Rate Reimbursement Sheet
Rates Effective 10/1/2024
| ADvantage Medicaid Waiver Services | |||||
|---|---|---|---|---|---|
| Waiver Services | Unit of Service | Unit Rate | Service Code | Modifier 1 | Modifier 2 |
| Case Management - Standard | 15 minutes | $21.02 | T1016 | - | - |
| Transitional Case Management - Standard | 15 minutes | $21.02 | T1016 | U3 | - |
| Case Management - Very Rural | 15 minutes | $30.10 | T1016 | TN | - |
| Transitional Case Management – Very Rural | 15 minutes | $30.10 | T1016 | TN | U3 |
| ADvantage Personal Care | 15 minutes | $6.58 | T1019 | - | - |
| Advanced Supportive/Restorative | 15 minutes | $7.06 | T1019 | TF | - |
| Registered Nurse (RN only) Skilled Nursing – Home Health Setting | 15 minutes | $21.45 | G0299 | - | - |
| Registered Nurse (RN only) Skilled Nursing – Extended State Plan Skilled Nursing | 15 minutes | $21.45 | G0299 | TF | - |
| Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) – Home Health Setting | 15 minutes | $20.02 | G0300 | - | - |
| Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN only) - Extended State Plan Skilled Nursing | 15 minutes | $20.02 | G0300 | TF | - |
| RN Assessment/Evaluation | 15 minutes | $21.45 | T1002 | - | - |
| Occupational Therapy | 15 minutes | $26.00 | G0152 | - | - |
| Physical Therapy | 15 minutes | $26.00 | G0151 | - | - |
| Adult Day Health | 15 minutes | $2.86 | S5100 | U1 | - |
| Adult Day Health – Personal Care | 1 session/day | $11.37 | 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 | $5.79 | T1005 | - | - |
| Respite – In-Home Extended (8+ hours) | 1 day | $241.38 | 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 | $3.61 | T1019-TG | - | - |
| Remote Supports - Unpaid Emergency Supports | 15 minutes | $1.99 | 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 | $6.58 | T1019 | | - | - |
| SPPC Nurse Assessment/Evaluation | Per Visit | $107.25 | 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 | - | - |
