IHCP bulletin

INDIANA HEALTH COVERAGE PROGRAMS BT202083 JUNE 30, 2020

FSSA changes rates and services for the FSW and

CIH Waiver
Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) has
received approval from the Centers for Medicare & Medicaid Services (CMS) for changes to services for the Division of
Disability and Rehabilitative Services (DDRS) Bureau of Developmental Disabilities Services (BDDS) Family Supports
Waiver (FSW) and the Community Integration and Habilitation (CIH) Waiver.

IHCP Bulletin BT202020 previously announced these changes. However, due to the coronavirus disease 2019
(COVID-19) national public health emergency, these changes were put on hold. As a result, the implementation dates
have changed to July 16, 2020, with some services beginning on August 1, 2020.

The following tables outline the changes, along with the effective dates (be sure to make note of the effective dates for
billing purposes):

 Table 1 introduces the new rate for Case

Management.

 Table 2 lists the services added to the FSW:

− Environmental Modification
− Equipment – Assess/Inspect/Train
− Remote Supports
− Transportation Levels 2 and 3

 Table 3 shows the services that the name/description is being changed for the CIH:

− Remote Supports, formerly Electronic Monitoring

 Table 4 lists the services for CIH that are receiving an increase in their cap:

− Community Transition

 Table 5 has the services for the FSW and the CIH that are receiving an increase in their cap:

− Family & Caregiver Training, Family

− Family & Caregiver Training, Non-Family

 Table 6 contains the services that have a name change for the FSW and CIH (these services are a combination
of Community Habilitation and Facility Habilitation; some of these services have new procedure code and
modifier combinations and some have the same procedure code and modifier combination of previous
services):− Day Habilitation, Individual
− Day Habilitation, Small Group, 2:1, 3:1, 4:1

Page 1 of 2
IHCP bulletin BT202083 JUNE 30, 2020

 Day Habilitation, Medium Group, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1
 Day Habilitation, Large Group, 11:1, 12:1, 13:1, 14:1, 15:1, 16:1

 Table 7 encompasses the codes that will be end-dated:

− Case Management Annual PCISP Work– ending 6/30/2020
− Facility Habilitation, Group 2:1
− Facility Habilitation, Group 4:1
− Facility Habilitation, Group 6:1
− Facility Habilitation, Group 8:1
− Facility Habilitation, Group 10:1
− Facility Habilitation, Group 12:1
− Facility Habilitation, Group 14:1
− Facility Habilitation, Group 16:1
− Community Habilitation, Group 3:1
− Community Habilitation, Group 4:1
− Community Habilitation, Group 6:1
− Community Habilitation, Group 8:1

 Table 8 contains all the services that are not changing for the FSW and the CIH Waiver.

Questions or concerns should be directed to the FSSA Indiana Health Coverage Programs (IHCP) reimbursement
mailbox, (FSSA.IHCPReimbursement@fssa.in.gov). Please be sure to send communications containing
personal health information (PHI) to this mailbox via secure email.

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Page 2 of 2
IHCP bulletin BT202083 JUNE 30, 2020

Table 1 – New rate for FSW and CIH Waiver service, effective for DOS on or after July 16, 2020

Service Code Mod Mod Mod Dsc Proc FSW Old FSW New CIH Old CIH New Notes
1 2 3 Modified

