ModifiedIowa Department of Health and Human ServicesPolicy N/A

HCBS Habilitation and Waiver Upper Rate Limits

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Sets upper rate limits and reimbursement methodologies for Home and Community-Based Services (HCBS) habilitation and waiver services, listing fee schedule rules, unit types, procedure codes, and fallback rates for multiple service types.

Policy Summary

PayerIowa Department of Health and Human Services

PolicyHCBS Habilitation and Waiver Upper Rate Limits

Policy CodePolicy N/A

Change TypeRevised rates, added caps and fallback rules

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen converting historical provider rates to 15-minute units, use the provider's rate in effect 6/30/24 plus 4.1%; if no prior rate exists, apply the published fallback per-15-minute rates.

SourceLink

POLICY UPDATE CHANGES

Rates and fee schedule conversions updated with example increases (e.g., provider's rate in effect 6/30/24 plus 4.1% converted to 15-minute rates and specified fallback unit rates).

Published fee schedule references and monthly/annual limits added or clarified for supported employment, enabling technology, and other services (e.g., $3,692.34 monthly cap for supported employment; $4,500 annual member limit for enabling technology).

Monthly caps on total cost of waiver services by level of care are specified (e.g., ICF/ID Max Payment Rate $487.81 and various waiver caps like $4,244.04 for ICFID).

$356.93daily respite cap

$98.87nursing fallback visit

$9.85nutrition 15-min

$3,692.34supported employment monthly

$4,500.00enabling tech annual

Coverage Criteria and Upper Rate Limits

Adult Day Care reimbursement rules

Reimbursement methodology and fallback rate rules for Adult Day Care and related services

Adult Day Care (codes S5100, S5101, S5102) — units: 15-minute, half day, full day; fee schedule effective 7/1/24: provider's rate in effect 06/30/2024 plus 4.1% converted to applicable unit rates.

If provider 6/30/24 rate is not available: Use Veterans Administration contract rate OR specified fallback amounts: $1.64 per 15-minute unit, $26.37 per half day, $52.51 per full day (extended-day example $78.73 where applicable).

Intellectual disability waiver (member acuity tier): Rates determined by the member's acuity-tier fee schedule (see published fee schedule); example half-day rate: $35.14 for ID waiver when applicable.

Nursing and home health aide

Nursing and home health aide upper rate rules

Nursing Care (RN T1030 and LPN T1031; S9123/S9124 for ID waivers) — unit: per visit (or hour where specified); fee schedule effective 7/1/24: provider's rate in effect 06/30/2024 plus 4.1% converted to visit/hour rates.

If provider 6/30/24 rate is not available: Fallback per-visit rate: $98.87 (applies to RN and LPN visits).

Home Health Aide (T1021, S9122) — unit: per visit or per hour; upper rate is the lesser of the maximum Medicare rate in effect 6/30/24 plus 4.1% or the maximum Medicaid rate in effect 6/30/24 plus 4.1% converted to an hourly rate.

Respite and facility care limits

Respite and group/facility care rate limits and daily caps

Respite services (various settings, codes S5150, T1005) — fee schedule effective 08/01/25: provider's rate in effect 07/31/2025 plus 0.9%, converted to 15‑minute rates; where converted rates exceed limits or no prior rate exists, specified fallback per‑15‑minute rates apply.

If provider 07/31/25 rate is not available: Fallback per-15-minute rates include $10.15 (specialized respite), $5.41 (basic individual respite), $3.94 (group respite) depending on service type.

Daily cap: All respite and applicable facility/group services are subject to a per-day not-to-exceed limit of $356.93 regardless of converted or fallback per-unit rates.

Maximums and counseling/outreach

One-time and lifetime maximums; counseling and outreach limits

Home and Vehicle Modification — unit: lifetime maximum; Fee Schedule. Lifetime maximum examples: Intellectual Disability Waiver $5,962.19; Elderly Waiver $1,192.44.

Mental Health Outreach (H0036) — unit: 15-minute; fee schedule effective 7/1/24: provider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units; if no 6/30/24 rate use on-site Medicaid reimbursement rate for center or provider; maximum of 1,440 units per year.

Nutritional Counseling (CPT 97802, 97803) — unit: 15-minute; fee schedule rule or fallback applies; example rate: $9.85 per 15-minute unit (initial and subsequent sessions).

Personal support and management services

Attendant care, companion, supported living, and case management

Companion (S5135) — unit: 15-minute; fee schedule 7/1/24 converted from provider 6/30/24 rate plus 4.1%; if no 6/30/24 rate: $2.12 per 15-minute unit.

Attendant Care (S5125) — unit: 15-minute; fee schedule 7/1/24: provider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units; if no 6/30/24 rate: $6.02 per 15-minute unit, not to exceed $139.18 per day.

Case Management (T1016) — unit: 15-minute; fee schedule in effect 7/1/24: provider's rate in effect 6/30/24 plus 4.1% converted to a 15-minute rate; example upper rate: $72.59 per 15-minute unit.

