IHCP bulletin

INDIANA HEALTH COVERAGE PROGRAMS BT202359 JUNE 6, 2023

IHCP announces new rates for DA and DDRS

waivers, effective July 1, 2023
The Indiana Health Coverage Programs (IHCP) announces, effective July 1, 2023, the Division of Aging (DA) Aged
and Disable (A&D) Waiver and the Traumatic Brain Injury (TBI) Waiver, along with the Division of Disability and
Rehabilitation Services (DDRS) Community Integration and Habilitation (CIH) Waiver and the Family Supports Waiver
(FSW) will have new rates, pending approval from the Centers for Medicare & Medicaid Services (CMS).

Providers are asked to begin billing with the new rates for
claims with dates of service (DOS) on or after July 1, 2023.
After the CMS approves the rates, Gainwell Technologies
will mass adjust all claims for these home- and community-
based services (HCBS) waivers with DOS on or after July 1,
2023. For any waiver claims that are submitted with the old
rates with DOS on or after July 1, 2023, providers will be
required to submit corrected claims to get paid the new rate.
Table 1 shows the new rates for the A&D and TBI waiver
services and Table 2 reflects the CIH and FSW new rates.

All questions can be emailed to FSSA HCBS Rate Methodology.

COPIES OF THIS PUBLICATION SIGN UP FOR IHCP EMAIL NOTIFICATIONS

If you need additional copies of this publication, To receive email notices of IHCP publications, subscribe
please download them from the IHCP Bulletins by clicking the blue subscription envelope
page of the IHCP provider website at or sign up from the IHCP provider website
in.gov/medicaid/providers. at in.gov/medicaid/providers.

Page 1 of 1
IHCP bulletin BT202359 JUNE 6, 2023

Table 1 – A&D and TBI rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Service Service unit Waiver Old rate New rate Limits
code 1 2 3
97535 U7 Residential Based 15 minutes TBI $6.99 $9.45
Habilitation
B4150 U7 Nutritional Supplements Cap A&D/TBI Individual Individual $1,200/year
H0004 U7 U1 Behavioral Health 15 minutes TBI $18.20 $18.56
Counseling – Level 1
H0004 U7 U2 Behavioral Health 15 minutes TBI $18.20 $18.56
Counseling – Level 2
H0004 U7 U4 Caregiver Coaching and 15 minutes A&D $10.00 $15.75 Max of 8 hours/month
Behavioral Management
H2023 U7 Supported Employment 15 minutes TBI $9.17 $11.91
S5100 U7 U1 UC Adult Day Service – Level 1 15 minutes A&D/TBI $2.82 $3.32
(Category 1)
S5100 U7 U2 UC Adult Day Service – Level 2 15 minutes A&D/TBI $3.40 $3.74
(Category 1)
S5100 U7 U3 UC Adult Day Service – Level 3 15 minutes A&D/TBI $3.91 $4.76
(Category 1)
S5100 U7 U1 Adult Day Service – Level 1 15 minutes A&D/TBI $2.64 $2.93
(Category 2)
S5100 U7 U2 Adult Day Service – Level 2 15 minutes A&D/TBI $3.18 $3.30
(Category 2)
S5100 U7 U3 Adult Day Service – Level 3 15 minutes A&D/TBI $3.66 $4.20
(Category 2)
S5125 U7 UA Attendant Care (Agency) 15 minutes A&D/TBI $5.82 $8.59
S5125 U7 UA UC Attendant Care (Agency 15 minutes A&D/TBI $5.82 $8.59
NEMT)
S5125 U7 Attendant Care – Non- 15 minutes A&D/TBI $4.05 $8.21
Agency
S5125 U7 U1 Attendant Care – 15 minutes A&D $3.61 $8.21
Consumer Directed
S5125 U7 U1 TU Attendant Care – 15 minutes A&D $1.81 $1.81
Consumer Directed
Overtime
S5125 U7 U2 UA Participant-Directed 15 minutes A&D $11.99 $14.97
Attendant Care (PDAC)
S5125 U7 U2 U9 Participant-Directed Home 15 minutes A&D $5.82 $8.59
Care Services (PDHCS)
S5130 U7 UA Home and Community 15 minutes A&D/TBI $4.99 $7.93
Assistance – Agency

