Minnesota Department of human services
Continuing Care Service Rate Limits Effective July 1, 2014
Alternative Care (AC)
2
Brain Injury Waiver (BI)
6
Community Alternative Care Waiver (CAC)
13
Community Alternatives for Disabled Individuals Waiver (CADI)
19
Developmental Disabilities Waiver (DD)
25
Elderly Waiver (EW)
30
Program Annual Income Limits: Family Support Grant (FSG)
35
Home Care (HC)
36
Moving Home Minnesota (MHM)
38
Monthly Budget Limits by Need: Consumer Support Grant (CSG)
41
Monthly Budget Limits by Home Care Rating: Consumer Support Grant (CSG): Private Duty Nursing (PDN) and Vent Dependent
42
Monthly Budget Limits by Home Care Rating: Private Duty Nursing (PDN) and Vent Dependent
43
Alternative Care (AC) and Elderly Waiver (EW) Program Budgets by Case Mix: CDCS Sevice
44
Alternative Care (AC) and Elderly Waiver (EW) Program Monthly Budget Caps by Case Mix
45
Elderly Waiver (EW) Program Service Rate Limits by Case Mix: 24-Hour Customized Living (24CL)
46
Elderly Waiver (EW) Program Service Rate Limits: 24-Hour Customized Living (24CL) Component Rates
46
Elderly Waiver (EW) Program Service Rate Limits by Case Mix: Customized Living (T2030) and Residential Care (T2032)
47
Personal Care Assistance (PCA) Authorization
49
Links:
Community-Based Services Manual
Disability Waivers Rate System
Minnesota Department of Human Services Continuing Care Administration
Report run: 9/15/2014
Page 1 of 49
Alternative Care (AC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Adult Day Service
service unit
Adult Day Service
service unit
Adult Day Service - FADS
service unit
Adult Day Service - FADS
service unit
Adult Day Service Bath
service unit
Case Management
service unit
Case Management - Conversion
service unit
Case Management Aide (Paraprofessional)
service unit
CDCS Background Check
service unit
CDCS Mandatory Case Management
service unit
Chore Services
service unit
Companion Services
service unit
Consumer Directed Community Supports (CDCS)
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Daily
15 Minutes
Daily
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Per Print
15 Minutes
15 Minutes
15 Minutes
Per Month
Discretionary Services Option
Procedure Code
and Modifiers
S5100
S5102
S5100
U7
S5102
U7
S5100
TF
T1016
UC
T1016
T1016
TF
UC
T2040
T2041
S5120
S5135
T2028
service name
Environmental Accessibility Adaptations / Home
Assessment
service name
X5527
Per Assessment
service unit
Minnesota Department of Human Services Continuing Care Administration
T1028
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$3.18
$3.34
$42.58
$44.71
$3.18
$3.34
$42.58
$44.71
$7.12
$7.48
$24.01
$25.21
$24.01
$25.21
$8.86
$9.30
$25.00
$25.00
Up to the Required Case
Management cap amount
Up to the Required Case
Management cap amount
$3.54
$3.72
$2.05
$2.15
Up to the CDCS case mix
cap amount
Up to the CDCS case mix
cap amount
Limited to 25% of the
county's base allocation
amount
Limited to 25% of the
county's base allocation
amount
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
Page 2 of 49
Alternative Care (AC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Environmental Accessibility Adaptations / Home Install
service unit
Environmental Accessibility Adaptations / Vehicle
Assessment
service unit
Environmental Accessibility Adaptations / Vehicle
Install
service unit
Family Caregiver Coaching and Counseling (including
assessment)
service unit
Family Caregiver Training and Education
service unit
Home Delivered Meals
service unit
Home Health Aide
service unit
Home Health Aide
service unit
Home Health Service - Skilled Nursing
service unit
Home Health Service - Skilled Nursing
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Per Waiver Year
Per Assessment
Per Waiver Year
15 Minutes
15 Minutes
One meal Per
Day
15 Minutes
Visit
15 Minutes
Visit
Home Health Service - Telehomecare
Procedure Code
and Modifiers
S5165
T2039
UD
T2039
S5115
TF
S5115
S5170
T1004
T1021
G0154
T1030
service name
Homemaker / Assistance with Personal Cares
service unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Cleaning
service unit
service name
service name
service name
service name
15 Minutes
Daily
15 Minutes
Daily
Minnesota Department of Human Services Continuing Care Administration
T1030
GT
S5130
TG
S5131
TG
S5130
S5131
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
$17.08
$17.93
$17.08
$17.93
$6.16
$6.47
$7.55
$7.93
$54.29
$57.00
$8.62
$9.05
$70.74
$74.28
$70.74
$74.28
$4.34
$4.56
$41.99
$44.09
$4.34
$4.56
$41.99
$44.09
Page 3 of 49
Alternative Care (AC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Homemaker Services / Home Management
service unit
Homemaker Services / Home Management
service unit
Nutrition Services
service unit
PERS Installation and Testing
service unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
Personal Care Assistance (PCA) - 1:1 Ratio
service unit
Personal Care Assistance (PCA) - 1:2 Ratio
service unit
Personal Care Assistance (PCA) - 1:3 Ratio
service unit
Personal Care Assistance (PCA) - RN supervision
service unit
Private Duty Nursing-LPN
service unit
Private Duty Nursing-LPN Complex
service unit
Private Duty Nursing-LPN Shared 1:2 Ratio
service unit
Private Duty Nursing-RN
service unit
Private Duty Nursing-RN Complex
service unit
Private Duty Nursing-RN Shared 1:2 Ratio
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Daily
Visit
Each Time
Per Month
Each Time
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
S5130
TF
S5131
TF
S9470
S5160
S5161
S5162
T1019
T1019
TT
T1019
HQ
T1019
UA
T1003
T1003
TG
T1003
TT
T1002
T1002
TG
T1002
TT
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$4.34
$4.56
$41.99
$44.09
$76.03
$79.83
$500.00
$500.00
$110.00
$110.00
$1,500.00
$1,500.00
$3.96
$4.16
$2.97
$3.12
$2.61
$2.74
$6.96
$7.31
$6.30
$6.62
$7.39
$7.76
$4.73
$4.97
$8.21
$8.62
$9.85
$10.34
$6.16
$6.47
Page 4 of 49
Alternative Care (AC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
Respite Care Services, out of Home
service unit
Respite Certified Facility
service unit
Respite Hospital, 24 hours
service unit
Specialized Supplies & Equipment
service unit
Transportation
service unit
Transportation, Mileage (Commercial Vehicle)
service unit
Transportation, Mileage (Non-commercial Vehicle)
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Daily
15 Minutes
Daily
Daily
Daily
Per Item
One Way Trip
Per Mile
Per Mile
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
S5150
S5151
S5150
UB
H0045
H0045
H0045
E1399
T2003
S0215
UC
S0215
UC
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$5.11
$5.37
$92.06
$96.66
$5.11
$5.37
$92.06
$96.66
NF's per diem for the client's
case mix
NF's per diem for the client's
case mix
$139.42
$146.39
$0.00
$0.00
$19.06
$20.01
$1.48
$1.55
$0.56
$0.56
Page 5 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
24-Hour Customized Living Services
service unit
24-Hour Customized Living, Corporate Foster Care
service unit
24-Hour Emergency Assistance
service unit
24-Hour Emergency Assistance
service unit
Adult Companion
service unit
Adult Day Care
service unit
Adult Day Care
service unit
Adult Day Care - FADS
service unit
Adult Day Care - FADS
service unit
Adult Day Care Bath
service unit
Behavior Support by Analyst
service unit
Behavior Support by Professional
service unit
Behavior Support by Specialist
service unit
Caregiver Living Expenses
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Daily
Daily
15 Minutes
Daily
15 Minutes
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
H2011
Maximum Rate Not
Published
Maximum Rate Not
Published
T2034
Maximum Rate Not
Published
Maximum Rate Not
Published
S5135
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
Maximum Rate Not
Published
Maximum Rate Not
Published
T2031
TG
T2031
TG
U9
S5100
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
H0025
H0025
TG
Maximum Rate Not
Published
Maximum Rate Not
Published
H0025
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
S5126
Report run: 9/15/2014
Page 6 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Case Management
service unit
Case Management Aide (Paraprofessional)
service unit
CDCS Background Check
service unit
Certified Peer Specialist (CPS) - Group Setting, MHM
only
service unit
Certified Peer Specialist (CPS) - Level I, MHM only
service unit
Certified Peer Specialist (CPS) - Level II, MHM only
service unit
Chore Services
service unit
Comprehensive Community Support Services, MHM
only
service unit
Consumer Directed Community Supports (CDCS)
service unit
Customized Living Services
service unit
Environmental Accessibility Adaptations / Home
Assessment
service unit
Environmental Accessibility Adaptations / Home Install