Case Management T2022 U7 U5 U7=Waiver $131.25 $143.75 $131.25 $143.75 1/Month

U5=DD

Table 2 – Services added to FSW, effective for DOS on or after July 16, 2020

Service Code Mod Mod Mod Dsc Proc Modified FSW Notes
1 2 3

Environmental S5165 U7 U5 NU U7=Waiver Individual 1/Unit

Modification, Install U5=DD $15,0000 Lifetime
NU=New DME
Environmental S5165 U7 U5 U8 U7=Waiver Individual 1/Unit
Modification, Maintain U5=DD $500/Year
U8=Repair
Equipment – T1028 U7 U5 U7=Waiver $17.99 15 Minutes
Assess/Inspect/Train U5=DD
Remote Supports, A9279 U7 U5 NU U7=Waiver Individual 1 Unit; $500 Lifetime
Equipment U5=DD Cap
NU=New DME
Remote Supports, A9279 U7 U5 UA U7=Waiver $13.62 Hour
1 Participant U5=DD
UA=Agency
Remote Supports, A9279 U7 U5 U2 U7=Waiver $6.81 Hour
2 Participants U5=DD
U2=Tier 2/Level 2
Remote Supports, A9279 U7 U5 U3 U7=Waiver $4.54 Hour
3 Participants U5=DD
U3=Tier 3/Level 3
Remote Supports, A9279 U7 U5 U4 U7=Waiver $3.41 Hour
4 Participants U5=DD
U4=Tier 4/Level 4
Transportation, Level 2 T2002 U7 U5 U2 U7=Waiver $21.00 Per Trip; 2
U5=DD Trips/Day;
U2=Tier 2/Level 2 $5,250/Year
Transportation, Level 3 T2002 U7 U5 U3 U7=Waiver $42.00 Per Trip; 2
U5=DD Trips/Day;
U3=Tier 3/Level 3 $7,875/Year

FSW and CIH Waiver Servic e Table Updates 1 of 9

IHCP bulletin BT202083 JUNE 30, 2020

Table 3 – Service name changes for CIH Waiver, effective July 16, 2020

Service Code Mod Mod Mod Dsc Proc Modified CIH Notes
1 2 3

Remote Supports, A9279 U7 U5 UA U7=Waiver $13.62 Previously Electronic

1 Participant U5=DD Monitoring
UA=Agency
Remote Supports, A9279 U7 U5 U2 U7=Waiver $6.81 Previously Electronic
2 Participants U5=DD Monitoring
U2=Tier 2/Level 2
Remote Supports, A9279 U7 U5 U3 U7=Waiver $4.54 Previously Electronic
3 Participants U5=DD Monitoring
U3=Tier 3/Level 3
Remote Supports, A9279 U7 U5 U4 U7=Waiver $3.41 Previously Electronic
4 Participants U5=DD Monitoring
U4=Tier 4/Level 4

Table 4 – Cap increase for CIH Waiver service, effective for DOS on or after July 16, 2020

Service Code Mod Mod Mod Dsc Proc Modified CIH Notes
1 2 3
Community Transition T2038 U7 U5 U7=Waiver Individual $2,500 Lifetime
U5=DD

Table 5 – Cap increases for FSW and CIH Waiver services, effective for DOS on or after July 16, 2020

Service Code Mod Mod Mod Dsc Proc FSW CIH Notes
1 2 3 Modified
Family & Caregiver S5111 U7 U5 U7=Waiver Individual Individual $5,000/Year
Training, Family U5=DD
Family & Caregiver S5116 U7 U5 U7=Waiver Individual Individual $5,000/Year
Training, Non-Family U5=DD

FSW and CIH Waiver Servic e Table Updates 2 of 9

IHCP bulletin BT202083 JUNE 30, 2020

Table 6 – Service changes and name change for FSW and CIH Waiver services, effective for DOS on or after August 1, 2020

Service Code Mod Mod Mod Dsc Proc Modified FSW CIH Notes
1 2 3
Day Habilitation, T2020 U7 U5 U7=Waiver $24.85 $24.85 Hour
Individual U5=DD
Day Habilitation, Small T2020 U7 U5 U2 U7=Waiver $8.90 $8.90 Hour
Group 2:1, 3:1, 4:1 U5=DD
U2=Small Group
Day Habilitation, Medium T2020 U7 U5 UA U7=Waiver $4.96 $4.96 Hour
Group 5:1, 6:1, 7:1, 8:1, U5=DD
9:1, 10:1 UA=Medium Group
Day Habilitation, Large T2020 U7 U5 UB U7=Waiver $3.15 $3.15 Hour
Group 11:1, 12:1, 13:1, U5=DD
14:1, 15:1, 16:1** UB=Large Group
**This code combination is new.