Division of Aging and DDRS Waiver Rate Updates 1 of 6

IHCP bulletin BT202359 JUNE 6, 2023

Table 1 – A&D and TBI rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Service Service unit Waiver Old rate New rate Limits
code 1 2 3
S5130 U7 Home and Community 15 minutes A&D/TBI $4.59 $7.68
Assistance – Non-Agency
S5140 U7 U1 Structured Family Per day A&D $60.50 $77.54
Caregiving – Level 1
S5140 U7 U2 Structured Family Per day A&D $71.04 $99.71
Caregiving – Level 2
S5140 U7 U3 Structured Family Per day A&D $81.58 $133.44
Caregiving – Level 3
S5141 U7 U1 Adult Family Care – Level 1 1 day A&D/TBI $60.23 $67.93
S5141 U7 U2 Adult Family Care – Level 2 1 day A&D/TBI $69.50 $72.34
S5141 U7 U3 Adult Family Care – Level 3 1 day A&D/TBI $82.14 $90.64
S5150 U7 UA U9 Respite – Unskilled 15 minutes A&D/TBI $5.59 $9.23
S5160 U7 Emergency Response – One time A&D/TBI $54.41 $54.41
Install
S5161 U7 Emergency Response – Monthly A&D/TBI $54.41 $54.41
Service
S5165 U7 NU Home Modification – Install Cap A&D/TBI Individual Individual $20,000 lifetime cap
S5165 U7 U8 Home Modification – Cap A&D/TBI Individual Individual $1,000/year
Maintenance
S5170 U7 Home Delivered Meals Per meal A&D/TBI $6.00 $7.76
T1005 U7 UA TE Respite – LPN 15 minutes A&D/TBI $10.57 $13.69
T1005 U7 UA TD Respite – RN 15 minutes A&D/TBI $14.33 $17.10
T1028 U7 Home Modification – Per project A&D $574.38 $628.00
Assessment
T2003 U7 U1 UB Non-Medical Base trip A&D/TBI $8.02 $12.12
Transportation/Non-
Assisted
T2003 U7 U1 Non-Medical Mileage A&D/TBI $1.06 $1.06 Round-trip mile
Transportation/Non-
Assisted
T2003 U7 U2 UB Non-Medical Base trip A&D/TBI $12.03 $20.19
Transportation/Assisted
T2003 U7 U2 Non-Medical Mileage A&D/TBI $1.54 $1.54 Round-trip mileage
Transportation/Assisted
T2021 U7 HQ Structured Day Program – 15 minutes TBI $1.67 $2.35
Group
T2021 U7 Structured Day Program – 15 minutes TBI $8.38 $10.05
Individual
T2022 U7 Care Management Monthly A&D/TBI $134.33 $189.56

Division of Aging and DDRS Waiver Rate Updates 2 of 6

IHCP bulletin BT202359 JUNE 6, 2023

Table 1 – A&D and TBI rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Service Service unit Waiver Old rate New rate Limits
code 1 2 3
T2022 U7 U1 Healthcare Coordination 15 minutes A&D/TBI $10.30 $14.21 Max of 16 hours/month
T2025 U7 U1 Pest Control Cap A&D/TBI Individual Individual $4,000/year
T2029 U7 NU Specialized Medical Cap A&D/TBI Individual Individual $15,000 cap subject to
Equipment – New DME review; no limit
T2029 U7 U8 Specialized Medical Cap A&D/TBI Individual Individual $1,000/year
Equipment –
Replacement/Repair
T2031 U7 U1 Assisted Living – Level 1 Daily A&D/TBI $75.35 $101.98
T2031 U7 U2 Assisted Living – Level 2 Daily A&D/TBI $83.68 $112.15
T2031 U7 U3 Assisted Living – Level 3 Daily A&D/TBI $96.85 $132.04
T2031 U7 U1 UA Assisted Living – Level 1 Monthly A&D/TBI $2,237.90 $3,028.81
T2031 U7 U2 UA Assisted Living – Level 2 Monthly A&D/TBI $2,485.30 $3,330.86
T2031 U7 U3 UA Assisted Living – Level 3 Monthly A&D/TBI $2,876.45 $3,921.59
T2038 U7 Community Transition Cap A&D/TBI $1,500.00 $2,500.00 Lifetime cap
T2039 U7 Vehicle Modification Cap A&D Individual Individual $15,000/every 10 years
T2039 U7 U8 Vehicle Modification – Cap A&D Individual Individual $1,000/year
Maintenance

Table 2 – CIH and FSW rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Mod 4 Service Service unit Waiver Old rate New rate Limits
code 1 2 3
90846 U7 U5 Psychological Therapy 15 minutes CIH/FSW $17.27 $17.27
90853 U7 U5 Psychological Therapy 15 minutes CIH/FSW $4.81 $4.81
92507 U7 U5 UA Speech/Language Therapy 15 minutes CIH/FSW $18.12 $18.12
A9279 U7 U5 NU Remote Supports – Cap CIH/FSW Individual Individual $500/year
Equip/Install
A9279 U7 U5 UA Remote Supports – 1 hour CIH/FSW $13.62 $24.26
1 Individual
A9279 U7 U5 U2 Remote Supports – 1 hour CIH/FSW $6.81 $12.13
2 Individuals
A9279 U7 U5 U3 Remote Supports – 1 hour CIH/FSW $4.54 $8.09
3 Individuals
A9279 U7 U5 U4 Remote Supports – 1 hour CIH/FSW $3.41 $6.06
4 Individuals
G0151 U7 U5 Physical Therapy 15 minutes CIH/FSW $18.12 $18.12
G0152 U7 U5 UA Occupational Therapy 15 minutes CIH/FSW $17.99 $17.99