service unit
Environmental Accessibility Adaptations / Vehicle
Assessment
service unit
Environmental Accessibility Adaptations / Vehicle
Install
service unit
Family Counseling
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
Per Print
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Decremental
Daily
Per Assessment
Per Waiver Year
Per Assessment
Per Waiver Year
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$23.08
$24.23
$8.86
$9.30
$25.00
$25.00
$5.81
$6.10
$11.55
$12.13
$13.21
$13.87
$3.54
$3.72
$8.23
$8.64
Individual Budget
Individual Budget
T2031
Maximum Rate Not
Published
Maximum Rate Not
Published
T1028
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
S5165
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
T2039
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
H0004
Maximum Rate Not
Published
Maximum Rate Not
Published
T1016
UC
T1016
TF
UC
T2040
H0038
U6
H0038
U6
H0038
U6
HQ
U5
S5120
H2015
U6
T2028
T2039
UD
Report run: 9/15/2014
Page 7 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Family Memory Care Intervention, MHM only
service unit
Family Training
service unit
Foster Care, Adult Family
service unit
Foster Care, Adult, Corporate
service unit
Foster Care, Child Corporate
service unit
Home Delivered Meals
service unit
Home Health Aide, Extended
service unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Home Management
service unit
Housing Access Coordination
service unit
Independent Living Skills Training 1:1
service unit
Independent Living Skills Training 1:2
service unit
Independent Living Skills, Group Therapy
service unit
Independent Living Skills, Individual Therapy
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
Daily
Daily
Daily
Per Meal
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$17.08
$17.93
S5110
Maximum Rate Not
Published
Maximum Rate Not
Published
S5140
Maximum Rate Not
Published
Maximum Rate Not
Published
S5115
U6
S5140
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
S5145
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
$6.16
$6.47
$5.18
$5.44
$4.34
$4.56
$4.34
$4.56
$4.34
$4.56
Maximum Rate Not
Published
Maximum Rate Not
Published
S5170
T1004
S5130
TG
S5130
S5130
TF
H2015
H2032
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
H2032
TT
Maximum Rate Not
Published
Maximum Rate Not
Published
H2032
HQ
Maximum Rate Not
Published
Maximum Rate Not
Published
H2032
TG
Maximum Rate Not
Published
Maximum Rate Not
Published
Report run: 9/15/2014
Page 8 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
LPN/LVN - Complex, Extended
service unit
LPN/LVN - Regular, Extended
service unit
LPN/LVN - Shared 1:2 Ratio, Extended
service unit
Membership Fees (exercise classes, health
club/fitness center), MHM only
service unit
service name
service name
service name
service name
15 Minutes
15 Minutes
15 Minutes
Actual Costs /
Year
MSHO/MSC+ Home Care Services
Procedure Code
and Modifiers
T1003
TG
UC
T1003
UC
T1003
TT
UC
S9970
U6
U5
service name
X5609
Night Supervision
service unit
Occupational Therapy Assistant, Extended
service unit
Occupational Therapy, Extended
service unit
Overnight Assistance, MHM Only
service unit
PERS Installation and Testing
service unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
Personal Care Assistance (PCA) - 1:1 Ratio, Extended
service unit
Personal Care Assistance (PCA) - Shared 1:2 Ratio,
Extended
service unit
Personal Care Assistance (PCA) - Shared 1:3 Ratio,
Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Visit
Visit
15 Minutes
Each Time
Per Month
Each Time
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
S5135
UA
S9129
TF
S9129
UC
S5135
U6
UC
UA
S5160
S5161
S5162
T1019
UC
T1019
TT
UC
T1019
HQ
UC
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$7.39
$7.76
$6.30
$6.62
$4.73
$4.97
$800.00
$800.00
PCA, HHA, SN, PDN
provided by health plan
PCA, HHA, SN, PDN
provided by health plan
Maximum Rate Not
Published
Maximum Rate Not
Published
$44.03
$46.22
$67.72
$71.11
$2.05
$2.15
$500.00
$500.00
$110.00
$110.00
$1,500.00
$1,500.00
$3.96
$4.16
$2.97
$3.12
$2.61
$2.74
Page 9 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Physical Therapy Assistant, Extended
service unit
Physical Therapy, Extended
service unit
Post-Discharge Case Consultation and Collaboration,
MHM only
service unit
Prevocational Services
service unit
Prevocational Services
service unit
Psychoeducation Services, MHM only
service unit
Residential Care Services
service unit
Respiratory Therapy, Extended
service unit
Respite Care Services with Room and Board
service unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
RN - Complex, Extended
service unit
RN - Regular, Extended
service unit
RN - Shared 1:2 Ratio, Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Visit
Visit
Per hour
Daily (6 or more
hours / day)
Per hour
15 Minutes
Daily
Visit
Daily (10 or more
hours / day)
15 Minutes
Daily (10 or more
hours / day)
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$43.14
$45.30
$66.37
$69.69
$137.19
$144.05
T2014
Maximum Rate Not
Published
Maximum Rate Not
Published
T2015
Maximum Rate Not
Published
Maximum Rate Not
Published
$34.30
$36.02
Maximum Rate Not
Published
Maximum Rate Not
Published
$46.90
$49.25
H0045
Maximum Rate Not
Published
Maximum Rate Not
Published
S5150
Maximum Rate Not
Published
Maximum Rate Not
Published
S5151
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
$9.85
$10.34
$8.21
$8.62
$6.16
$6.47
S9131
UC
S9131
UC
T2013
U6
H2027
TF
U6
T2033
S5181
UC
S5150
UB
T1002
TG
T1002
UC
T1002
TT
UC
UC
Report run: 9/15/2014
Page 10 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
SNBC Services
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
HHA and SN provided by
health plan
HHA and SN provided by
health plan
$3,909.00
$3,909.00
$67.38
$70.75
T2021
Maximum Rate Not
Published
Maximum Rate Not
Published
T2020
Maximum Rate Not
Published
Maximum Rate Not
Published
T2019
Maximum Rate Not
Published
Maximum Rate Not
Published
service name
X5609
Specialized Supplies & Equipment
service unit
Speech Therapy, Extended
service unit
Structured Day Program
service unit
Structured Day Program
service unit
Supported Employment 1:1
service unit
Supported Employment 1:2
service unit
Supported Employment 1:3
service unit
Supported Employment Benchmark Incentive
Payment, MHM only
service unit
Supported Employment Services, MHM only
service unit
Transitional Services
service unit
Transitional Services- Furniture
service unit
Transitional Services- Household Supplies
service unit
Transportation, Mileage (Commercial Vehicle)
service unit
Transportation, Mileage (Non-commercial Vehicle)
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Per Year
Visit
15 Minutes
Daily
15 Minutes
15 Minutes
15 Minutes
Daily
15 Minutes
Decremental
Decremental
Decremental
Per Mile
Per Mile
Minnesota Department of Human Services Continuing Care Administration
T2029
S9128
UC
T2019
TT
Maximum Rate Not
Published
Maximum Rate Not
Published
T2019
HQ
Maximum Rate Not
Published
Maximum Rate Not
Published
T2018
U6
$760.00
$760.00
T2019
U6
$9.48
$9.95
$3,000.00
$3,000.00
$1,000.00
$1,000.00
$300.00
$300.00
$1.48
$1.55
$0.56
$0.56
T2038
T2038
U1
T2038
U2
S0215
UC
S0215
UC
Report run: 9/15/2014
Page 11 of 49
Brain Injury (BI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Transportation, Extra Attendant
service unit
Transportation, One Way Trip
service unit
Youth Assertive Community Treatment, MHM only
service unit
service name
service name
service name
Extra Attendant
One Way Trip
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T2001
UC
T2003
UC
H0040
U6
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
Maximum Rate Not
Published
Maximum Rate Not
Published
$19.06
$20.01
$151.17
$158.73
Page 12 of 49
Community Alternative Care (CAC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
24-Hour Emergency Assistance
service unit
24-Hour Emergency Assistance
service unit
Adult Day Care - FADS
service unit
Adult Day Care - FADS
service unit
Behavior Support by Analyst
service unit
Behavior Support by Professional
service unit
Behavior Support by Specialist
service unit
Caregiver Living Expenses
service unit
Case Management
service unit
Case Management Aide (Paraprofessional)
service unit
CDCS Background Check
service unit
Certified Peer Specialist (CPS) - Group Specialist,
MHM only
service unit
Certified Peer Specialist (CPS) - Level I, MHM only
service unit
Certified Peer Specialist (CPS) - Level II, MHM only
service unit
Chore Services
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Daily
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
15 Minutes
15 Minutes
Daily
15 Minutes
