DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED FEES ...

1 DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . FEE SCHEDULE RATES AND DEPARTMENT - ESTABLISHED fees TABLES: EFFECTIVE JULY 1, 2017 . Enhanced Staffing Procedure Modifier Modifier Statewide Service Name Communication Level Code 1 2 Fee Statewide Fee 1:3 W1724 $ $ Companion 1:2 W1725 $ $ Services 1:1 W1726 $ $ $ 1:1 W7283 N/A. Homemaker/ (per hour). Chore 1:1 $ W7283 UA N/A. (temporary) (per hour). 1:3 W7058 $ $ 1:2 W7059 $ $ 1:1 W7060 $ $ In-Home and Community 1:1 TD and W7061 $ $ Supports enhanced TE. 2:1 W7068 $ $ 2:1 TD and W7069 $ $ enhanced TE. Older Adult Daily Living N/A W7094 $ $ Centers <25%. Community Community 1:2 or 1:3. Participation and W5945 SE $ $ Support (CPS). >75%. Facility 1:11. to 1:15. W5946. <25% SE $ $ Community DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . 1:2 or 1:3. and >75%. Facility 1:7. to 1:10. <25%. Community 1:2 or 1:3.

2 And W5947 SE $ $ >75%. Facility 1:2. to 1:6. <25%. Community 1:1. and W5948 SE $ $ >75%. Facility 1:7. to 1:15. <25%. Community 1:1. and W5950 SE $ $ >75%. Facility 1:2. to 1:6. <25%. Community 1:1. W5951 SE $ $ and >75%. Facility 1:1. <25%. Community TD and 1:1 W5952 SE $ $ TE. Enhanced and DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . >75%. Facility 1:1. Enhanced <25%. Community 2:1. and W5943 SE $ $ >75%. Facility 2:1. to 1:1. <25%. Community 2:1. Enhanced TD and W5944 SE $ $ and TE. >75%. Facility 2:1. Enhanced <25%. Community 2:3. and W5940 SE $ $ >75%. Facility 1:11. to 1:15. <25%. Community 2:3. and W5941 SE $ $ >75%. Facility 1:7. to 1:10. <25%. Community 2:3 W5942 SE $ $ and >75%. DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . Facility 1:2. to 1:6. 25%. Community 1:2 or 1:3. W5958 SE $ $ and 75% Facility 1:11 to 1:15.

3 25%. Community 1:2 or 1:3. W5959 SE $ $ and 75% Facility 1:7 to 1:10. 25%. Community 1:2 or 1:3. W5960 SE $ $ and 75% Facility 1:2 to 1:6. 25%. Community 1:1. W5961 SE $ $ and 75% Facility 1:7 to 1:15. 25%. Community 1:1. W5962 SE $ $ and 75% Facility 1:2 to 1:6. 25%. Community W5963 SE $ $ 1:1. DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . and 75% Facility 1:1. 25%. Community 1:1. Enhanced TD and and W5964 SE $ $ TE. 75% Facility 1:1. Enhanced 25%. Community 2:1. W5956 SE $ $ and 75% Facility 2:1. 25%. Community Community 2:1. Participation Enhanced TD and (continued) W5957 SE $ $ and TE. 75% Facility 2:1. Enhanced 25%. Community 2:3. W5953 SE $ $ and 75% Facility 1:11 to 1:15. 25%. Community 2:3. W5954 SE $ $ and 75% Facility 1:7 to 1:10. DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . 25%. Community 2:3. W5955 SE $ $ and 75% Facility 1:2 to 1:6.

