Rate Reimbursement Sheet

Updated 3/12/24

ADvantage Medicaid Waiver Services
Waiver Services	Unit of Service	Unit Rate	Service Code	Modifier 1	Modifier 2
Case Management - Standard	15 minutes	$19.11	T1016	-	-
Transitional Case Management - Standard	15 minutes	$19.11	T1016	U3	-
Case Management - Very Rural	15 minutes	$27.36	T1016	TN	-
Transitional Case Management – Very Rural	15 minutes	$27.36	T1016	TN	U3
ADvantage Personal Care	15 minutes	$5.26	T1019	-	-
Advanced Supportive/Restorative	15 minutes	$5.65	T1019	TF	-
Registered Nurse (RN only) Skilled Nursing – Home Health Setting	15 minutes	$19.50	G0299	-	-
Registered Nurse (RN only) Skilled Nursing – Extended State Plan Skilled Nursing	15 minutes	$19.50	G0299	TF	-
Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) – Home Health Setting	15 minutes	$18.20	G0300	-	-
Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) - Extended State Plan Skilled Nursing	15 minutes	$18.20	G0300	TF	-
RN Assessment/Evaluation	15 minutes	$19.50	T1002	-	-
Occupational Therapy	15 minutes	$26.00	G0152	-	-
Physical Therapy	15 minutes	$26.00	G0151	-	-
Adult Day Health	15 minutes	$2.60	S5100	U1	-
Adult Day Health – Personal Care	1 session/day	$10.34	S5105	-	-
Adult Day Health - Therapy	1 session/day	$14.63	S5105	TG	-
Adult Day Health – Laundry Service	1 session/day	$9.75	S5175	-	-
Home Delivered Meals	1 meal	$6.44	S5170	-	-
Respite – Nursing Facility Extended (8+ hours)	1 day	As Billed	UB120	-	-
Respite – In-Home (2-7 hours)	15 minutes	$5.26	T1005	-	-
Respite – In-Home Extended (8+ hours)	1 day	$219.44	S9125	-	-
Environmental Modifications	As Billed	As Billed	S5165	-	-
Hospice	1 day	$154.75	S9126	-	-
Specialized Medical Equipment and Supplies	As Billed	As Prior Authorized	various HCPCS	-	-
Assistive Technology	As Billed	As Prior Authorized	Various HCPCS	-	-
Remote Supports - Paid Emergency Supports	15 minutes	$3.28	T1019-TG	-	-
Remote Supports - Unpaid Emergency Supports	15 minutes	$1.81	T1019-U1	-	-
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	$61.24	T2031	-	-
Intermediate Care Level	Per day	$82.64	T2031	TF	-
High Care Level	Per day	$115.59	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	$5.26	T1019		-	-
SPPC Nurse Assessment/Evaluation	Per Visit	$97.50	T1001		--	--

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	-	-