15 Minutes
Per Print
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
H2011
Maximum Rate Not
Published
T2034
Maximum Rate Not
Published
S5100
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
H0025
H0025
TG
Maximum Rate Not
Published
H0025
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
S5126
T1016
UC
T1016
TF
UC
T2040
H0038
U6
H0038
U6
H0038
U6
HQ
U5
S5120
Report run: 9/15/2014
$23.08
$24.23
$8.86
$9.30
$25.00
$25.00
$5.81
$6.10
$11.55
$12.13
$13.21
$13.87
$3.72
Page 13 of 49
Community Alternative Care (CAC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Comprehensive Community Support Services, MHM
only
service unit
Consumer Directed Community Supports (CDCS)
service unit
Environmental Accessibility Adaptations / Home
Assessment
service unit
Environmental Accessibility Adaptations / Home Install
service unit
Environmental Accessibility Adaptations / Vehicle
Assessment
service unit
Environmental Accessibility Adaptations / Vehicle
Install
service unit
Family Counseling
service unit
Family Memory Care Intervention, MHM only
service unit
Family Training
service unit
Foster Care, Adult Family
service unit
Foster Care, Adult, Corporate
service unit
Foster Care, Child Corporate
service unit
Home Delivered Meals
service unit
Home Health Aide, Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Decremental
Per Assessment
Per Waiver Year
Per Assessment
Per Waiver Year
15 Minutes
15 Minutes
15 Minutes
Daily
Daily
Daily
Per Meal
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$8.23
$8.64
Individual Budget
Individual Budget
T1028
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
S5165
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
T2039
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
H0004
Maximum Rate Not
Published
Maximum Rate Not
Published
$17.08
$17.93
S5110
Maximum Rate Not
Published
Maximum Rate Not
Published
S5140
Maximum Rate Not
Published
Maximum Rate Not
Published
H2015
U6
T2028
T2039
S5115
UD
U6
S5140
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
S5145
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
$6.16
$6.47
$5.18
$5.44
S5170
T1004
Report run: 9/15/2014
Page 14 of 49
Community Alternative Care (CAC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Home Management
service unit
Housing Access Coordination
service unit
Independent Living Skills Training 1:1
service unit
Independent Living Skills Training 1:2
service unit
LPN/LVN - Complex, Extended
service unit
LPN/LVN - Regular, Extended
service unit
LPN/LVN - Shared 1:2 Ratio, Extended
service unit
Membership Fees (exercise classes, health
club/fitness center), MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Actual Costs /
Year
MSHO/MSC+ Home Care Services
Procedure Code
and Modifiers
S5130
TG
S5130
S5130
TF
service unit
Occupational Therapy, Extended
service unit
Overnight Assistance, MHM Only
service unit
PERS Installation and Testing
service unit
service name
service name
service name
Visit
Visit
15 Minutes
Each Time
Minnesota Department of Human Services Continuing Care Administration
$4.34
$4.56
$4.34
$4.56
$4.34
$4.56
Maximum Rate Not
Published
H2032
TF
Maximum Rate Not
Published
H2032
TT
Maximum Rate Not
Published
T1003
TG
T1003
UC
T1003
TT
UC
S9970
U6
U5
UC
X5609
Occupational Therapy Assistant, Extended
Rate 7/1/14
H2015
service name
service name
Rate 4/1/14
S9129
TF
S9129
UC
S5135
U6
UC
UA
S5160
Report run: 9/15/2014
$7.39
$7.76
$6.30
$6.62
$4.73
$4.97
$800.00
$800.00
PCA, HHA, SN, PDN
provided by health plan
PCA, HHA, SN, PDN
provided by health plan
$44.03
$46.22
$67.72
$71.11
$2.05
$2.15
$500.00
$500.00
Page 15 of 49
Community Alternative Care (CAC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
Personal Care Assistance (PCA) - 1:1 Ratio, Extended
service unit
Personal Care Assistance (PCA) - Shared 1:2 Ratio,
Extended
service unit
Personal Care Assistance (PCA) - Shared 1:3 Ratio,
Extended
service unit
Physical Therapy Assistant, Extended
service unit
Physical Therapy, Extended
service unit
Post-Discharge Case Consultation and Collaboration,
MHM only
service unit
Psychoeducation Services, MHM only
service unit
Respiratory Therapy, Extended
service unit
Respite Care Services with Room and Board
service unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
RN - Complex, Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Per Month
Each Time
15 Minutes
15 Minutes
15 Minutes
Visit
Visit
Per hour
15 Minutes
Visit
Daily (10 or more
hours / day)
15 Minutes
Daily (10 or more
hours / day)
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$110.00
$110.00
$1,500.00
$1,500.00
$3.96
$4.16
$2.97
$3.12
$2.61
$2.74
$43.14
$45.30
$66.37
$69.69
$137.19
$144.05
$34.30
$36.02
$46.90
$49.25
H0045
Maximum Rate Not
Published
Maximum Rate Not
Published
S5150
Maximum Rate Not
Published
Maximum Rate Not
Published
S5151
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
$9.85
$10.34
S5161
S5162
T1019
UC
T1019
TT
UC
T1019
HQ
UC
S9131
UC
TF
S9131
UC
T2013
U6
H2027
U6
S5181
UC
S5150
UB
T1002
TG
UC
Report run: 9/15/2014
Page 16 of 49
Community Alternative Care (CAC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
RN - Regular, Extended
service unit
RN - Shared 1:2 Ratio, Extended
service unit
service name
service name
15 Minutes
15 Minutes
SNBC Services
Procedure Code
and Modifiers
T1002
UC
T1002
TT
UC
service name
X5609
Specialized Supplies & Equipment
service unit
Speech Therapy, Extended
service unit
Supported Employment 1:1
service unit
Supported Employment 1:2
service unit
Supported Employment 1:3
service unit
Supported Employment Benchmark Incentive
Payment, MHM only
service unit
Supported Employment Services, MHM only
service unit
Transitional Services
service unit
Transitional Services- Furniture
service unit
Transitional Services- Household Supplies
service unit
Transportation, Mileage (Commercial Vehicle)
service unit
Transportation, Mileage (Non-commercial Vehicle)
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Per Year
Visit
15 Minutes
15 Minutes
15 Minutes
Daily
15 Minutes
Decremental
Decremental
Decremental
Per Mile
Per Mile
Minnesota Department of Human Services Continuing Care Administration
T2029
S9128
UC
Rate 4/1/14
Rate 7/1/14
$8.21
$8.62
$6.16
$6.47
HHA and SN provided by
health plan
HHA and SN provided by
health plan
$3,909.00
$3,909.00
$67.38
$70.75
Maximum Rate Not
Published
T2019
T2019
TT
Maximum Rate Not
Published
T2019
HQ
Maximum Rate Not
Published
T2018
U6
T2019
U6
T2038
T2038
U1
T2038
U2
S0215
UC
S0215
UC
Report run: 9/15/2014
$760.00
$760.00
$9.48
$9.95
$3,000.00
$3,000.00
$1,000.00
$1,000.00
$300.00
$300.00
$1.48
$1.55
$0.56
$0.56
Page 17 of 49
Community Alternative Care (CAC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Transportation, Extra Attendant
service unit
Transportation, One Way Trip
service unit
Youth Assertive Community Treatment, MHM only
service unit
service name
service name
service name
Extra Attendant
One Way Trip
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T2001
UC
T2003
UC
H0040
U6
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
Maximum Rate Not
Published
Maximum Rate Not
Published
$19.06
$20.01
$151.17
$158.73
Page 18 of 49
Community Alternatives for Disabled Individuals (CADI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
24-Hour Customized Living Services
service unit
24-Hour Customized Living, Corporate Foster Care
service unit
24-Hour Emergency Assistance
service unit
24-Hour Emergency Assistance
service unit
Adult Companion
service unit
Adult Day Care
service unit
Adult Day Care
service unit
Adult Day Care - FADS
service unit
Adult Day Care - FADS
service unit
Adult Day Care Bath
service unit
Behavior Support by Analyst
service unit
Behavior Support by Professional
service unit
Behavior Support by Specialist
service unit
Caregiver Living Expenses
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Daily
Daily
15 Minutes
Daily
15 Minutes
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
H2011
Maximum Rate Not
Published
Maximum Rate Not
Published
T2034
Maximum Rate Not
Published
Maximum Rate Not
Published
S5135
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
Maximum Rate Not
Published
Maximum Rate Not
Published
T2031
TG
T2031
TG
U9
S5100
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
H0025
H0025
TG
Maximum Rate Not
Published
Maximum Rate Not
Published
H0025
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
S5126
Report run: 9/15/2014
Page 19 of 49
Community Alternatives for Disabled Individuals (CADI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Case Management
service unit
Case Management Aide (Paraprofessional)
service unit
CDCS Background Check