Table 7 – End-dated codes

Service Code Mod Mod Mod Mod Dsc Proc Modified Waiver Program End Date
1 2 3 4
Case Management T2024 U7 U5 U7=Waiver FSW 6/30/2020
Annual PCISP Work U5=DD CIH
Facility Habilitation, T2020 U7 U5 UA U2 U7=Waiver FSW 7/31/2020
Group 2:1 UA=Agency CIH
U5=DD
U2=Tier 2/Level 2
Facility Habilitation, T2020 U7 U5 UA U4 U7=Waiver FSW 7/31/2020
Group 4:1 UA=Agency CIH
U5=DD
U4=Tier 4/Level 4
Facility Habilitation, T2020 U7 U5 UA U6 U7=Waiver FSW 7/31/2020
Group 6:1 U5=DD CIH
UA=Agency
U6=Tier 6/Level 6
Facility Habilitation, T2020 U7 U5 UA U8 U7=Waiver FSW 7/31/2020
Group 8:1 U5=DD CIH
UA=Agency
U8=Tier 8/Level 8

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IHCP bulletin BT202083 JUNE 30, 2020

Service Code Mod Mod Mod Mod Dsc Proc Modified Waiver Program End Date
1 2 3 4
Facility Habilitation, T2020 U7 U5 UA UB U7=Waiver FSW 7/31/2020
Group 10:1 U5=DD CIH
UA=Agency
UB=Tier 10/Level 10
Facility Habilitation, T2020 U7 U5 UA UC U7=Waiver FSW 7/31/2020
Group 12:1 U5=DD CIH
UA=Agency
UC=Tier 12/Level 12
Facility Habilitation, T2020 U7 U5 UA UD U7=Waiver FSW 7/31/2020
Group 14:1 U5=DD CIH
UA=Agency
UD=Tier 14/Level 14
Facility Habilitation, T2020 U7 U5 UA U9 U7=Waiver FSW 7/31/2020
Group 16:1 U5=DD CIH
UA=Agency
U9=Tier 16/Level 16
Community Habilitation, T2020 U7 U5 U3 U7=Waiver FSW 7/31/2020
Group 3:1 U5=DD CIH
U3=Tier 3/Level 3
Community Habilitation, T2020 U7 U5 U4 U7=Waiver FSW 7/31/2020
Group 4:1 U5=DD CIH
U4=Tier 4/Level 4
Community Habilitation, T2020 U7 U5 U6 U7=Waiver FSW 7/31/2020
Group 6:1 U5=DD CIH
U6=Tier 6/Level 6
Community Habilitation, T2020 U7 U5 U8 U7=Waiver FSW 7/31/2020
Group 8:1 U5=DD CIH
U8=Tier 8/Level 8

Table 8 – Unchanged services or codes for FSW and/or CIH Waiver

Service Code Mod Mod Mod Mod Dsc Proc FSW FSW CIH CIH Notes
1 2 3 4 Modified Old New Old New

Adult Day Services, S5101 U7 U5 U1 U7=Waiver $23.05 $23.05 $23.05 $23.05 Half Day
Level 1 U5=DD
U1=Tier 1/Level 1
Adult Day Services, S5101 U7 U5 U2 U7=Waiver $30.24 $30.24 $30.24 $30.24 Half Day
Level 2 U5=DD
U2=Tier 2/Level 2

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IHCP bulletin BT202083 JUNE 30, 2020

Service Code Mod Mod Mod Mod Dsc Proc FSW FSW CIH CIH Notes
1 2 3 4 Modified Old New Old New

