Skip to Main Content

Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

600.4 Billing For Group Work For Skill Building, Respite And Family Support Services

General Group Composition

Groups can consist of Waiver children and/or their families (see rules below for each service) as well as non-Waiver children and/or their families. In such instances where both Waiver and non-Waiver participants are represented, billing must be done at the group rate appropriate to the total number of participants. Billing is for Waiver children and/or family members in the group. For example, if there is one Waiver child and two non-Waiver children represented in the group, Waiver services can be billed for the one Waiver child at the 3:1 group rate.

Waiver Represented Composition in Groups

Documentation

All groups must be clearly identified in the methods section of the Service Plans and must support achieving a specific goal of the child. Group Progress Notes must be written for each Waiver child being billed in the group. Progress notes must clearly indicate that the modality was a group, which service provided it, the participant to worker ratio (including any non-Waiver children present or represented in the Group), the Waiver participants as well as all other Medicaid and OMH required elements.

Billing for Group Work Services

Respite, Skill Building and Family Support services are no longer billed in one hour increments. They are billed in 15 minute increments using the appropriate group rate code. Billing for these services must be in 15 minute increments and must be claimed for the actual date of service. . All billing must follow Medicaid billing guidelines and timeframes.

The service must be of at least 30 minutes in duration (2 billing units of 15 minutes). To accrue an additional 15 minute unit beyond the required 2 units (30 minutes) for billing, the group must run for a full 15 minutes longer. Rounding is always down to the closest 15 minutes of service delivered. Group work service must be continuous per billable contact in a day.

Billing and Participant to Worker Ratios

Billing is not allowed for groups exceeding the ratios outlined below. The maximum worker to participant ratio allowed for billing for both Respite and Skill Building is one (1) worker to three (3) group members and for Family Support is one (1) Family Support worker for eight (8) group members. If there are multiple workers working with a given group, the total group size may be larger as long as the maximum ratio for worker to Waiver children, siblings and/or parents is maintained.

The following outlines group rates for the three services for each allowable participant to worker ratio.

Upstate Group Rates –Effective April 1, 2009 per 15 Minute Increments

Ratio(participant to worker) Respite Skill Building Family Support
1:1 $12.34 $12.34 $12.34
2:1 $6.79 each $6.79 each $6.79 each
3:1 $4.93 each $4.93 each $4.93 each
4:1 X X $3.70 each
5-8:1 X X $3.09 each

Downstate Group Rates – Effective April 1, 2009 per 15 Minute Increments

Ratio (participant to worker) Respite Skill Building Family Support
1:1 $13.00 $13.00 $13.00
2:1 $7.15 each $7.15 each $7.15 each
3:1 $5.20 each $5.20 each $5.20 each
4:1 X X $3.90 each
5-8:1 X X $3.25 each

Rules for Skill Building Groups That Include Siblings and/or Caregivers
The Waiver child, the Waiver child’s sibling(s) and the Waiver child’s parent/primary caregiver may participate in Skill Building groups and billing can occur for each.

For Skill Building groups consisting of the Waiver child and/or siblings or caregivers, a 1:2 group ratio would be billed for four 15 minute units for each 30 minute group and a 1:3 group ratio would be billed for six 15 minute units for each 30 minute group. When Skill Building groups include the Waiver sibling(s) and/or caregiver(s), the sibling and caregiver must be noted in the service plan to be billable and their purpose in the group must be directly related to the Waiver child’s goals and objectives. A Group Progress Note with information pertaining to each billable participant must be present for each Skill Building group.

Home and Community Based Services Waiver Group Progress Notes

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.