A. Billing Guidance by Activity/Service Type

• Participating in Personal Plan development and monitoring
• Visiting individuals, including travel time
• Completing and filing required documents, such as the annual redetermination of Waiver Eligibility and visiting notes
• Telephone calls on behalf of the individual
• See the Independent Service Coordination Manual 9.1 for more specific information

• Time spent assessing or determining initial eligibility of an individual for waiver services
• Time spent providing a service to an individual or family after the individual is no longer receiving the direct waiver service
• QIDP training time or other general activities that are not for the direct benefit of the waiver individual
• Time spent entering billing in ROCS

• Bill daily for every date the individual is present and receiving services in the residential site for at least part of the date (the date is considered to be from midnight to midnight).
  • Use the code: P - present.

• Absence code days using the following absence codes:
  • F - vacation or family/home visits
  • H - hospitalization
  • C - convalescent care
  • S - State-operated facility stays
  • I - incarceration

Direct and limited Indirect Contact Time:

• Direct contact time is direct engagement with the individual(s) in-person, by phone or virtually.
• Reimbursement rate is set according to the ratio of the number of individuals served at one time by one provider agency staff (1:1, 1:2, 1:3).
• A provider agency can't service more than 3 individuals with 1 staff member and bill for any individual over 3.
• Agency staff must document the date of service, start time, stop time, and names of individuals served.

Indirect Contact Time:

• While the predominance of billing for any day, week or month must be direct contact, billing may also be submitted for indirect services and supports.
• Billing for indirect services and supports may not exceed 15% of the weekly award.
  • If an individual is awarded 10 hours per week, no more than 1.5 of those hours may be billed as indirect support.
  • If an individual is awarded 15 hours per week, no more than 2.25 of those hours may be billed as indirect support.
  • If an individual is awarded 20 hours, billing for indirect services is capped at 3 hours per week.
• Indirect supports may include:
  • Documenting services of the in-person visits (case or progress notes)
  • Contact with family or guardian(s)
  • Contact with external behavioral or medical professionals
  • Contact with pharmacies for medication management
  • Contact with landlords, utility companies, household maintenance companies or other service providers that would support the person's living arrangement
  • Contact to maintain a person's benefits or entitlements
  • Contact with law enforcement / crisis abatement
• Indirect supports should never be billed at a 1:2 or 1:3 rate.

• More information under VI. Waiver Activities and Services - Residential Habilitation Services
• 61H, 62H, and 63H should not be provided at the same time as other services such as Behavior Intervention and Treatment, Counseling, Community Day Services or the Supported Employment Program.

• Bill daily for every date the individual is present and receiving services in the residential site for at least part of the date (the date is considered to be from midnight to midnight).
  • Use the code: P - present
• Bill Bed hold Days using the following bed hold codes:
  • F - vacation or family/home visits
  • H - hospitalization
  • C - convalescent care
  • S - State-operated facility stays
  • I - incarceration

• Bill daily for every date the individual is present and receiving services in the residential site for at least part of the date (the date is considered to be from midnight to midnight).
  • Use the code: P - present

• Bill Bed hold Days using the following bed hold codes:
  • F - vacation or family/home visits
  • H - hospitalization
  • C - convalescent care
  • S - State-operated facility stays
  • I - incarceration

• The payment rates include transportation costs.
• Only hours when the individual is participating actively in day program activities are billable.
• When conducting Community Day Services in the community (31C), a provider can begin billing when they arrive at the first site of the day and will stop billing for services when they leave the last site of the day. They can bill for all services in between other than during lunch as indicated below.

• Holidays and weekends when the programs are closed.
• Time beyond regularly scheduled program hours for special events, such as extended field trips, overnight outings, etc.
• Transportation time, unless the individual's Personal Plan indicates a need for transportation training and the training is being provided.
• Time between arrival and the start of active programming.
• Time after the end of active programming while waiting for transportation.
• Lunchtime, unless the individual's Personal Plan indicates a need for active programming during lunch and the training is being provided.
• Time spent receiving therapy services. Community Day program hours may not be billed when an individual is receiving direct professional behavior services or other non-day program services.