4 50%. Community 1:2 or 1:3. and W5970 SE $ $ 50% Facility 1:11 to 1:15. 50%. Community Community 1:2 or 1:3. Participation(c W5971 SE $ $ ontinued) and 50% Facility 1:7 to 1:10. 50%. Community 1:2 or 1:3. W5972 SE $ $ and 50% Facility 1:2 to 1:6. 50%. Community 1:1. W5973 SE $ $ and 50% Facility Community 1:7 to 1:15. Participation 50%. (continued). Community 1:1. W5974 SE $ $ and 50% Facility 1:2 to 1:6. DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . 50%. Community 1:1. W5975 SE $ $ and 50% Facility 1:1. 50%. Community 1:1 Enhanced TD and W5976 SE $ $ and TE. 50% Facility 1:1 Enhanced 50%. Community 2:1. W5968 SE $ $ and 50% Facility 2:1. 50%. Community 2:1 Enhanced TD and W5969 SE $ $ and TE. 50% Facility 2:1 Enhanced 50%. Community 2:3. W5965 SE $ $ and 50% Facility 1:11 to 1:15. 50%. Community 2:3. W5966 SE $ $ and 50% Facility 1:7 to 1:10. DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED .

5 fees fiscal year 2017 - 2018 . 50%. Community 2:3. W5967 SE $ $ and 50% Facility 1:2 to 1:6. 75%. Community 1:2 or 1:3. W5982 SE $ $ and 25% Facility 1:11 to 1:15. 75%. Community 1:2 or 1:3. W5983 SE $ $ and 25% Facility 1:7 to 1:10. 75%. Community 1:2 or 1:3. W5984 SE $ $ and 25% Facility Community 1:2 to 1:6. Participation (continued) 75%. Community 1:1. W5985 SE $ $ and 25% Facility 1:7 to 1:15. 75%. Community 1:1. W5990 SE $ $ and 25% Facility 1:2 to 1:6. DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . 75%. Community 1:1. W5991 SE $ $ and 25% Facility 1:1. 75%. Community 1:1 Enhanced TD and W5992 SE $ $ and TE. 25% Facility 1:1 Enhanced 75%. Community 2:1. W5980 SE $ $ and 25% Facility 2:1. 75%. Community 2:1 Enhanced TD and W5981 SE $ $ and TE. 25% Facility 2:1 Enhanced 75%. Community 2:3. W5977 SE $ $ and 25% Facility 1:11 to 1:15. 75%. Community 2:3. W5978 SE $ $ and 25% Facility 1:7 to 1:10.

6 DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . 75%. Community 2:3. W5979 SE $ $ and 25% Facility 1:2 to 1:6. 100%. Community W5995 $ $ 1:2 or 1:3. 100%. Community H2015 $ $ Community 2:3. Participation (continued) 100%. Community W5996 $ $ 1:1. 100%. TD and Community W5997 $ $ TE. 1:1 Enhanced 100%. Community W5993 $ $ 2:1. 100%. TD and Community W5994 $ $ TE. 2:1 Enhanced 1:10 to 1:6 W7237 $ $ < 1:6 to 1 W7239 $ $ Small Group Employment < 1 to >. W7241 $ $ 1:1. 1:1 W7245 $ $ Benefits 1:1 W1740 SE $ $ Counseling Supported Employment - 1:1 W7235 $ $ Career Assessment DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . Supported Employment - Job Finding 1:1 H2023 $ $ and Development Supported 1:2 H2025 $ $ Employment - Job Coaching 1:1 W9794 $ $ and Support 1:1. Advanced (Discovery Supported W7235 UD $4, Profile $3, Employment Outcome).

7 Advanced 1:1(Job Supported Acquisition H2023 UD $4, $3, Employment Outcome). Advanced 1:1 ( Job Supported Retention H2025 UD $11, $9, Employment Outcome). Shift Nursing - 1:2 T2025 TD UN $ $ RN 1:1 T2025 TD $ $ Shift Nursing - 1:2 T2025 TE UN $ $ LPN 1:1 T2025 TE $ $ Therapies - 1:1 T2025 GP $ $ Physical Therapies - 1:1 T2025 GO $ $ Occupational Therapies - Speech/Langu 1:1 T2025 GN $ $ age Therapies - Orientation, 1:1 W7246 $ $ Mobility, and Vision Music Therapy 1:1 G0176 SE $ $ DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . Art Therapy 1:1 G0176 $ $ Equine Assisted 1:1 S8940 $ $ Therapy Behavioral Supports - 1:1 W7095 $ $ Level 1. Behavioral Supports - 1:1 W8996 $ $ Level 2. Communicatio 1:1 T1013 $ $ n Specialist Consultative Nutritional 1:1 S9470 SE $ $ Services 1:1 without Family participant 90846 SE $ N/A. Caregiver present Support 1:1 with Counseling participant 90847 SE $ $ present $ 1:4 W9795 $ (per day).