Supported Community Living (H2015/H2016/S5136) — units: 15-minute and daily; examples include $11.59 per 15-minute unit and a daily example $565.02 depending on waiver and rate methodology (retrospectively limited prospective rates or acuity-tier fee schedule).

Coverage criteria and payment limits (selected highlights)

Coverage and payment limits are defined per service with unit, code, and dollar cap; many services reference published fee schedules or specific fallback rates when prior rates are absent.

Counseling Individual (H0004) — unit: 15-minute; if no 6/30/24 rate: $6.02 per 15-minute unit; daily not-to-exceed example $139.18.

Interim Medical Monitoring and Treatment (IMMT: T1003/T1004) — unit: 15-minute; rate rule: lesser of maximum Medicare rate in effect 6/30/24 plus 4.1% or maximum Medicaid rate in effect 6/30/24 plus 4.1% converted to 15-minute rate; example fallback $10.43 per 15-minute unit.

Day Habilitation (T2021) — unit: 15-minute; fee schedule effective 08/01/25: provider's rate in effect 07/31/25 plus 0.9% converted to 15-minute; if no 7/31/25 rate: $3.97 per 15-minute unit.

Supported Employment (T2018 UC, H2025 U4, etc.) — unit: monthly limit; published fee schedule applies; monthly cap example: $3,692.34.

Enabling Technology Assessment (T2029 UA) — unit: per assessment; example upper rate: $442.43 per assessment; Enabling Technology (BI and ID waivers) — per-member annual limit $4,500.00.

Financial Management Services (T2040) and Independent Support Broker (T2041) — unit rates referenced on fee schedule; example rates: $77.51 per member per month (T2040) and $18.06 per hour (T2041) as published.

Monthly caps on total cost of waiver services by level of care — examples: ICF/ID Max Payment Rate $487.81; ICFID cap $4,244.04; Health and Disability Waiver SNF $3,166.53; NF $1,087.96 (see published table for full list).

Procedure Codes, Units, and Caps

Adult Day Care codesHCPCSCovered

S5100	Adult Day Care (15-minute)
S5101	Adult Day Care (half day)
S5102	Adult Day Care (full day)

Adult Day Care (intellectual disability waiver) - half day variantHCPCSCovered

S5101

Adult Day Care (Half Day - ID waiver acuity tier / half-day rate $35.14)

Nursing care codesCPTCovered

T1030	Nursing Care (RN) per visit
T1031	Nursing Care (LPN) per visit

Attendant care and counselingmixedCovered

S5125	Attendant Care (15-minute)
H0004	Counseling Individual

Representative HCBS service codes and descriptorsmixedCovered

H0004	Counseling Individual
S5125 U3	Skilled Attendant Care (provider-specific rate reference)
T1016	Case management 15-minute
H2016	Supported Community Living
T2021	Day Habilitation
T2029 UA	Enabling Technology assessment
T2018 UC	Individual Supported Employment

Daily maximum for respite/group services

Daily maximum (respite/group/facility)$356.93 per day

Per 15-minute fallback example$3.94 per 15-minute unit if no 07/31/25 rate

Applies toRespite (group), facility care, camps, and adult day care daily limits

Mental Health Outreach annual unit cap

Annual unit cap1,440 units per year

Rate fallbackProvider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units; if no 6/30/24 rate, on-site Medicaid reimbursement rate applies

Service codeH0036 (Mental Health Outreach)

Supported Employment monthly cap

Monthly cap (supported employment)$3,692.34 per month

Applies toIndividual Supported Employment, Long-Term Job Coaching, Small-Group Supported Employment, IPS (see published fee schedule for detail)

Reference codesT2018 UC; H2025 U4; H2023 U3; T2018 U3-U6

Enabling Technology assessment limit

Per-assessment limit$442.43 per assessment

ServiceEnabling Technology Assessment (T2029 UA)

Fee scheduleFee Schedule effective; published amounts shown in fee schedule table

Enabling Technology per member annual limit (BI and ID waivers)

Per-member annual limit (BI and ID waivers)$4,500.00 per member per year

Applies toEnabling Technology for Remote Support (T2029 UA/T2029 UB) under Brain Injury and Intellectual Disability waivers

ReferenceSee published fee schedule entries for Enabling Technology — per member annual cap listed

Provider Billing, Conversion, and Actionable Limits

Documentation Required

Mental Health Outreach annual unit cap (1,440 units)

Maximum of 1,440 units per year when using the on-site Medicaid reimbursement rate fallback for Mental Health Outreach (H0036, 15-minute units).

Billing Rule

Rate conversion — use 6/30/24 rate +4.1% or specified fallback per-15-minute amounts

When converting historical provider rates to 15-minute units, use the provider's rate in effect 6/30/24 plus 4.1%; if no 6/30/24 rate exists, apply the published fallback per-15-minute amounts (examples: $10.43 for IMMT/SCL; $3.97 for Day Habilitation).