• See VI. Waiver Activities and Services
• Hours billed may not also be billed to the Division of Rehabilitation Services Vocational Rehabilitation Program.
• Supported Employment Program service payments are made only for the adaptations, supervision and training required by individuals receiving waiver services, as a result of their disabilities, to sustain employment at competitive wages in integrated settings.

Does not include payment for the supervisory activities rendered as a normal part of the business setting.

Examples of time that are not billable include:

• See VI. Waiver Activities and Services
• Transportation time, unless the individual's Personal Plan indicates a need for transportation training and the training is being provided.
• Time between arrival and the start of active programming.
• Time after the end of active programming while waiting for transportation.
• Lunchtime, unless the individual's Personal Plan indicates a need for active programming during lunch and the training is being provided.
• Supported Employment Program hours may not be billed for the same time an individual is receiving other Medicaid funded services.

• See VI. Waiver Activities and Services
• Hours billed may not also be billed to the Division of Rehabilitation Services Vocational Rehabilitation Program.
• Supported Employment Program service payments are made only for the adaptations, supervision and training required by individuals receiving waiver services, as a result of their disabilities, to sustain employment at competitive wages in integrated settings.

Does not include payment for the supervisory activities rendered as a normal part of the business setting.

Examples of time that are not billable include:

• See VI. Waiver Activities and Services
• Transportation time, unless the individual's Personal Plan indicates a need for transportation training and the training is being provided.
• Time between arrival and the start of active programming.
• Time after the end of active programming while waiting for transportation.
• Lunchtime, unless the individual's Personal Plan indicates a need for active programming during lunch and the training is being provided.
• Supported Employment Program hours may not be billed for the same time an individual is receiving other Medicaid funded services.

• The payment rates include transportation costs.
• Only hours when the individual is participating actively in day program activities are billable.

Hours billed may not also be billed to the Department on Aging or the Division of Rehabilitation Services Home Services Program.

Examples of time that are not billable include:

• Holidays and weekends when the program is closed.
• Time beyond regularly scheduled program hours for special events, such as extended field trips, overnight outings, etc.
• Transportation time, unless the individual's Personal Plan indicates a need for transportation training and the training is being provided.
• Time between arrival and the start of active programming.
• Time after the end of active programming while waiting for transportation.
• Lunchtime, unless the individual's Personal Plan indicates a need for active programming during lunch and the training is being provided.
• Time spent receiving therapy services. Day program hours may not be billed when an individual is receiving direct professional behavior services or other non-day program services.

• The payment rates include transportation costs.
• Only hours when the individual is participating actively in day program activities are billable.

• Holidays and weekends when the program is closed.
• Time beyond regularly scheduled program hours for special events, such as extended field trips, overnight outings, etc.
• Transportation time, unless the individual's Personal Plan indicates a need for transportation training and the training is being provided.
• Lunchtime, unless the individual's Personal Plan indicates a need for active programming during lunch and the training is being provided.
• Time spent receiving therapy services. Day program hours may not be billed when an individual is receiving direct professional behavior services or other non-day program services.

• Only hours when the individual is actively participating in the VDS activity are billable.

• *Anytime when the service is not being provided.
• *VDS facilitator time between arrival to the virtual setting and the start of active programming.
• *VDS activities should not be billed and provided during an individual's lunch hours unless there is programming occurring. Break times can be scheduled as part of the program, but these break times are not billable.
• *Individuals can't receive any other waiver services (such as therapy, counseling, etc.) during the time the VDS provider is billing, with the exception of Enhanced Residential (37U).

