Appendix I PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE Effective 7/1/18 HOME SUPPORT: AGENCY T2016 AGENCY HOME SUPPORT (Habilitation, residential, waiver) See Appendix II and IIB Per diem** T2016 SC AGENCY HOME SUPPORT (Habilitation, residential, waiver) with Medical Add On See Appendix II and IIB Per diem** HOME SUPPORT: QUARTER HOUR T2017 HOME SUPPORT (Habilitation, residential, waiver) $7.75 ¼ hr T2017 SC HOME SUPPORT (Habilitation, residential, waiver) with Medical Add On $9.27 ¼ hr HOME SUPPORT: REMOTE SUPPORT T2017 QC HOME SUPPORT (Habilitation, residential, waiver)-REMOTE SUPPORT-Monitor Only $2.00 ¼ hr T2017 GT HOME SUPPORT (Habilitation, residential, waiver)-REMOTE SUPPORT-Interactive Support $7.75 ¼ hr HOME SUPPORT: FAMILY CENTERED SUPPORT T2016 U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support -One member served $128.78 Per diem T2016 TG U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support -One member served- increased level of support $268.22 Per diem T2016 UN U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Two members served $106.06 Per diem UN TG U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Two members served- increased level of support $243.27 Per diem T2016 UP U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Three members served $90.44 Per diem UP TG U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Three members served- increased level of support $220.54 Per diem
PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE Effective 7/1/18 T2016 UQ U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Four members served- $76.64 Per diem T2016 UQ TG U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Four members served- increased level of support $200.48 Per diem T2016 UR U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Five or more members served $68.36 Per diem T2016 UR TG U5 HOME SUPPORT (Habilitation, residential, waiver)- Family-Centered Support-Five or more members served- increased of support $188.86 Per diem SHARED LIVING S5140 SHARED LIVING (Foster Care, adult)-Shared Living Model-One member served $156.00 Per diem S5140 TG SHARED LIVING (Foster Care, adult)-Shared Living Model-One member served- increased level of support $226.88 Per diem S5140 UN SHARED LIVING (Foster Care, adult)-Shared Living Model-Two members served $78.02 Per diem S5140 UN TG SHARED LIVING (Foster Care, adult)-Shared Living Model-Two members served- increased level of support $148.87 Per diem H2023 WORK SUPPORT (supported employment)-Individual $8.46 ¼ hr H2023 SC WORK SUPPORT (supported employment)- with Medical Add On $9.89 ¼ hr UN WORK SUPPORT (supported employment)-Group 2 members served up to $4.24 per ¼ hr H2023 UP WORK SUPPORT (supported employment)-Group 3 members served up to $2.82 per ¼ hr H2023 UQ WORK SUPPORT (supported employment)-Group 4 members served up to $2.12 per ¼ hr UR WORK SUPPORT (supported employment)-Group 5 members served up to $1.69 per ¼ hr H2023 US WORK SUPPORT (supported employment)-Group 6 members served up to $1.41 per ¼ hr CAREER PLANNING (Habilitation, prevocational) $34.29 hr
PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE Effective 7/1/18 T2019 EMPLOYMENT SPECIALIST SERVICES (Habilitation, supported employment waiver) $9.09 ¼ hr T2019 SC EMPLOYMENT SPECIALIST SERVICES (Habilitation, supported employment waiver)- with Medical Add-On $10.51 ¼ hr T2021 COMMUNITY SUPPORT (Day habilitation, waiver) $6.53 ¼ hour SC COMMUNITY SUPPORT (Day habilitation, waiver) with Medical Add On $8.05 ¼ hr 97755 ASSISTIVE TECHNOLOGY-ASSESSMENT $14.44 ¼ hr T2035 ASSISTIVE TECHNOLOGY –TRANSMISSION (Utility Services) Up to $50.00 per month. ASSISTIVE TECHNOLOGY –DEVICES (Monitoring feature/device, stand alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified) Per invoice up to $6,000.00 per year SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES Per itemized invoice S5165 CG HOME ACCESSIBILITY ADAPTATIONS (Repairs) Per itemized invoice S5165 HOME ACCESSIBILITY ADAPTATIONS (Home Modifications) Per itemized invoice V5274 COMMUNICATION AIDS - SPEECH AMPLIFIER, AIDS, COMMUNICATORS (INCLUDING REPAIR AND MAINTENANCE), ASSISTIVE DEVICES Per itemized invoice GN COMMUNICATION AIDS - ONGOING VISUAL-GESTURAL AND FACILITATED COMMUNICATIONS SERVICES $5.40 ¼ hr G9007 NON-traditional communication CONSULTATION $9.00 ¼ hr NON-traditional communication assessment $9.00 ¼ hr
THE DEPARTMENT EXPRESSLY DISCLAIMS THE ACCURACY OF THE CALCULATIONS TABULATED IN TABLES 1 & 2 AND EXPRESSLY DISCLAIMS ANY AND ALL LIABILITY FOR LOSSES, INCURRED COSTS, OR OTHER DETRIMENT SUFFERED BY ANY PROVIDER AS A RESULT OF RELIANCE UPON INFORMATION CONTAINED IN Appendix IIA or IIB. Appendix IIA is for members Authorized with Regular service. Appendix IIB is for members authorized with Medical Add On services. MaineCare Member Regular Support Rate up to 168 Hours in excess of 168 Medical Support Rate A B C D E F MaineCare Member Actual Regular Support Hours up to 168 Hours in excess of 168 Actual Medical Support Hours Actual Total Support Hours (sum total of all types of support hours) A B C D E F Actual support hours provided in a week by Type