Division of Aging and DDRS Waiver Rate Updates 3 of 6

IHCP bulletin BT202359 JUNE 6, 2023

Table 2 – CIH and FSW rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Mod 4 Service Service unit Waiver Old rate New rate Limits
code 1 2 3
H0004 U7 U5 U2 Behavioral Management – 15 minutes CIH/FSW $18.20 $18.56
Basic
H0004 U7 U5 U1 Behavioral Management – 15 minutes CIH/FSW $18.20 $18.56
Level 1
H0004 U7 U5 U3 Psychological Therapy 15 minutes CIH/FSW $15.45 $15.45
H2020 U7 U5 U1 Intensive Behavioral 1 hour CIH/FSW $104.60 $104.60
Intervention – Level 1
H2020 U7 U5 U2 Intensive Behavioral 1 hour CIH/FSW $25.00 $39.53
Intervention – Level 2
H2032 U7 U5 U1 Music Therapy 15 minutes CIH/FSW $10.78 $16.81
H2032 U7 U5 U2 Recreational Therapy 15 minutes CIH/FSW $10.78 $16.81
S5100 U7 U5 U1 Adult Day Services – Level 1 15 minutes CIH/FSW $1.65 $2.93
S5100 U7 U5 U2 Adult Day Services – Level 2 15 minutes CIH/FSW $2.15 $3.30
S5100 U7 U5 U3 Adult Day Services – Level 3 15 minutes CIH/FSW $2.57 $4.20
S5101 U7 U5 U1 Adult Day Service – Level 1 Half day CIH/FSW $26.28 $37.18

S5101 U7 U5 U2 Adult Day Service – Level 2 Half day CIH/FSW $34.47 $43.75
S5101 U7 U5 U3 Adult Day Service – Level 3 Half day CIH/FSW $41.04 $54.74
S5111 U7 U5 Family & Caregiver Training – Cap CIH/FSW Individual Individual $5,000/year
Family
S5116 U7 U5 Family & Caregiver Training – Cap CIH/FSW Individual Individual $5,000/year
Non-Family
S5151 U7 U5 Respite – Unskilled 1 hour CIH/FSW $29.81 $43.38
S5160 U7 U5 Personal Response System, One time CIH/FSW $52.07 $54.41
Install
S5161 U7 U5 Personal Response System, Monthly CIH/FSW $52.07 $54.41
Service
S5165 U7 U5 NU Environmental Modification – Cap CIH/FSW $15,000 Individual $20,000 lifetime
Install
S5165 U7 U5 U8 Environmental Modification – Cap CIH/FSW $500.00 Individual $1,000/year
Maintenance
T1005 U7 U5 TD Respite – RN 15 minutes CIH/FSW $8.88 $17.10
T1005 U7 U5 TE Respite – LPN 15 minutes CIH/FSW $6.74 $13.69
T1020 U7 U5 Workplace Assistance 1 hour CIH/FSW $31.57 $38.36
T1020 U7 U5 UA Facility Based Support 1 hour CIH/FSW $2.21 $2.51
T1028 U7 U5 Equipment – 15 minutes CIH/FSW $17.99 $18.53
Assess/Inspect/Train
T2002 U7 U5 Transportation, Level 1 1 trip CIH/FSW $5.99 $15.05 $6,600 max/year