service unit
Certified Peer Specialist (CPS) - Group Specialist,
MHM only
service unit
Certified Peer Specialist (CPS) - Level I, MHM only
service unit
Certified Peer Specialist (CPS) - Level II, MHM only
service unit
Chore Services
service unit
Comprehensive Community Support Services, MHM
only
service unit
Consumer Directed Community Supports (CDCS)
service unit
Customized Living Services
service unit
Environmental Accessibility Adaptations / Home
Assessment
service unit
Environmental Accessibility Adaptations / Home Install
service unit
Environmental Accessibility Adaptations / Vehicle
Assessment
service unit
Environmental Accessibility Adaptations / Vehicle
Install
service unit
Family Counseling
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
Per Print
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Per Month
Daily
Per Assessment
Per Waiver Year
Per Assessment
Per Waiver Year
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$23.08
$24.23
$8.86
$9.30
$25.00
$25.00
$5.81
$6.10
$11.55
$12.13
$13.21
$13.87
$3.54
$3.72
$8.23
$8.64
Individual Budget
Individual Budget
T2031
Maximum Rate Not
Published
Maximum Rate Not
Published
T1028
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
S5165
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
T2039
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
H0004
Maximum Rate Not
Published
Maximum Rate Not
Published
T1016
UC
T1016
TF
UC
T2040
H0038
U6
H0038
U6
H0038
U6
HQ
U5
S5120
H2015
U6
T2028
T2039
UD
Report run: 9/15/2014
Page 20 of 49
Community Alternatives for Disabled Individuals (CADI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Family Memory Care Intervention, MHM only
service unit
Family Training
service unit
Foster Care, Adult Family
service unit
Foster Care, Adult, Corporate
service unit
Foster Care, Child Corporate
service unit
Home Delivered Meals
service unit
Home Health Aide, Extended
service unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Home Management
service unit
Housing Access Coordination
service unit
Independent Living Skills Training 1:1
service unit
Independent Living Skills Training 1:2
service unit
LPN/LVN - Complex, Extended
service unit
LPN/LVN - Regular, Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
Daily
Daily
Daily
Per Meal
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$17.08
$17.93
S5110
Maximum Rate Not
Published
Maximum Rate Not
Published
S5140
Maximum Rate Not
Published
Maximum Rate Not
Published
S5115
U6
S5140
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
S5145
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
$6.16
$6.47
$5.18
$5.44
$4.34
$4.56
$4.34
$4.56
$4.34
$4.56
S5170
T1004
S5130
TG
S5130
S5130
TF
H2015
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
H2032
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
H2032
TT
T1003
TG
T1003
UC
procedure code and modifiers
Maximum Rate Not
Published
UC
Report run: 9/15/2014
$7.39
$7.76
$6.30
$6.62
Page 21 of 49
Community Alternatives for Disabled Individuals (CADI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
LPN/LVN - Shared 1:2 Ratio, Extended
service unit
Membership Fees (exercise classes, health
club/fitness center), MHM only
service unit
service name
service name
15 Minutes
Actual Costs /
Year
MSHO/MSC+ Home Care Services
Procedure Code
and Modifiers
T1003
TT
UC
S9970
U6
U5
service name
X5609
Occupational Therapy Assistant, Extended
service unit
Occupational Therapy, Extended
service unit
Overnight Assistance, MHM Only
service unit
PERS Installation and Testing
service unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
Personal Care Assistance (PCA) - 1:1 Ratio, Extended
service unit
Personal Care Assistance (PCA) - Shared 1:2 Ratio,
Extended
service unit
Personal Care Assistance (PCA) - Shared 1:3 Ratio,
Extended
service unit
Physical Therapy Assistant, Extended
service unit
Physical Therapy, Extended
service unit
Post-Discharge Case Consultation and Collaboration,
MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Visit
Visit
15 Minutes
Each Time
Per Month
Each Time
15 Minutes
15 Minutes
15 Minutes
Visit
Visit
Per hour
Minnesota Department of Human Services Continuing Care Administration
S9129
TF
S9129
UC
S5135
U6
UC
UA
S5160
S5161
S5162
T1019
UC
T1019
TT
UC
T1019
HQ
UC
S9131
UC
TF
S9131
UC
T2013
U6
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$4.73
$4.97
$800.00
$800.00
PCA, HHA, SN, PDN
provided by health plan
PCA, HHA, SN, PDN
provided by health plan
$44.03
$46.22
$67.72
$71.11
$2.05
$2.15
$500.00
$500.00
$110.00
$110.00
$1,500.00
$1,500.00
$3.96
$4.16
$2.97
$3.12
$2.61
$2.74
$43.14
$45.30
$66.37
$69.69
$137.19
$144.05
Page 22 of 49
Community Alternatives for Disabled Individuals (CADI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Prevocational Services
service unit
Prevocational Services
service unit
Psychoeducation Services, MHM only
service unit
Residential Care Services
service unit
Respiratory Therapy, Extended
service unit
Respite Care Services with Room and Board
service unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
RN - Complex, Extended
service unit
RN - Regular, Extended
service unit
RN - Shared 1:2 Ratio, Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Daily (6 or more
hours / day)
Per hour
15 Minutes
Daily
Visit
Daily (10 or more
hours / day)
15 Minutes
Daily (10 or more
hours / day)
15 Minutes
15 Minutes
15 Minutes
15 Minutes
SNBC Services
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
T2014
Maximum Rate Not
Published
Maximum Rate Not
Published
T2015
Maximum Rate Not
Published
Maximum Rate Not
Published
$34.30
$36.02
Maximum Rate Not
Published
Maximum Rate Not
Published
$46.90
$49.25
H0045
Maximum Rate Not
Published
Maximum Rate Not
Published
S5150
Maximum Rate Not
Published
Maximum Rate Not
Published
S5151
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
$9.85
$10.34
$8.21
$8.62
$6.16
$6.47
HHA and SN provided by
health plan
HHA and SN provided by
health plan
$3,909.00
$3,909.00
$67.38
$70.75
H2027
U6
T2033
S5181
UC
S5150
UB
T1002
TG
T1002
UC
T1002
TT
UC
UC
service name
X5609
Specialized Supplies & Equipment
service unit
Speech Therapy, Extended
service unit
service name
service name
Per Year
Visit
Minnesota Department of Human Services Continuing Care Administration
T2029
S9128
UC
Report run: 9/15/2014
Page 23 of 49
Community Alternatives for Disabled Individuals (CADI) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Supported Employment 1:1
service unit
Supported Employment 1:2
service unit
Supported Employment 1:3
service unit
Supported Employment Benchmark Incentive
Payment, MHM only
service unit
Supported Employment Services, MHM only
service unit
Transitional Services
service unit
Transitional Services- Furniture
service unit
Transitional Services- Household Supplies
service unit
Transportation, Mileage (Commercial Vehicle)
service unit
Transportation, Mileage (Non-commercial Vehicle)
service unit
Transportation, Extra Attendant
service unit
Transportation, One Way Trip
service unit
Youth Assertive Community Treatment, MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
15 Minutes
Daily
15 Minutes
Decremental
Decremental
Decremental
Per Mile
Per Mile
Extra Attendant
One Way Trip
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T2019
Rate 4/1/14
Rate 7/1/14
Maximum Rate Not
Published
Maximum Rate Not
Published
T2019
TT
Maximum Rate Not
Published
Maximum Rate Not
Published
T2019
HQ
Maximum Rate Not
Published
Maximum Rate Not
Published
T2018
U6
$760.00
$760.00
T2019
U6
$9.48
$9.95
$3,000.00
$3,000.00
$1,000.00
$1,000.00
$300.00
$300.00
$1.48
$1.55
$0.56
$0.56
Maximum Rate Not
Published
Maximum Rate Not
Published
$19.06
$20.01
$151.17
$158.73
T2038
T2038
U1
T2038
U2
S0215
UC
S0215
UC
T2001
UC
T2003
UC
H0040
U6
Report run: 9/15/2014
Page 24 of 49
Developmental Disabilities (DD) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
24-Hour Emergency Assistance
service unit
24-Hour Emergency Assistance
service unit
Adult Day Care
service unit
Adult Day Care
service unit
Adult Day Care - FADS
service unit
Adult Day Care - FADS
service unit
Adult Day Care Bath
service unit
Assistive Technology / Assessment
service unit
Assistive Technology / Equipment
service unit
Caregiver Living Expenses
service unit
Case Management
service unit
CDCS Background Check
service unit
Certified Peer Specialist (CPS) - Group Setting, MHM
only
service unit
Certified Peer Specialist (CPS) - Level I, MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Daily
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
Daily (6 or more
hours / day)
15 Minutes
Per Assessment
Per Waiver Year
Daily
15 Minutes
Per Print