Adult Day Services, S5101 U7 U5 U3 U7=Waiver $36.00 $36.00 $36.00 $36.00 Half Day
Level 3 U5=DD
U3=Tier 3/Level 3
Adult Day Services, S5100 U7 U5 U1 U7=Waiver $1.45 $1.45 $1.45 $1.45 15 Minutes
¼ hour, Level 1 U5=DD
U1=Level 1
Adult Day Services, S5100 U7 U5 U2 U7=Waiver $1.89 $1.89 $1.89 $1.89 15 Minutes
¼ hour, Level 2 U5=DD
U2=Level 2
Adult Day Services, S5100 U7 U5 U3 U7=Waiver $2.25 $2.25 $2.25 $2.25 15 Minutes
¼ hour, Level 3 U5=DD
U3=Level 3
Psychological Therapy, H0004 U7 U5 U3 U7=Waiver $15.45 $15.45 $15.45 $15.45 15 Minutes
Individual U5=DD
U3=Level 3
Psychological Therapy, H0004 U7 U5 U2 U7=Waiver $18.20 $18.20 $18.20 $18.20 15 Minutes
Individual U5=DD
U2=Level 2
Behavior Management, H0004 U7 U5 U1 U7=Waiver $18.20 $18.20 $18.20 $18.20 15 Minutes
Level 1 U5=DD
U1=Level 1
Transitional Case T2038 U7 U5 UA U7=Waiver N/A N/A $131.25 $131.25 Monthly; 1 Unit/
Management Activities U5=DD Month up to 6
UA=Agency Units/Successful
Transition
Extended Services T2025 U7 U5 UA U7=Waiver $36.96 $36.96 $36.96 $36.96 Hour
U5=DD
UA=Agency
Rent & Food for T2025 U7 U5 U7=Waiver N/A N/A $545.00 $545.00 Month
Unrelated Live-In U5=DD
Caregiver
Equipment – T1028 U7 U5 U7=Waiver N/A N/A $36.96 $36.96 15 Minutes
Assess/Inspect/Train U5=DD
Intensive Behavioral H2020 U7 U5 U1 U7=Waiver $104.60 $104.60 $104.60 $104.60 Hour
Intervention, Level 1 U5=DD
U1=Level 1
Intensive Behavioral H2020 U7 U5 U2 U7=Waiver $25.00 $25.00 $25.00 $25.00 Hour
Intervention, Level 2 U5=DD
U2=Level 2

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IHCP bulletin BT202083 JUNE 30, 2020

Service Code Mod Mod Mod Mod Dsc Proc FSW FSW CIH CIH Notes
1 2 3 4 Modified Old New Old New

Music Therapy H2032 U7 U5 U1 U7=Waiver $10.78 $10.78 $10.78 $10.78 15 Minutes

U5=DD
U1=Level 1
Recreational Therapy H2032 U7 U5 U2 U7=Waiver $10.78 $10.78 $10.78 $10.78 15 Minutes
U5=DD
U2=Level 2
Occupational Therapy G0152 U7 U5 UA U7=Waiver $17.99 $17.99 $17.99 $17.99 15 Minutes
U5=DD
UA=Agency
Participant Assistance T2033 U7 U5 U7=Waiver $24.40 $24.40 N/A N/A Hour
and Care U5=DD
UA=Agency
Structured Family T2033 U7 U5 U1 U7=Waiver N/A N/A $51.87 $51.87 1 Unit/Day
Caregiving, Level 1 U5=DD
U1=Level 1
Structured Family T2033 U7 U5 U2 U7=Waiver N/A N/A $75.67 $75.67 1 Unit/Day
Caregiving, Level 2 U5=DD
U2=Level 2
Structured Family T2033 U7 U5 U3 U7=Waiver N/A N/A $102.87 $102.87 1 Unit/Day
Caregiving, Level 3 U5=DD
U3=Level 3
Personal Response S5160 U7 U5 U7=Waiver $52.07 $52.07 $52.07 $52.07 1 Unit
System, Install U5=DD
Personal Response S5161 U7 U5 U7=Waiver $52.07 $52.07 $52.07 $52.07 1 Unit/Month
System, Maintain U5=DD
Physical Therapy G0151 U7 U5 UA U7=Waiver $18.12 $18.12 $18.12 $18.12 15 Minutes
U5=DD
UA=Agency
Prevocational 2:1 T2015 U7 U5 U2 U7=Waiver $8.90 $8.90 $8.90 $8.90 Hour
U5=DD Oasis
U2=Level 2
Prevocational 4:1 T2015 U7 U5 U4 U7=Waiver $8.90 $8.90 $8.90 $8.90 Hour
U5=DD
U4=Level 4
Prevocational 6:1 T2015 U7 U5 U6 U7=Waiver $4.96 $4.96 $4.96 $4.96 Hour
U5=DD
U6=Level 6
Prevocational 8:1 T2015 U7 U5 U8 U7=Waiver $4.96 $4.96 $4.96 $4.96 Hour
U5=DD
U8=Level 8