Division of Aging and DDRS Waiver Rate Updates 4 of 6

IHCP bulletin BT202359 JUNE 6, 2023

Table 2 – CIH and FSW rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Mod 4 Service Service unit Waiver Old rate New rate Limits
code 1 2 3
T2002 U7 U5 U2 Transportation, Level 2 1 trip CIH/FSW $23.94 $26.52 $6,600 max/year
T2002 U7 U5 U3 Transportation, Level 3 1 trip CIH/FSW $47.88 $47.88 $7,875 max/year
T2015 U7 U5 U2 UF or UG Prevocational (2:1) 1 hour CIH/FSW $10.15 $10.81
T2015 U7 U5 U4 UF or UG Prevocational (4:1) 1 hour CIH/FSW $10.15 $10.81
T2015 U7 U5 U6 UF or UG Prevocational (6:1) 1 hour CIH/FSW $5.65 $5.66
T2015 U7 U5 UA UF or UG Prevocational (8:1) 1 hour CIH/FSW $5.65 $5.66
T2015 U7 U5 UB UF or UG Prevocational (10:1) 1 hour CIH/FSW $5.65 $5.66
T2015 U7 U5 UC UF or UG Prevocational (12:1) 1 hour CIH/FSW $3.59 $3.73
T2015 U7 U5 UD UF or UG Prevocational (14:1) 1 hour CIH/FSW $3.59 $3.73
T2015 U7 U5 U9 UF or UG Prevocational (16:1) 1 hour CIH/FSW $3.59 $3.73
T2016 U7 U5 UA Residential Habilitation – 1 hour CIH $29.51 $36.27
Level 1 (35 hours or
less/week)
T2016 U7 U5 Residential Habilitation – 1 hour CIH $25.05 $32.27
Level 2 (over 35 hours/week)
T2016 U7 U5 UN UA RHS Daily – Level 1 (2- Per day CIH $195.32 $219.47
Person Setting, Algo Level 3)
T2016 U7 U5 UN UB RHS Daily – Level 2 (2- Per day CIH $275.46 $305.43
Person Setting, Algo Level 4)
T2016 U7 U5 UN UC RHS Daily – Level 3 (2- Per day CIH $300.49 $336.61
Person Setting, Algo Level 5)
T2016 U7 U5 UP UA RHS Daily – Level 4 (3- Per day CIH $195.32 $206.87
Person Setting, Algo Level 3)
T2016 U7 U5 UP UB RHS Daily – Level 5 (3- Per day CIH $252.91 $280.27
Person setting, Algo Level 4)
T2016 U7 U5 UP UC RHS Daily – Level 6 (3- Per day CIH $275.46 $319.32
Person Setting, Algo Level 5)
T2016 U7 U5 UQ UA RHS Daily – Level 7 (4- Per day CIH $182.80 $202.86
Person Setting, Algo Level 3)
T2016 U7 U5 UQ UB RHS Daily – Level 8 (4- Per day CIH $235.38 $255.62
Person Setting, Algo Level 4)
T2016 U7 U5 UQ UC RHS Daily – Level 9 (4- Per day CIH $250.41 $284.91
Person Setting, Algo Level 5)
T2020 U7 U5 UF or Day Habilitation – Individual 1 hour CIH/FSW $28.33 $36.88
UG
T2020 U7 U5 U2 UF or UG Day Habilitation – Group 1 hour CIH/FSW $10.15 $13.28
Small (2:1 to 4:1)
T2020 U7 U5 UA UF or UG Day Habilitation – Group 1 hour CIH/FSW $5.65 $6.54
Medium (5:1 to 10:1)

Division of Aging and DDRS Waiver Rate Updates 5 of 6

IHCP bulletin BT202359 JUNE 6, 2023

Table 2 – CIH and FSW rates, effective for DOS on or after July 1, 2023

Procedure Mod Mod Mod

Mod 4 Service Service unit Waiver Old rate New rate Limits
code 1 2 3
T2020 U7 U5 UB UF or UG Day Habilitation – Group 1 hour CIH/FSW $3.59 $4.20
Large (11:1 to 16:1)
T2022 U7 U5 Case Management Monthly CIH/FSW $143.75 $189.56
T2022 U7 U5 U1 Wellness Coordination, Tier 1 Monthly CIH $52.77 $118.66
T2022 U7 U5 U2 Wellness Coordination, Tier 2 Monthly CIH $111.96 $163.02
T2022 U7 U5 U3 Wellness Coordination, Tier 3 Monthly CIH $223.92 $251.74
T2025 U7 U5 Rent & Food for Unrelated Monthly CIH $545.00 $545.00
Live-in Caregiver
T2025 U7 U5 UA Extended Services 1 hour CIH/FSW $42.13 $52.85
T2029 U7 U5 NU Specialized Medical Cap CIH/FSW $7500.00 Individual $15,000 lifetime cap
Equip/Install
T2029 U7 U5 U8 Specialized Medical Cap CIH/FSW $500.00 Individual $1,000/year
Equip/Maintain
T2033 U7 U5 U1 Structured Family Caregiving, Per day CIH $51.87 $77.54
Level 1
T2033 U7 U5 U2 Structured Family Caregiving, Per day CIH $75.67 $99.71
Level 2
T2033 U7 U5 U3 Structured Family Caregiving, Per day CIH $102.87 $133.44
Level 3
T2033 U7 U5 Participant Assistance and 1 hour FSW $27.82 $34.39
Care
T2038 U7 U5 Community Transition Cap CIH Individual Individual $2,500/lifetime
T2038 U7 U5 UA Transitional Case Monthly CIH $131.25 $180.55 Up to six months
Management Activities based on successful
transition
T2039 U7 U5 Vehicle Modification, Install Cap CIH/FSW Individual Individual $15,000/every 10
years
T2039 U7 U5 U8 Vehicle Modification, Cap CIH/FSW Individual Individual $1,000/year
Maintenance

Division of Aging and DDRS Waiver Rate Updates 6 of 6