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
H2011
Maximum Rate Not
Published
Maximum Rate Not
Published
T2034
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5102
U7
Maximum Rate Not
Published
Maximum Rate Not
Published
S5100
TF
Maximum Rate Not
Published
Maximum Rate Not
Published
T2029
UD
Maximum Rate Not
Published
Maximum Rate Not
Published
T2029
Maximum Rate Not
Published
Maximum Rate Not
Published
S5126
Maximum Rate Not
Published
Maximum Rate Not
Published
$21.87
$22.96
$25.00
$25.00
$5.81
$6.10
$11.55
$12.13
T1016
UC
T2040
H0038
U6
H0038
U6
HQ
Report run: 9/15/2014
Page 25 of 49
Developmental Disabilities (DD) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Certified Peer Specialist (CPS) - Level II, MHM only
service unit
Chore Services
service unit
Comprehensive Community Support Services, MHM
only
service unit
Consumer Directed Community Supports (CDCS)
service unit
Consumer Training and Education
service unit
Crisis Respite
service unit
Crisis Respite
service unit
Crisis Respite, Specialized
service unit
DT&H (Does not include transportation time to/from)
service unit
DT&H (Does not include transportation time to/from)
service unit
DT&H (Does not include transportation time to/from)
service unit
DT&H Transportation
service unit
Environmental Accessibility Adaptations / Home
Assessment
service unit
Environmental Accessibility Adaptations / Home Install
service unit
Environmental Accessibility Adaptations / Vehicle
Assessment
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
15 Minutes
Decremental
Per Session
15 Minutes
Daily
15 Minutes
15 Minutes
Daily (6 or more
hours / day)
Partial Day
Transportation
Per Assessment
Per Waiver Year
Per Assessment
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$13.21
$13.87
$3.54
$3.72
$8.23
$8.64
Individual Budget
Individual Budget
S5109
Maximum Rate Not
Published
Maximum Rate Not
Published
T1005
Maximum Rate Not
Published
Maximum Rate Not
Published
S9125
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Provider Specific
Provider Specific
Provider Specific
Provider Specific
Provider Specific
Provider Specific
Provider Specific
Provider Specific
T1028
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
S5165
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
H0038
U6
U5
S5120
H2015
U6
T2028
T1005
TG
T2021
T2020
T2020
U5
T2002
T2039
UD
Report run: 9/15/2014
Page 26 of 49
Developmental Disabilities (DD) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Environmental Accessibility Adaptations / Vehicle
Install
service unit
Family Caregiver Training and Education
service unit
Family Memory Care Intervention, MHM only
service unit
Home Delivered Meals
service unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Home Management
service unit
Housing Access Coordination
service unit
In-Home Family Support
service unit
Membership Fees (exercise classes, health
club/fitness center), MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Per Waiver Year
Per Session
15 Minutes
Per Meal
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Actual Costs /
Year
MSHO/MSC+ Home Care Services
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
T2039
EAA services cannot exceed
$40,000
EAA services cannot exceed
$40,000
S5116
Maximum Rate Not
Published
Maximum Rate Not
Published
$17.08
$17.93
$6.16
$6.47
$4.34
$4.56
$4.34
$4.56
$4.34
$4.56
H2015
Maximum Rate Not
Published
Maximum Rate Not
Published
S5125
Maximum Rate Not
Published
Maximum Rate Not
Published
$800.00
$800.00
PCA, HHA, SN, PDN
provided by health plan
PCA, HHA, SN, PDN
provided by health plan
$2.05
$2.15
$500.00
$500.00
$110.00
$110.00
$1,500.00
$1,500.00
S5115
U6
S5170
S5130
TG
S5130
S5130
S9970
TF
U6
U5
service name
X5609
Overnight Assistance, MHM Only
service unit
PERS Installation and Testing
service unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
service name
service name
service name
service name
15 Minutes
Each Time
Per Month
Each Time
Minnesota Department of Human Services Continuing Care Administration
S5135
U6
UA
S5160
S5161
S5162
Report run: 9/15/2014
Page 27 of 49
Developmental Disabilities (DD) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Personal Care Assistance (PCA) - 1:1 Ratio, Extended
service unit
Personal Care Assistance (PCA) - Shared 1:2 Ratio,
Extended
service unit
Personal Care Assistance (PCA) - Shared 1:3 Ratio,
Extended
service unit
Personal Support
service unit
Post-Discharge Case Consultation and Collaboration,
MHM only
service unit
Psychoeducation Services, MHM only
service unit
Respite Care Services with Room and Board
service unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Per Session
15 Minutes
Daily (10 or more
hours / day)
15 Minutes
Daily (10 or more
hours / day)
15 Minutes
SNBC Services
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$3.96
$4.16
$2.97
$3.12
$2.61
$2.74
Maximum Rate Not
Published
Maximum Rate Not
Published
$137.19
$144.05
$34.30
$36.02
H0045
Maximum Rate Not
Published
Maximum Rate Not
Published
S5150
Maximum Rate Not
Published
Maximum Rate Not
Published
S5151
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
Maximum Rate Not
Published
X5609
HHA and SN provided by
health plan
HHA and SN provided by
health plan
T2013
Maximum Rate Not
Published
Maximum Rate Not
Published
T2019
Maximum Rate Not
Published
Maximum Rate Not
Published
$760.00
$760.00
T1019
UC
T1019
TT
UC
T1019
HQ
UC
S5135
T2013
U6
H2027
U6
S5150
UB
service name
Specialist Service
service unit
Supported Employment 1:1
service unit
Supported Employment Benchmark Incentive
Payment, MHM only
service unit
service name
service name
service name
Per hour
15 Minutes
Daily
Minnesota Department of Human Services Continuing Care Administration
T2018
U6
Report run: 9/15/2014
Page 28 of 49
Developmental Disabilities (DD) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Supported Employment Services, MHM only
service unit
Supported Living Services, Adult
service unit
Supported Living Services, Adult
service unit
Supported Living Services, Adult, Corporate
service unit
Supported Living Services, Adult, Corporate
service unit
Supported Living Services, Child Corporate
service unit
Supported Living Services, Child Corporate
service unit
Transitional Services
service unit
Transitional Services- Furniture
service unit
Transitional Services- Household Supplies
service unit
Transportation, Mileage (Commercial Vehicle)
service unit
Transportation, Mileage (Non-commercial Vehicle)
service unit
Transportation, One Way Trip
service unit
Youth Assertive Community Treatment, MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
Daily
15 Minutes
Daily
15 Minutes
Daily (10 or more
hours / day)
Decremental
Decremental
Decremental
Per Mile
Per Mile
One Way Trip
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$9.48
$9.95
T2017
Maximum Rate Not
Published
Maximum Rate Not
Published
T2016
Maximum Rate Not
Published
Maximum Rate Not
Published
T2019
U6
T2017
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
T2016
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
T2017
HA
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
T2016
HA
U9
Maximum Rate Not
Published
Maximum Rate Not
Published
$3,000.00
$3,000.00
$1,000.00
$1,000.00
$300.00
$300.00
$1.48
$1.55
$0.56
$0.56
$19.06
$20.01
$151.17
$158.73
T2038
T2038
U1
T2038
U2
S0215
UC
S0215
UC
T2003
UC
H0040
U6
Report run: 9/15/2014
Page 29 of 49
Elderly Waiver (EW) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
24-Hour Customized Living Services
service unit
Adult Day Service
service unit
Adult Day Service
service unit
Adult Day Service - FADS
service unit
Adult Day Service - FADS
service unit
Adult Day Service Bath
service unit
Case Management
service unit
Case Management Aide (Paraprofessional)
service unit
CDCS Background Check
service unit
CDCS Mandatory Case Management
service unit
Certified Peer Specialist (CPS) - Group Setting, MHM
only
service unit
Certified Peer Specialist (CPS) - Level I, MHM only
service unit
Certified Peer Specialist (CPS) - Level II, MHM only
service unit
Chore Services
service unit
Companion Services
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Per Month
15 Minutes
Daily
15 Minutes
Daily
15 Minutes
15 Minutes
15 Minutes
Per Print
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T2030
TG
S5100
S5102
S5100
U7
S5102
U7
S5100
TF
T1016
UC
T1016
TF
UC
T2040
T2041
H0038
U6
H0038
U6
H0038
U6
HQ
U5
S5120
S5135
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
See 24-Hour CL service rate
Limits
See 24-Hour CL service rate
Limits
$3.18
$3.34
$42.58
$44.71
$3.18
$3.34
$42.58
$44.71
$7.12
$7.48
$24.01
$25.21
$8.86
$9.30
$25.00