• For HBS, Behavior Intervention and Treatment is included in the individual's monthly cost limit/individual budget.
• Adult Waiver: State fiscal year maximum of 104 hours (including adult HBS).
• Children's Support Waiver (Children's HBS): No fiscal year service maximum.
• Children's Residential Waiver: State fiscal year maximum of 66 hours.

Hours and minutes will be rounded to the nearest 15 minutes. 7 minutes or less can be rounded down. 7.5 minutes or above is to be rounded up.

There are two levels:

• Level 1: Licensed clinical psychologists and certified behavior analysts
• Level 2: All other qualified providers

• Services that directly benefit the individual, are within the statewide maximums and the agreed hours in the HBS Service Agreement, if applicable, and the therapist delivered and documented.
• Indirect services such as writing recommendations, planning, and consultations with school personnel are permitted.

• No direct services may be delivered under the Waiver during the typical school day relative to the age of the individual or during times when educational services are being provided.
• Planning for school services and training for school staff may not be billed.
• Behavior service hours may not be billed during day program hours, unless the professional is observing the behaviors in the natural environment while the individual is participating as usual in the day program.

• Services that directly benefit the individual, are within the statewide maximums, and the agreed hours in the HBS Service Agreement, if applicable, and the counselor delivered and documented.
• Up to 15% of billable time may be billed for indirect or administrative services such as writing recommendations, planning, and developing the treatment plan.

• Time billed may not also be billed to the Division of Mental Health Community Mental Health Medicaid Rehabilitation Option or Clinic Option (MRO/MCO).
• Behavior service hours may not be billed during day program hours, unless the professional is observing the behaviors in the natural environment while the individual is participating as usual in the day program.

• Services that directly benefit the individual, are within the statewide maximums, and the agreed hours in the HBS Service Agreement, if applicable, and the counselor delivered and documented.
• Up to 15% of billable time may be billed for indirect or administrative services such as writing recommendations, planning, and developing the treatment plan.

• Time billed may not also be billed to the Division of Mental Health Community Mental Health Medicaid Rehabilitation Option or Clinic Option (MRO/MCO).
• Behavior service hours may not be billed during day program hours, unless the professional is observing the behaviors in the natural environment while the individual is participating as usual in the day program.

• Services that directly benefit the individual, are within the statewide maximums, and the agreed hours in the HBS Service Agreement, if applicable, and the therapist delivered and documented.
• Up to 15% of billable time may be billed for indirect or administrative services such as writing recommendations, planning, and developing the treatment plan.

• Time billed may not also be billed to the Division of Mental Health Community Mental Health Medicaid Rehabilitation Option or Clinic Option (MRO/MCO).
• Behavior service hours may not be billed during day program hours, unless the professional is observing the behaviors in the natural environment while the individual is participating as usual in the day program.

• Services that directly benefit the individual, are within the statewide maximums, and the agreed hours in the HBS Service Agreement, if applicable, and the therapist delivered and documented.
• Up to 15% of billable time may be billed for indirect or administrative services such as writing recommendations, planning, and developing the treatment plan.

• Time billed may not also be billed to the Division of Mental Health Community Mental Health Medicaid Rehabilitation Option or Clinic Option (MRO/MCO).
• Behavior service hours may not be billed during day program hours, unless the professional is observing the behaviors in the natural environment while the individual is participating as usual in the day program.

• The therapist may bill for time spent working directly with the individual or, for occupational and physical therapy, the time a certified/licensed assistant under his or her direct supervision spends working directly with the individual in accordance with the individual Personal Plan. Direct supervision means the therapist is accessible at all times while the assistant is treating individuals. It also means the therapist does on-site supervision every four to six sessions to assess progress and revise the treatments as needed.
• Time spent with the individual demonstrating specific interventions to be used by family, direct support, and other workers to ensure they will be done properly and frequently enough to be effective.
• Participation in development of the Personal Plan.