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IHCP bulletin BT202083 JUNE 30, 2020

Service Code Mod Mod Mod Mod Dsc Proc FSW FSW CIH CIH Notes
1 2 3 4 Modified Old New Old New

Prevocational 10:1 T2015 U7 U5 UB U7=Waiver $4.96 $4.96 $4.96 $4.96 Hour

U5=DD
UB=Level 10
Prevocational 12:1 T2015 U7 U5 UC U7=Waiver $3.15 $3.15 $3.15 $3.15 Hour
U5=DD
UC=Level 12
Prevocational 14:1 T2015 U7 U5 UD U7=Waiver $3.15 $3.15 $3.15 $3.15 Hour
U5=DD
UD=Level 14
Prevocational 16:1 T2015 U7 U5 U9 U7=Waiver $3.15 $3.15 $3.15 $3.15 Hour
U5=DD
U9=Level 16
Psychological Therapy, 90846 U7 U5 U7=Waiver $17.27 $17.27 $17.27 $17.27 15 Minutes
Family U5=DD
Psychological Therapy, 90853 U7 U5 U7=Waiver $4.81 $4.81 $4.81 $4.81 15 Minutes
Group U5=DD
Residential Habilitation T2016 U7 U5 UA U7=Waiver N/A N/A $26.15 $26.15 Hour
Services, Level 1 (35 or U5=DD
Less Hours/Week) UA=Agency
Residential Habilitation T2016 U7 U5 U7=Waiver N/A N/A $21.97 $21.97 Hour
Services, Level 2 (Over U5=DD
35 Hours/Week)
RHS Daily Level 1 T2016 U7 U5 UN UA U7=Waiver N/A N/A $171.33 $171.33 1 Unit/Day
(2 Person Setting, Algo U5=DD
Level 3) UN=2 Patients
UA=Agency
RHS Daily Level 2 T2016 U7 U5 UN UB U7=Waiver N/A N/A $241.63 $241.63 1 Unit/Day
(2 Person Setting, Algo U5=DD
Level 4) UN=2 Patients
UB=Face 2 Face
RHS Daily Level 3 T2016 U7 U5 UN UC U7=Waiver N/A N/A $263.59 $263.59 1 Unit/Day
(2 Person Setting, Algo U5=DD
Level 5) UN=2 Patients
UC=Case Mgmt
RHS Daily Level 4 T2016 U7 U5 UP UA U7=Waiver N/A N/A $171.33 $171.33 1 Unit/Day
(3 Person Setting, Algo U5=DD
Level 3) UP=3 Patients
UA=Agency

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IHCP bulletin BT202083 JUNE 30, 2020

Service Code Mod Mod Mod Mod Dsc Proc FSW FSW CIH CIH Notes
1 2 3 4 Modified Old New Old New

