H2022 UA 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 4 or fewer person homes H2022 UA 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 4 4 or fewer person homes H2022 UA 344 billing days Per Diem NOVA $ ROS $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate Group Home Residential- Tier 1 5 person homes H2022 U2 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 5 person homes H2022 U2 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 5 person homes H2022 U2 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 4 5 person homes H2022 U2 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 1 6 person homes H2022 U3 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 6 person homes H2022 U3 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 6 person homes H2022 U3 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 4 6 person homes H2022 U3 344 billing days Per Diem NOVA $
5 ROS $ Group Home Residential- Tier 1 7 person homes H2022 U4 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 7 person homes H2022 U4 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 7 person homes H2022 U4 344 billing days Per Diem NOVA $ ROS $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate Group Home Residential- Tier 4 7 person homes H2022 U4 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 1 8 person homes H2022 U5 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 8 person homes H2022 U5 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 8 person homes H2022 U5 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 4 8 person homes H2022 U5 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 1 9 person homes H2022 U6 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 9 person homes H2022 U6 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 9 person homes H2022 U6 344 billing days Per Diem NOVA $
6 ROS $ Group Home Residential- Tier 4 9 person homes H2022 U6 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 1 10 person homes H2022 U7 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 10 person homes H2022 U7 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 10 person homes H2022 U7 344 billing days Per Diem NOVA $ ROS $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate Group Home Residential- Tier 4 10 person homes H2022 U7 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 1 11 person homes H2022 U8 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 11 person homes H2022 U8 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 11 person homes H2022 U8 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 4 11 person homes H2022 U8 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 1 12 person homes H2022 U9 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 2 12 person homes H2022 U9 344 billing days Per Diem NOVA $ ROS $ Group Home Residential- Tier 3 12 person homes H2022 U9 344 billing days Per Diem
7 NOVA $ ROS $ Group Home Residential- Tier 4 12 person homes H2022 U9 344 billing days Per Diem NOVA $ ROS $ Crisis Support Options community -Based Crisis Supports (professional) (Code effective 7/1/2021) S9484 U1 Hour NOVA $ ROS $ community -Based Crisis Supports (non-professional) (Code effective 7/1/2021) S9484 N/A Hour NOVA $ ROS $ Center-Based Crisis Supports (professional) H2011 U1 Hour NOVA $ ROS $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver ; CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate Center-Based Crisis Supports (non-professional) H2011 UA Hour NOVA $ ROS $ Crisis Support Services (professional) T2034 U1 Hour NOVA $ ROS $ Crisis Support Services (non-professional) T2034 N/A Hour NOVA $ ROS $ Medical and Behavioral Support Options Skilled Nursing , RN S9123 N/A 15 minutes NOVA $ ROS $ Skilled Nursing, LPN S9124 N/A 15 minutes NOVA $ ROS $ Private Duty Nursing, RN T1002 N/A 15 minutes NOVA $ ROS $ Private Duty Nursing, LPN T1003 N/A 15 minutes NOVA $ ROS $ Therapeutic Consultation, Therapist/Behavior Analysts/Rehab.
8 Engineers 97139 N/A Hour NOVA $ ROS $ Therapeutic Consultation, Psychologist/Psychiatrist H2017 N/A Hour NOVA $ ROS $ Therapeutic Consultation, Other Professionals 97530 N/A Hour NOVA $ ROS $ RN/ Personal Emergency Response System (PERS) H2021 TD 30 minutes NOVA $ ROS $ LPN/ Personal Emergency Response System (PERS) H2021 TE 30 minutes NOVA $ ROS $ PERS Installation S5160 N/A One-time Purchase NOVA $ ROS $ PERS Installation and Medication Monitoring S5160 U1 One-time Purchase NOVA $ ROS $ PERS Monitoring S5161 N/A Month NOVA $ ROS $ PERS Medication Monitoring S5185 N/A Month NOVA $ ROS $ Employment & community Transportation Options Trips Under 10 Miles A0090 N/A NOVA $ Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver .
9 CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate (one way) - 1 Passenger Miles per passenger ROS $ Trips Under 10 Miles (one way) - 2 Passengers A0090 N/A Miles per passenger NOVA $ ROS $ Trips Under 10 Miles (one way) - 3 Passengers A0090 N/A Miles per passenger NOVA $ ROS $ Trips of 10 to 20 Miles (one way) - 1 Passenger A0090 N/A Miles per passenger NOVA $ ROS $ Trips of 10 to 20 Miles (one way) - 2 Passengers A0090 N/A Miles per passenger NOVA $ ROS $ Trips of 10 to 20 Miles (one way) - 3 Passengers A0090 N/A Miles per passenger NOVA $ ROS $ Trips Over 20 Miles (one way) - 1 Passenger A0090 N/A Miles per passenger NOVA $ ROS $ Trips Over 20 Miles (one way) - 2 Passengers A0090 N/A Miles per passenger NOVA $ ROS $ Trips Over 20 Miles (one way) - 3 Passengers A0090 N/A Miles per passenger NOVA $ ROS $ Public Transit: Non-Emergency Transportation & Bus A0110 N/A Per Trip Statewide $ Public Transit: Para-Transit A0120 N/A Per Trip Statewide $ Additional Options Assistive Technology Only T1999 N/A *Per Item NOVA IC ROS IC Assistive Technology Maintenance Cost Only T1999 U5 *Per Item NOVA IC ROS IC Electronic-Based Home Supports A9279 N/A *Per Item NOVA IC ROS IC Environmental Modifications Only S5165 N/A *Per Item NOVA IC ROS IC Environmental Modifications, Maintenance Costs Only 99199 U4 *Per Item NOVA IC ROS IC Transition Services T2038 N/A **Per Item NOVA IC ROS IC Developmental Disabilities Waiver Services & Rates Rates Effective 07/01/2021 BI= Building Independence Waiver ; FIS= Family & Individual Support Waiver .
10 CL= community Living Waiver Service Name National Code BI FIS CL Modifier Units Location Rate Benefits Planning (9/1/2018) T1023 NA Hour NOVA $ ROS $ * Individual Consideration (IC) will be based on approved cost up to $5,000 per year consistent with the service authorization. The total authorized amount can be used on one single item or multiple items during the year. ** Individual Consideration (IC) will be based on approved cost up to $5,000 consistent with the service authorization and is considered a lifetime limit. ** Individual Consideration (IC) will be based on approved cost up to $4,000 per ISP year. Change Log: Description Effective Date Date Entered community -Based Crisis Supports (H0040) will move to procedure code S9484 for dates of service on or after July 1, 2021 7/1/2021 6/29/2021 Updated Rates for Independent Living Supports, Supported Living, In-home Support Services , Group Supported Employment, Workplace Assistance, community Engagement, community Coaching, and Therapeutic Consultation.