$25.00
Up to the Required Case
Management cap amount
Up to the Required Case
Management cap amount
$5.81
$6.10
$11.55
$12.13
$13.21
$13.87
$3.54
$3.72
$2.05
$2.15
Page 30 of 49
Elderly Waiver (EW) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Comprehensive Community Support Services, MHM
only
service unit
Consumer Directed Community Supports (CDCS)
service unit
Customized Living Services
service unit
Environmental Accessibility Adaptations / Home
Assessment
service unit
Environmental Accessibility Adaptations / Home Install
service unit
Environmental Accessibility Adaptations / Vehicle
Assessment
service unit
Environmental Accessibility Adaptations / Vehicle
Install
service unit
Family Caregiver Coaching and Counseling (including
assessment)
service unit
Family Caregiver Training and Education
service unit
Family Memory Care Intervention, MHM only
service unit
Foster Care, Adult Family
service unit
Foster Care, Adult, Corporate
service unit
Home Delivered Meals
service unit
Home Health Aide, Extended
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Per Month
Per Month
Per Assessment
Per Waiver Year
Per Assessment
Per Waiver Year
15 Minutes
15 Minutes
15 Minutes
Per Month
Per Month
One meal Per
Day
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$8.23
$8.64
T2028
Up to the CDCS case mix
cap amount
Up to the CDCS case mix
cap amount
T2030
See EW Customized Living
(T2030) Limits
See EW Customized Living
(T2030) Limits
T1028
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
S5165
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
EAA services cannot exceed
$10,000
$17.08
$17.93
$17.08
$17.93
$17.08
$17.93
Up to the case mix budget
cap
Up to the case mix budget
cap
Up to the case mix budget
cap
Up to the case mix budget
cap
$6.16
$6.47
$7.55
$7.93
H2015
T2039
U6
UD
T2039
S5115
TF
S5115
S5115
U6
S5141
S5141
HQ
S5170
T1004
Report run: 9/15/2014
Page 31 of 49
Elderly Waiver (EW) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker / Assistance with Personal Cares
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Cleaning
service unit
Homemaker Services / Home Management
service unit
Homemaker Services / Home Management
service unit
LPN Complex, Extended
service unit
LPN Regular, Extended
service unit
LPN Shared 1:2 Ratio, Extended
service unit
Membership Fees (exercise classes, health
club/fitness center), MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Daily
15 Minutes
Daily
15 Minutes
Daily
15 Minutes
15 Minutes
15 Minutes
Per Month
MSHO/MSC+ Home Care Services
Procedure Code
and Modifiers
S5130
TG
S5131
TG
S5130
S5131
S5130
TF
S5131
TF
T1003
TG
T1003
UC
T1003
TT
UC
S9970
U6
U5
UC
service name
X5609
Overnight Assistance, MHM Only
service unit
PERS Installation and Testing
service unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
Personal Care Assistance (PCA) - 1:1 Ratio, Extended
service unit
service name
service name
service name
service name
service name
15 Minutes
Each Time
Per Month
Each Time
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
S5135
U6
UA
S5160
S5161
S5162
T1019
UC
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$4.34
$4.56
$41.99
$44.09
$4.34
$4.56
$41.99
$44.09
$4.34
$4.56
$41.99
$44.09
$7.39
$7.76
$6.30
$6.62
$4.73
$4.97
$66.66
$66.66
PCA, HHA, SN, PDN
provided by health plan
PCA, HHA, SN, PDN
provided by health plan
$2.05
$2.15
$500.00
$500.00
$110.00
$110.00
$1,500.00
$1,500.00
$3.96
$4.16
Page 32 of 49
Elderly Waiver (EW) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Personal Care Assistance (PCA) - Shared 1:2 Ratio,
Extended
service unit
Personal Care Assistance (PCA) - Shared 1:3 Ratio,
Extended
service unit
Post-Discharge Case Consultation and Collaboration,
MHM only
service unit
Residential Care Services
service unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
Respite Care Services, out of Home
service unit
Respite Certified Facility
service unit
Respite Hospital, 24 hours
service unit
RN - Complex, Extended
service unit
RN Regular Extended 1:1 Ratio
service unit
RN Shared Extended 1:2 Ratio
service unit
Specialized Supplies & Equipment
service unit
Transitional Services
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
Per Session
Per Month
15 Minutes
Daily
15 Minutes
Daily
Daily
Daily
15 Minutes
15 Minutes
15 Minutes
Per Item
Per Occurence
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T1019
TT
UC
T1019
HQ
UC
T2013
U6
T2032
S5150
S5151
S5150
UB
H0045
H0045
H0045
T1002
TG
T1002
UC
T1002
TT
UC
UC
T2029
T2038
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$2.97
$3.12
$2.61
$2.74
$137.19
$144.05
See EW Residential Living
(T2032) Limits
See EW Residential Living
(T2032) Limits
$5.11
$5.37
$92.06
$96.66
$5.11
$5.37
$92.06
$96.66
NF's per diem for the client's
case mix
NF's per diem for the client's
case mix
$139.42
$146.39
$9.85
$10.34
$8.21
$8.62
$6.16
$6.47
$0.00
$0.00
Up to the case mix budget
cap
Up to the case mix budget
cap
Page 33 of 49
Elderly Waiver (EW) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Transportation
service unit
Transportation, Mileage (Commercial Vehicle)
service unit
Transportation, Mileage (Non-commercial Vehicle)
service unit
service name
service name
service name
One Way Trip
Per Mile
Per Mile
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T2003
UC
S0215
UC
S0215
UC
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$19.06
$20.01
$1.48
$1.55
$0.56
$0.56
Page 34 of 49
Family Support Grant (FSG) Program Annual Income Limits Effective 07/01/2014
Service Name
Service Unit
Family Support Grant Annual Adjusted Gross Income
Limit
Procedure Code
and Modifiers
service name
Minnesota Department of Human Services Continuing Care Administration
T2025
UD
Report run: 9/15/2014
Limit 1/1/14
Limit 1/1/14
$98,564.00
$98,564.00
Page 35 of 49
Home Care (HC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Home Health Aide
service unit
LPN/LVN - Complex, Private Duty
service unit
LPN/LVN - Regular, Private Duty
service unit
LPN/LVN - Shared 1:2 Ratio, Extended
service unit
Occupational Therapy
service unit
Occupational Therapy Assistant
service unit
Personal Care Assistance (PCA) - 1:1 Ratio (PCPO)
service unit
Personal Care Assistance (PCA) - 1:2 Ratio (PCPO)
service unit
Personal Care Assistance (PCA) - 1:3 Ratio (PCPO)
service unit
Personal Care Assistance (PCA) - Temporary 45 Day
Increase
service unit
PHN Face to Face Assessment for PCA
service unit
PHN Service Update for PCA
service unit
PHN Temporary Service Increase for PCA
service unit
Physical Therapy
service unit
Physical Therapy Assistant
service unit
Respiratory Therapy
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Visit
15 Minutes
15 Minutes
15 Minutes
Visit
Visit
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Visit
Visit
Visit
Visit
Visit
Visit
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T1021
T1003
TG
T1003
T1003
TT
S9129
S9129
TF
T1019
T1019
TT
T1019
HQ
T1019
U6
T1001
T1001
TS
T1001
U6
S9131
S9131
TF
S5181
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$54.29
$57.00
$7.39
$7.76
$6.30
$6.62
$4.73
$4.97
$67.72
$71.11
$44.03
$46.22
$3.96
$4.16
$2.97
$3.12
$2.61
$2.74
$3.96
$4.16
$260.87
$273.91
$130.43
$136.95
$130.43
$136.95
$66.37
$69.69
$43.14
$45.30
$46.90
$49.25
Page 36 of 49
Home Care (HC) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
RN Complex, 1:1 Ratio
service unit
RN Regular 1:1 Ratio, Private Duty
service unit
RN Shared 1:2 Ratio, Private Duty
service unit
Skilled Nurse Visit
service unit
Skilled Nurse Visit - Telehomecare
service unit
Speech Therapy
service unit
Supervision of PCA (PCPO)
service unit
service name
service name
service name
service name
service name
service name
service name
15 Minutes
15 Minutes
15 Minutes
Visit
Visit
Visit
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T1002
TG
T1002
T1002
TT
T1030
T1030
GT
S9128
T1019
UA
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$9.85
$10.34
$8.21
$8.62
$6.16
$6.47
$70.74
$74.28
$70.74
$74.28
$67.38
$70.75
$6.96
$7.31
Page 37 of 49
Moving Home Minnesota (MHM) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Case Management - Demonstration
service unit
Certified Peer Specialist (CPS) - Group Setting, MHM
only
service unit
Certified Peer Specialist (CPS) - Level I, MHM only
service unit
Certified Peer Specialist (CPS) - Level II, MHM only
service unit
Comprehensive Community Support Services, MHM
only
service unit
Cost for Finding Housing/Employment (Case Worker)
service unit
Cost for Finding Housing/Employment (Escort
Lodging)
service unit
Cost for Finding Housing/Employment (Escort Meals)
service unit
Cost for Finding Housing/Employment (parking fees,
tolls, etc.)