8 (per day). $ 1:3 W9796 $ (per day). 24 Hour (per day). Respite (In- $ Home Respite 1:2 W9797 $ (per day). (per day). and Unlicensed $ 1:1 W9798 $ (per day). Out-of-Home (per day). Respite $ Services ) 1:1 Enhanced W9799 $ (per day). (per day). 2:1 W9800 $ (p $ (per day). er day). DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . $ 2:1 Enhanced W9801 $ (per day). (per day). 1:4 W8096 $ $ 15 Minute 1:3 W9860 $ $ Respite (In-h- Home Respite 1:2 W9861 $ $ and 1:1 W9862 $ $ Unlicensed Out-of-Home 1:1 Enhanced W9863 $ $ Respite Services) 2:1 W9864 $ $ 2:1 Enhanced W8095 $ $ Needs Group $ W9791 U5 $ (per day). 1 - 2 Person (per day). Needs Group $ W9792 U5 $ (per day). 1 - 3 Person (per day). Needs Group $ W9793 U5 $ (per day). 1 - 4 Person (per day). Needs Group $ W9791 U6 $ (per day). 2 - 2 Person (per day). Needs Group $ W9792 U6 $ (per day). 24 Hour 2 - 3 Person (per day). Respite Needs Group $ (Licensed W9793 U6 $ (per day).)

9 2 - 4 Person (per day). Respite Group Homes) Needs Group $ W9790 U7 $ (per day). 3 - 1 Person (per day). Needs Group $ W9791 U7 $ (per day). 3 - 2 Person (per day). Needs Group $ W9792 U7 $ (per day). 3 - 3 Person (per day). Needs Group $ W9793 U7 $ (per day). 3 - 4 Person (per day). Needs Group $ W9790 U8 $1, (per day). 4 - 1 Person (per day). DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . Needs Group $ W9791 U8 $ (per day). 4 - 2 Person (per day). Needs Group $ W9792 U8 $ (per day). 4 - 3 Person (per day). Needs Group $ W9793 U8 $ (per day). 4 - 4 Person (per day). Needs Group W9865 U5 $ (p $ (per day). 1 - 2 Person er day). Needs Group W9866 U5 $ (p $ (per day). 1 - 3 Person er day). Needs Group W9871 U5 $ (p $ (per day). 1 - 4 Person er day). Needs Group W9865 U6 $ (p $ (per day). 2 - 2 Person er day). 24 Hour Needs Group W9866 U6 $ (p $ (per day). Respite 2 - 3 Person er day).

10 (Respite Only Home) Needs Group W9871 U6 $ (p $ (per day). 2 - 4 Person er day). Needs Group W9865 U7 $ (p $ (per day). 3 - 2 Person er day). Needs Group $ (p W9866 U7 $ (per day). 3 - 3 Person er day). Needs Group W9871 U7 $ (p $ (per day). 3 - 4 Person er day). Needs Group W9865 U8 $ (p $ (per day). 4 - 2 Person er day). DRAFT -June 22, 2017 . DRAFT FEE SCHEDULE RATES AND DEPARTMENT ESTABLISHED . fees fiscal year 2017 - 2018 . Needs Group W9866 U8 $ (p $ (per day). 4 - 3 Person er day). Needs Group W9871 U8 $ (p $ (per day). 4 - 4 Person er day). Supports Broker 1:1 W7096 $ $ Services Supports 1:1 W7210 $ $ Coordination Targeted Services 1:1 T1017 $ $ Management Housing Transition and 1:1 H0043 $ $ Tenancy Sustaining Supplemental 1:1 W7070 $ $ Habilitation 2:1 W7084 $ $ Additional 1:1 W7085 $ $ Individualized Staffing (effective July 1, 2017 2:1 W7086 $ $ through December 31, 2017 ). AWC FMS. Monthly Per Person W7319 $ N/A. Administrative Per Month Fee DRAFT -June 22, 2017 .