RHS Daily Level 5 T2016 U7 U5 UP UB U7=Waiver N/A N/A $221.85 $221.85 1 Unit/Day
(3 Person Setting, Algo U5=DD
Level 4) UP=3 Patients
UB=Face 2 Face
RHS Daily Level 6 T2016 U7 U5 UP UC U7=Waiver N/A N/A $241.63 $241.63 1 Unit/Day
(3 Person Setting, Algo U5=DD
Level 5) UP=3 Patients
UC=Case Mgmt
RHS Daily Level 7 T2016 U7 U5 UQ UA U7=Waiver N/A N/A $160.35 $160.35 1 Unit/Day
(4 Person Setting, Algo U5=DD
Level 3) UQ=4 Patients
UA=Agency
RHS Daily Level 8 T2016 U7 U5 UQ UB U7=Waiver N/A N/A $206.47 $206.47 1 Unit/Day
(4 Person Setting, Algo U5=DD
Level 4) UQ=4 Patients
UB=Face 2 Face
RHS Daily Level 9 T2016 U7 U5 UQ UC U7=Waiver N/A N/A $219.66 $219.66 1 Unit/Day
(4 Person Setting, Algo U5=DD
Level 5) UQ=4 Patients
UC=Case Mgmt
Respite S5151 U7 U5 U7=Waiver $26.15 $26.15 $26.15 $26.15 Hour
U5=DD
Respite T1005 U7 U5 TD U7=Waiver $7.79 $7.79 $7.79 $7.79 15 minutes
U5=DD
TD=RN
Respite T1005 U7 U5 TE U7=Waiver $5.91 $5.91 $5.91 $5.91 15 minutes
U5=DD
TE=LPN
Specialized Medical T2029 U7 U5 NU U7=Waiver Individual Individual N/A N/A $7,500 Lifetime
Equip/Supply, Install U5=DD
NU=New DME
Specialized Medical T2029 U7 U5 NU U7=Waiver N/A N/A Individual Individual
Equip/Supply, Install U5=DD
NU=New DME
Specialized Medical T2029 U7 U5 U8 U7=Waiver Individual Individual Individual Individual $500/Year
Equip/Supply, Maintain U5=DD
U8=Repair
Speech Therapy 92507 U7 U5 UA U7=Waiver $18.12 $18.12 $18.12 $18.12 15 Minutes
U5=DD
UA=Agency

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IHCP bulletin BT202083 JUNE 30, 2020

Service Code Mod Mod Mod Mod Dsc Proc FSW FSW CIH CIH Notes
1 2 3 4 Modified Old New Old New

Transportation, Level 1 T2002 U7 U5 U7=Waiver $5.25 $5.25 N/A N/A 2 Trips/Day

U5=DD
Transportation, Level 1 T2002 U7 U5 U7=Waiver N/A N/A $5.25 $5.25 Per Trip; 2
U5=DD Trips/Day;
$2,625/Year
Transportation, Level 2 T2002 U7 U5 U2 U7=Waiver N/A Added $21.00 $21.00 Per Trip; 2
U5=DD Trips/Day;
U2=Level 2 $5,250/Year
Transportation, Level 3 T2002 U7 U5 U3 U7=Waiver N/A Added $42.00 $42.00 Per Trip; 2
U5=DD Trips/Day;
U3=Level 3 $7,875/Year
Vehicle Modification, T2039 U7 U5 U7=Waiver Individual Individual N/A N/A $7,500 Lifetime
Install U5=DD
Vehicle Modification, T2039 U7 U5 U7=Waiver N/A N/A Individual Individual $15,000 Lifetime
Install U5=DD
Vehicle Modification, T2039 U7 U5 U8 U7=Waiver Individual Individual Individual Individual $500/Year
Maintain U5=DD
U8=Repair
Wellness Coordination, T2022 U7 U5 U1 U7=Waiver N/A N/A $52.77 $52.77 1 Unit/Month
Tier 1 U5=DD
U1=Level 1
Wellness Coordination, T2022 U7 U5 U2 U7=Waiver N/A N/A $111.96 $111.96 1 Unit/Month
Tier 2 U5=DD
U2=Level 2
Wellness Coordination, T2022 U7 U5 U3 U7=Waiver N/A N/A $223.92 $223.92 1 Unit/Month
Tier 3 U5=DD
U3=Level 3
Workplace Assistance T1020 U7 U5 U7=Waiver $27.69 $27.69 $27.69 $27.69 Hour
U5=DD
Facility-Based Support T1020 U7 U5 UA U7=Waiver $1.94 $1.94 $1.94 $1.94 Hour
U5=DD
UA=Agency
Environmental S5165 U7 U5 NU U7=Waiver N/A Added Individual Individual 1 Unit/$15,000
Modification, Install U5=DD Lifetime Cap
NU=New DME
Environmental S5165 U7 U5 U8 U7=Waiver N/A Added Individual Individual 1 Unit/$500 per
Modification, Maintain U5=DD Year
U8=Repair

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