service unit
Cost for Finding Housing/Employment (Recipient
Meals)
service unit
Cost for Finding Housing/Employment-Ancillary
(Recipient Lodging)
service unit
Environmental Accessibility Adaptations / Home
Assessment
service unit
Environmental Accessibility Adaptations / Home Install
service unit
Family Memory Care Intervention, MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
15 Minutes
Procedure Code
and Modifiers
Rate 4/1/14
Rate 7/1/14
$23.08
$24.23
$5.81
$6.10
$11.55
$12.13
$13.21
$13.87
$8.23
$8.64
$0.56
$0.56
$125.00
$125.00
$37.00
$37.00
$20.00
$20.00
$37.00
$37.00
$125.00
$125.00
T1016
U6
H0038
U6
H0038
U6
H0038
U6
H2015
U6
A0160
U6
Actual CostDaily Maximum
A0200
U6
Actual CostDaily Maximum
A0210
U6
Actual CostDaily Maximum
A0170
U6
Actual CostDaily Maximum
A0190
U6
Actual CostDaily Maximum
A0180
U6
T1028
U6
2 MHM EAA services cannot
exceed $3,000
2 MHM EAA services cannot
exceed $3,000
S5165
U6
2 MHM EAA services cannot
exceed $3,000
2 MHM EAA services cannot
exceed $3,000
S5115
U6
$17.08
$17.93
15 Minutes
15 Minutes
15 Minutes
15 Minutes
Per Mile
Per Assessment
Per Year
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
HQ
U5
Report run: 9/15/2014
Page 38 of 49
Moving Home Minnesota (MHM) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Membership Fees (exercise classes, health
club/fitness center), MHM only
service unit
Overnight Assistance, MHM Only
service unit
PERS Installation and Testing
service unit
PERS Monthly Service Fee
service unit
PERS Purchase
service unit
Post-Discharge Case Consultation and Collaboration,
MHM only
service unit
Pre-Discharge Case Consultation and Collaboration
service unit
Psychoeducation Services, MHM only
service unit
Respite Care Services, in Home
service unit
Respite Care Services, in Home
service unit
Respite Care Services, out of Home
service unit
Respite Care Services, out of Home
service unit
Specialized Supplies & Equipment
service unit
Supported Employment Benchmark Incentive
Payment, MHM only
service unit
Supported Employment Services, MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
service name
Actual Costs /
Year
15 Minutes
Each Time
Per Month
Each Time
Per Session
Per Session
15 Minutes
15 Minutes
Daily
15 Minutes
Daily
Per Item
Daily
15 Minutes
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
S9970
U6
U5
S5135
U6
UA
S5160
U6
S5161
U6
S5162
U6
T2013
U6
H2000
U6
H2027
U6
S5150
U6
S5151
U6
S5150
U6
H0045
U6
T2029
U6
T2018
U6
T2019
U6
UB
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$800.00
$800.00
$2.05
$2.15
$500.00
$500.00
$110.00
$110.00
$1,500.00
$1,500.00
$137.19
$144.05
$137.19
$144.05
$34.30
$36.02
$5.16
$5.42
$328.54
$344.97
$5.16
$5.42
$342.47
$359.59
$0.00
$0.00
$760.00
$760.00
$9.48
$9.95
Page 39 of 49
Moving Home Minnesota (MHM) Program Service Rate Limits Effective 07/01/2014
Service Name
Service Unit
Tools, Clothing and Equipment - necessary for
employment
service unit
Transition Coordination
service unit
Transition Coordination - Furnishings
service unit
Transition Coordination - Moving Costs (Deposits,
application fees, movers, transition coordination
services on day of discharge, etc. )
service unit
Transition Coordination - Supplies
service unit
Transition Planning
service unit
Youth Assertive Community Treatment, MHM only
service unit
service name
service name
service name
service name
service name
service name
service name
Per Service
15 Minutes
Decremental
Decremental
Decremental
Decremental
Daily
Minnesota Department of Human Services Continuing Care Administration
Procedure Code
and Modifiers
T1999
U6
T2038
U6
UD
T2038
U6
U1
T2038
U6
UA
T2038
U6
U2
T2038
U6
H0040
U6
Report run: 9/15/2014
Rate 4/1/14
Rate 7/1/14
$500.00
$500.00
$15.69
$16.47
$1,000.00
$1,000.00
$1,700.00
$1,700.00
$300.00
$300.00
$1,500.00
$1,500.00
$151.17
$158.73
Page 40 of 49
Consumer Support Grant (CSG) Monthly Budget Limits Effective 07/01/2014
Step 1: Person has one dependency in an Activity of Living (ADL) and/or Level I Behavior. Use the home care rating LT and corresponding monthly amount for the
monthly CSG budget. Steps 2-3 do not apply to this home care rating. No additional time is given for critical ADLs, behaviors or complex health needs.
Step 2: Person has two or more dependencies in ADLs. Use steps 2 and 3 below to determine the home care rating and total time.
NOTE: Each additional critical ADL, complex health or behavioral need would add another $97.00 to the monthly grant amount.
Step 3: Determination of Total Time: If the PCA assessment shows a person has one or more of the following descriptions, an additional 2 units or $97.00 per
month is added to the CSG monthly base amount for the Critical ADLs, Behavior, and Complex Health needs listed below:
Critical ADLs
· Eating
· Transferring
· Mobility
· Toileting
Behavior
· Increased vulnerability due to cognitive deficits or socially inappropriate behaviors
· Resistive to care including verbally aggressive
· Physical aggression towards self, others or destruction of property
Potential Maximum Total
8 units
Potential Maximum Total
6 units
Complex Health
· Tube Feeding
· Wounds
· Parenteral/IV Therapy
· Respiratory Interventions
· Catheter
· Bowel Program
· Neurological Intervention
· Other Congenital or Acquired Diseases
Potential Maximum Total
16 units
CSG Monthly Amounts based on number of
Critical ADLs/Behavior Descriptions/Complex Health Needs
Dependencies
Level 1
Behavior?
Complex
Needs?
HC
Rating
0
Yes
No
LT
$97
1
Yes or No
No
LT
$97
2-3
No
No
P
$242
$339
$436
$533
$630
$727
$824
$921
$1,018
Yes
No
Q
$291
$388
$485
$582
$679
$776
$873
$970
$1,067
Yes or No
Yes
R
$339
$436
$533
$630
$727
$824
$921
$1,018
$1,115
No
No
S
$484
$581
$678
$775
$872
$969
$1,066
$1,163
$1,260
Yes
No
T
$533
$630
$727
$824
$921
$1,018
$1,115
$1,212
$1,309
Yes or No
Yes
U
$678
$775
$872
$969
$1,066
$1,163
$1,260
$1,357
$1,454
No
No
V
$823
$920
$1,017
$1,114
$1,211
$1,308
$1,405
$1,502
$1,599
Yes
No
W
$969
$1,066
$1,163
$1,260
$1,357
$1,454
$1,551
$1,648
$1,745
Yes or No
Yes
Z
$1,453
$1,550
$1,647
$1,744
$1,841
$1,938
$2,035
$2,132
$2,229
4-6
7-8
Monthly
Base
1
Minnesota Department of Human Services Continuing Care Administration
2
3
Report run: 9/15/2014
4
5
6
7
8
Page 41 of 49
Consumer Support Grant (CSG) Monthly Limits Private Duty Nursing (PDN) and Vent
Dependent Effective 07/01/2014
MA Home Care Rating
CA
CSG Monthly Budget
PDN Transfer to CAC Waiver
$2,107
EN
Vent Dependent
$7,012
HL
PDN Hospital Level
$5,783
PD
PDN Nursing Facility Level
$2,842
Minnesota Department of Human Services Continuing Care Administration
Report run: 9/15/2014
Page 42 of 49
Monthly Limits for Private Duty Nursing (PDN) and Vent Dependent Effective 07/01/2014
MA Home Care Rating
CA
EN
HL
PD
PDN Transfer to CAC Waiver
Vent Dependent
PDN Hospital Level
PDN Nursing Facility Level
Max Rate
Max Units
Max Daily
Max Monthly Budget
$10.34
$10.34
$10.34
$10.34
96
96
64
39
$993
$993
$662
$403
$30,792
$30,792
$20,507
$12,499
Minnesota Department of Human Services Continuing Care Administration
Report run: 9/15/2014
Page 43 of 49
Program Monthly Budget Caps by Case Mix Effective 07/01/2014
Case Mix
case mix
Alternative Care
4/1/2014
last period
$1,703
A
case mix
last period
last period
last period
last period
last period
last period
last period
last period
last period
last period
last period
Elderly Waiver
last period
last period
last period
last period
last period
last period
last period
last period
last period
last period
last period
last period
last period
V
$5,547
this period
$1,750
L
case mix
$4,760
this period
$5,283
K
case mix
$4,465
this period
$4,533
J
case mix
$4,350
this period
$4,252
I
case mix
$3,856
this period
$4,143
H
case mix
$3,738
this period
$3,672
G
case mix
$3,627
this period
$3,560
F
case mix
$3,288
this period
$3,454
E
case mix
$3,184
this period
$3,131
D
case mix
$2,713
this period
$3,032
C
case mix
$2,386
this period
$2,584
B
case mix
$623
this period
$2,272
A
case mix
$4,161
this period
$593
L
case mix
$3,570
this period
$3,963
K
case mix
$3,350
this period
$3,400
J
case mix
$3,263
this period
$3,190
I
case mix
$2,893
this period
$3,108
H
case mix
$2,804
this period
$2,755
G
case mix
$2,720
this period
$2,670
F
case mix
$2,468
this period
$2,590
E
case mix
$2,388
this period
$2,350
D
case mix
$2,035
this period
$2,274
C
case mix
$1,788
this period
$1,938
B
case mix
7/1/2014
this period
$1,837
this period
$19,217
Minnesota Department of Human Services Continuing Care Administration
$20,178
Report run: 9/15/2014