• Time spent by the therapist supervising assistants.
• Time spent in general staff training.
• Evaluations, including evaluations for equipment or fittings, may not be billed to the Division of DD. They must be billed to the Department of Healthcare and Family Services Medicaid State Plan instead.
• Transportation time.
• Time when the individual is receiving therapy services is not billable as day program services.
• Time billed to the Department of Healthcare and Family Services for the service.

• For Home-Based Support Services (HBS), this service is not included in the individual's monthly cost limit/individual budget.
• For all three waivers, a $15,000 maximum per individual per five-year period applies for any combination of adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and/or remote support, as applicable.

• For Home-Based Support Services (HBS), this service is not included in the individual's monthly cost limit/individual budget.
• For all three waivers, a $15,000 maximum per individual per five-year period applies for any combination of adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and/or remote support, as applicable.

• For Home-Based Support Services (HBS), this service is not included in the individual's monthly cost limit/individual budget.
• For all three waivers, a $15,000 maximum per individual per five-year period applies for any combination of adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and/or remote support, as applicable.
• Within the five-year maximum, there is also a $5,000 maximum per address for permanent home modifications for rented homes.

• For Home-Based Support Services (HBS), this service is not included in the individual's monthly cost limit/individual budget.
• For all three waivers, a $15,000 maximum per individual per five-year period applies for any combination of adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and/or remote support, as applicable.

• See VI. Waiver Activities and Services
• See SDA Guidelines

• See VI. Waiver Activities and Services
• See SDA Guidelines

• Face-to-face time
• Time for participation in Personal Plan meeting

• Time when individual is not present
• Commute time (travel to and from worker's home)

The individual, family, and/or guardian, if applicable, negotiate mutually acceptable rates for personal support services. The Home Based Support (HBS) Service Agreement form (pdf) must specify an agreed upon hourly rate and maximum monthly units of service.

For Personal Support Workers hired directly by an individual, family and/or guardian, if applicable, wages earned are considered taxable income. Payroll is issued by a Fiscal/Employer Agent (F/EA) if applicable. Payment authorization is sent by the Employer of Record to the F/EA based on the Personal Plan. Payment may not be made to a legally responsible individual, who is any person who has a duty under state law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. See IX. Provider Enrollments and Qualifications for requirements and restrictions on certain relatives. Summary of Specific Provider Qualifications and Credentials.

• Limited to individuals enrolled in Home-Based Support Services for children or adults
• Face-to-face time
• Time consulting with the ISC about the individual

• Time when individual is not present
• Travel time (commute to and from worker's home)

The individual, family, and/or guardian, if applicable, negotiate mutually acceptable rates for personal support services. The Home Based Support (HBS) Service Agreement form (pdf) must specify an agreed upon hourly rate and maximum monthly units of service.

For Personal Support Workers hired directly by an individual, family and/or guardian, if applicable, wages earned are considered taxable income. Payroll is issued by a Fiscal/Employer Agent (F/EA) if applicable. Payment authorization is sent by the Employer of Record to the F/EA based on the Personal Plan. Payment may not be made to certain legally responsible relatives for children. See IX. Provider Enrollments and Qualifications for requirements and restrictions on certain relatives. Summary of Specific Provider Qualifications and Credentials.

• Face-to-face with HBS individual
• Time spent participating in Personal Plan meeting
• Time spent writing progress notes
• Time spent consulting with the ISC

• Time when individual is not present
• Travel time (commute to and from worker's home)

• Level 1: One-time charged billed as Event mode
• Level 2: Monthly charge billed as Event mode

Not a covered service for children.

If an HBS individual is not purchasing personal support services or opts to purchase the non-medical transportation through a personal support agency, the individual will not be able to use a private auto driver. The service must be provided by a community-based DD waiver agency enrolled to provide non-medical transportation or a bus, taxi, service car or Medicare provider approved by HFS and DHS/DDD.

• directly benefit the individual
• are within statewide maximums (if applicable)
• within agreed hours in HBS Service Agreement and Personal Plan
• time counselor delivered counseling service, with documentation to support hours being billed