Skip to main content

Rate Reimbursement Sheet

Rate Reimbursement Sheet

ADvantage Medicaid Waiver Services
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Case Management - Standard 15 minutes $15.29 T1016 - -
Transitional Case Management - Standard 15 minutes 15.29 T1016 U3 -
Case Management - Very Rural 15 minutes 21.89 T1016 TN -
Transitional Case Management – Very Rural 15 minutes 21.89 T1016 TN U3
ADvantage Personal Care 15 minutes  4.21 T1019 - -
Advanced Supportive/Restorative 15 minutes  4.52 T1019 TF -
Registered Nurse (RN only) Skilled Nursing – Home Health Setting 15 minutes 15.60 G0299 - -
Registered Nurse (RN only) Skilled Nursing – Extended State Plan Skilled Nursing 15 minutes 15.60 G0299 TF -
Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) – Home Health Setting 15 minutes 14.56 G0300 - -
Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) - Extended State Plan Skilled Nursing 15 minutes 14.56 G0300 TF -
RN Assessment/Evaluation 15 minutes 15.60 T1002 - -
Occupational Therapy 15 minutes 20.80 G0152 - -
Physical Therapy 15 minutes 20.80 G0151 - -
Speech/Language Therapy 15 minutes 20.80 G0153 - -
Adult Day Health 15 minutes  2.08 S5100 U1 -
Adult Day Health – Personal Care 1 session/day 8.27 S5105 - -
Adult Day Health - Therapy 1 session/day 11.70 S5105 TG -
Adult Day Health – Laundry Service 1 session/day 7.80 S5105 U1 -
Home Delivered Meals 1 meal 5.15 S5170 - -
Respite – Nursing Facility Extended (8+ hours) 1 day As Billed UB120 - -
Respite – In-Home (2-7 hours) 15 minutes  4.21 T1005 - -
Respite – In-Home Extended (8+ hours) 1 day 175.55 S9125 - -
Environmental Modifications As Billed As Billed S5165 - -
Hospice 1 day 123.80 S9126 - -
Specialized Medical Equipment and Supplies As Billed As Prior Authorized various HCPCS - -
Prescriptions (maximum of  7 prescriptions per month) As Ordered 83.00 each W1111 - -
Additional prescriptions available through Sooner Care. For assistance, contact the Sooner Care Helpline at 1-800-987-7767
Assisted Living Services ​ ​ ​ ​ ​ ​ ​ ​ ​
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Standard Care Level Per day $48.99 T2031 - -
Intermediate Care Level Per day $66.11 T2031 TF -
High Care Level Per day $92.47 T2031 TG -
Incontinence Supplies ​ ​ ​ ​ ​
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Adult Small Brief Each $0.78 T4521 - -
Adult Medium Brief Each $0.85 T4522 - -
Adult Large Brief Each $0.96 T4523 - -
Adult Extra Large Brief Each $1.13 T4524 - -
Adult Small Underwear Each $0.86 T4525 - -
Adult Medium Underwear Each $1.01 T4526 - -
Adult Large Underwear Each $1.10 T4527 - -
Adult Extra Large Underwear Each $1.25 T4528 - -
Disposable Guard/Liner Each $0.59 T4535 - -
Any Size Reusable Underpad Each $13.50 T4537 - -
Chair Size Reusable Underpad Each $14.40 T4540 - -
Large Disposable Underpad Each $0.58 T4541 - -
Small Disposable Underpad Each $0.38 T4542 - -
Disposable Incontinence product, brief/diaper, bariatric Each As Billed T4543 - -
Medicaid State Plan Personal Care Program ​ ​ ​ ​ ​ ​
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Prescriptions (maximum of 6 prescriptions per month) As Ordered Avg $83.00 S1111 - -
Personal Care 15 minutes $ 4.21 T1019 - -
Individual Provider Personal Care 15 minutes $ 2.15 T1019 - -
SPPC RN Assessment/EvaluationSkilled Nursing Visit15 minutes $62.40$13.50 T1001S9999 -- --
Medicare
Waiver Services Unit of Service Unit Rate Service Code Modifier 1 Modifier 2
Medicare Part D Prescriptions As Ordered Avg $83.00 each M1111 - -
Back to Top