Page 44 of 49
CDCS Budget Caps Effective 07/01/2014
Alternative Care
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
A
B
C
D
E
F
G
H
I
J
K
L
Monthly
Amount
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
Annual Maximum
CDCS Service
Budget Amount
$788
$1,066
$1,241
$1,418
$1,668
$1,772
$1,874
$2,310
$2,435
$2,560
$2,911
$788
$9,456
$12,792
$14,892
$17,016
$20,016
$21,264
$22,488
$27,720
$29,220
$30,720
$34,932
$9,456
Required Case
Management for
8 units amount
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
Required Case
Management Annual
Maximum Amount
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
Total: CDCS Service
Cap + Required Case
Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
$11,870
$15,209
$17,313
$19,430
$22,441
$23,689
$24,911
$30,140
$31,639
$33,139
$37,347
$11,870
Background Checks
Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
Elderly Waiver
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
Case Mix
A
B
C
D
E
F
G
H
I
J
K
L
V
Monthly
Amount
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
CDCS Monthly
$800
$1,196
$1,421
$1,546
$1,997
$2,051
$2,065
$2,706
$3,175
$3,253
$3,351
$800
$14,125
Annual Maximum
CDCS Service
Budget Amount
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
Annual Maximum CDCS Service Budget
$9,600
$14,352
$17,052
$18,552
$23,964
$24,612
$24,780
$32,472
$38,100
$39,036
$40,212
$9,600
$169,500
Required Case
Management for
8 units amount
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
Required Case Management, 8 units
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
$201.68
Minnesota Department of Human Services Continuing Care Administration
Required Case
Management Annual
Maximum Amount
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
Required Case Management Annual Maximum
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
$2,420
Report run: 9/15/2014
Total: CDCS Service
Cap + Required Case
Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
Total: CDCS Service Cap + Required Case Management
Maximum
$12,021
$16,771
$19,468
$20,967
$26,385
$27,028
$27,204
$34,890
$40,522
$41,455
$42,627
$12,021
$171,915
Background Checks
Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
Background Checks Maximum Payment
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
$25.00/check
Page 45 of 49
Elderly Waiver (EW) 24-Hour Customized Living (24CL) Service Rate Limits Effective 07/01/2014
Case Mix
A
B
C
D
E
F
G
H
I
J
K
V
Rate Limit
$1,993
$2,300
$2,705
$2,825
$3,143
$3,259
$3,389
$3,808
$3,915
$4,186
$4,889
$17,783
Elderly Waiver (EW) 24-Hour Customized Living (24CL) Component Service Rates Effective
07/01/2014
Service Component
Home Management / Support Services
Home Care Aide
Home Health Aide
Medication setups by licensed Nurse
Summoning device
Breakfast
Lunch
Supper
Snack
Socialization 1 staff: 1 resident ratio
Socialization 1 staff: 2-5 resident ratio
Socialization 1 staff: 6-12 resident ratio
Socialization 1 staff: 13-20 resident ratio
Socialization 1 staff: 21+ resident ratio
Individual transportation (1 rider)
Group transportation-mileage (2 riders)
Group transportation-mileage (3-5 riders)
Group transportation-mileage (6-10 riders)
Group transportation-mileage (11+ riders)
Mileage Rate - Individual
Group transportation-driver (2 riders)
Group transportation-driver (3-5 riders)
Group transportation-driver (6-10 riders)
Group transportation-driver (11+ riders)
Component Rate
$16.6711
$22.7901
$26.0141
$31.4438
$28.7173
$3.4254
$4.2738
$4.2738
$0.4242
$16.6711
$4.7616
$1.8559
$1.0181
$0.5515
$16.6711
$8.3355
$4.1678
$2.0892
$1.1135
$0.5196
$0.2651
$0.1273
$0.0742
$0.0424
Minnesota Department of Human Services Continuing Care Administration
Service Unit
Per hour
Per hour
Per hour
Per hour
Per Month
Per Meal
Per Meal
Per Meal
Per Snack
Per hour
Per hour
Per hour
Per hour
Per hour
Per hour
Per hour
Per hour
Per hour
Per hour
Per Mile
Per Mile
Per Mile
Per Mile
Per Mile
Report run: 9/15/2014
Page 46 of 49
Elderly Waiver (EW) Service Rate Limits for Customized Living (T2030) and Residential
Care (T2032) Effective 07/01/2014
Statewide EW
Monthly Limits
Case Mix
case mix
statewide ew monthly limits
A
case mix
group 1 limits for EW clients
$1,071
statewide ew monthly limits
B
case mix
$1,218
C
D
E
F
case mix
G
case mix
H
case mix
I
case mix
J
case mix
K
case mix
L
case mix
V
$2,367
group 3 limits for EW clients
$2,220
group 2 limits for EW clients
$734
group 1 limits for EW clients
$9,627
$1,947
$2,197
$804
$2,210
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,849
$1,897
$2,493
$2,152
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,784
$1,801
$2,137
$1,905
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,600
$1,751
$2,015
$1,809
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,505
$1,561
$1,953
$1,781
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,472
$1,505
$1,733
$1,629
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,364
$1,446
$1,679
$1,542
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
$1,294
$1,332
$1,629
statewide ew monthly limits
$1,284
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
$1,168
group 3 limits for EW clients
$1,119
$1,236
$1,569
group 3 limits for EW clients
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
case mix
$1,085
$1,429
Group 3 Limits
for EW Clients
$1,003
group 2 limits for EW clients
group 1 limits for EW clients
statewide ew monthly limits
case mix
group 2 limits for EW clients
$979
group 1 limits for EW clients
statewide ew monthly limits
case mix
Group 1 Limits Group 2 Limits
for EW Clients for EW Clients
$2,699
group 3 limits for EW clients
$753
group 2 limits for EW clients
$8,281
Minnesota Department of Human Services Continuing Care Administration
$876
group 3 limits for EW clients
$8,487
$10,036
Report run: 9/15/2014
Page 47 of 49
EW Nursing Home Geographic Groups
Group 1
Group 2
Group 3
Beltrami
Becker
Aitkin
Big Stone
Benton
Anoka
Cass
Blue Earth
Carlton
Chippewa
Brown
Carver
Clearwater
Chisago
Cook
Cottonwood
Clay
Dakota
Crow Wing
Dodge
Hennepin
Hubbard
Douglas
Itasca
Jackson
Faribault
Koochiching
Kandiyohi
Fillmore
Lake
Lac Qui Parle
Freeborn
Ramsey
Lake of the Woods
Goodhue
Scott
Lincoln
Grant
St. Louis
Lyon
Houston
Washington
Mahnomen
Isanti
Meeker
Kanabec
Morrison
Kittson
Murray
Le Sueur
Nobles
Marshall
Pipestone
Martin
Redwood
McLeod
Renville
Mille Lacs
Rock
Mower
Swift
Nicollet
Todd
Norman
Wadena
Olmsted
Yellow Medicine
Otter Tail
Pennington
Pine
Polk
Pope
Red Lake
Rice
Roseau
Sherburne
Sibley
Stearns
Steele
Stevens
Traverse
Wabasha
Waseca
Watonwan
Wilkin
Winona
Wright
Minnesota Department of Human Services Continuing Care Administration
Report run: 9/15/2014
Page 48 of 49
Personal Care Assistance (PCA) Authorization
Step 1: Person has one dependency in an Activity of Daily Living (ADL) and/or Level 1 Behavior. Use the home care rating LT with two units of PCA
services (30 minutes) per day. Steps 2-3 do not apply to this home care rating.
Step 2: Person has two or more dependencies in ADLs. Use steps 2 and 3 below to determine the home care rating and total time.
Step 3: Determination of Total Time: If the PCA assessment shows a person has one or more of the following descriptions, add an additional 2 units or
30 minutes to base time per day for each:
·
Dependency in critical Activity of Daily Living (ADL)
·
Behavior issue as defined
·
Complex health-related need
Critical ADLs
· Eating
· Transferring
· Mobility
· Toileting
Behavior
· Increased vulnerability due to cognitive deficits or socially inappropriate behaviors
· Resistive to care including verbally aggressive
· Physical aggression towards self, others or destruction of property
Potential Maximum Total
Potential Maximum Total
Complex Health
· Tube Feeding
· Wounds
· Parenteral/IV Therapy
· Respiratory Interventions
· Catheter
· Bowel Program
· Neurological Intervention
· Other Congenital or Acquired Diseases
Potential Maximum Total
8 units-120 minutes
6 units-90 minutes
16 units-240 minutes
# Dependencies in
ADLs
Level I Behavior
Complex Health Needs
0
1
2-3
2-3
2-3
4-6
4-6
4-6
7-8
7-8
7-8
Yes
Yes or No
No
Yes
Yes or No
No
Yes
Yes or No
No
Yes
Yes or No
No
No
No
No
Yes
No
No
Yes
No
No
Yes
Minnesota Department of Human Services Continuing Care Administration
Report run: 9/15/2014
Home Care
Rating
Base
Units
Minutes
LT
LT
P
Q
R
S
T
U
V
W
Z
2
2
5
6
7
10
11
14
17
20
30
30
30
75
90
105
150
165
210
255
300
450
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