Provider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units is the primary conversion method.
If no 6/30/24 rate exists, use the specified fallback per-15-minute rates (e.g., $10.43 for IMMT/SCL; $3.97 per 15-minute for Day Habilitation if no 7/31/25 rate).

Unit Definitions, Fallback Rates, and Fee Schedule Rules

Fee Schedule fallback rule

Primary ruleIf provider rate in effect on the specified prior date (e.g., 6/30/24 or 7/31/25) is not available, use the specified fallback amounts such as Veterans Administration contract rate or published per-unit fallback amounts

Fallback typesPer 15-minute unit, per half-day, per full-day, or applicable Medicare/Veterans Administration contract rate as specified per service

Conversion noteWhen prior rates exist, provider's rate in effect on the prior date is increased (e.g., +4.1% or +0.9%) then converted to the relevant unit (15-minute, half-day, full-day)

Unit definitions and conversion

Unit conversion conventionMany services are converted to 15-minute units or to per-visit/per-day rates to establish upper rate limits

ExamplesProvider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units (mental health outreach); Medicare/Medicaid rates in effect 7/31/25 plus .9% converted to 15-minute rates (respite)

Daily/visit capsSome services additionally have per-day caps (e.g., $356.93) applied after unit conversion

Fallback rate

Fallback per-15-minute rate examplesSpecified fallback per-15-minute dollar amounts apply when no prior rate exists (examples: $6.02 for Counseling Individual; $10.43 for IMMT/SCL; $3.94 for certain respite/facility services)

ApplicationUsed when provider's prior-date rate (e.g., 6/30/24 or 7/31/25) is not available for conversion to 15-minute units

Not to exceedSome fallback per-unit rates are subject to daily or program-specific maximums (e.g., per-day $356.93)

Acuity-tier fee schedule

Acuity-tier fee scheduleCertain services use a fee schedule for the member's acuity tier; rates vary by acuity tier and are published on the department's website

Services using acuity tiersHome- and community-based habilitation services (e.g., H2016 UA-UC) and adult day care for intellectual disability waiver

ImplementationFor services using acuity tiers, use the published fee schedule rates (daily or per-unit) as determined pursuant to the member's acuity tier

Policy Summary

PayerIowa Department of Health and Human Services

PolicyHCBS Habilitation and Waiver Upper Rate Limits

Policy CodePolicy N/A

Change TypeRevised rates, added caps and fallback rules

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen converting historical provider rates to 15-minute units, use the provider's rate in effect 6/30/24 plus 4.1%; if no prior rate exists, apply the published fallback per-15-minute rates.

SourceLink

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HCBS Habilitation and Waiver Upper Rate Limits

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Sign up for all Iowa Department of Health and Human Services policy alerts

Know when Iowa Department of Health and Human Services releases new policies or updates existing guidance.

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Coverage Criteria and Upper Rate Limits

Adult Day Care reimbursement rules

Reimbursement methodology and fallback rate rules for Adult Day Care and related services

Adult Day Care (codes S5100, S5101, S5102) — units: 15-minute, half day, full day; fee schedule effective 7/1/24: provider's rate in effect 06/30/2024 plus 4.1% converted to applicable unit rates.

Nursing and home health aide

Nursing and home health aide upper rate rules

If provider 6/30/24 rate is not available: Fallback per-visit rate: $98.87 (applies to RN and LPN visits).

Respite and facility care limits

Respite and group/facility care rate limits and daily caps

If provider 07/31/25 rate is not available: Fallback per-15-minute rates include $10.15 (specialized respite), $5.41 (basic individual respite), $3.94 (group respite) depending on service type.

Daily cap: All respite and applicable facility/group services are subject to a per-day not-to-exceed limit of $356.93 regardless of converted or fallback per-unit rates.

Maximums and counseling/outreach

One-time and lifetime maximums; counseling and outreach limits

Home and Vehicle Modification — unit: lifetime maximum; Fee Schedule. Lifetime maximum examples: Intellectual Disability Waiver $5,962.19; Elderly Waiver $1,192.44.

Nutritional Counseling (CPT 97802, 97803) — unit: 15-minute; fee schedule rule or fallback applies; example rate: $9.85 per 15-minute unit (initial and subsequent sessions).

Personal support and management services

Attendant care, companion, supported living, and case management

Companion (S5135) — unit: 15-minute; fee schedule 7/1/24 converted from provider 6/30/24 rate plus 4.1%; if no 6/30/24 rate: $2.12 per 15-minute unit.

Case Management (T1016) — unit: 15-minute; fee schedule in effect 7/1/24: provider's rate in effect 6/30/24 plus 4.1% converted to a 15-minute rate; example upper rate: $72.59 per 15-minute unit.

Coverage criteria and payment limits (selected highlights)

Coverage and payment limits are defined per service with unit, code, and dollar cap; many services reference published fee schedules or specific fallback rates when prior rates are absent.

Counseling Individual (H0004) — unit: 15-minute; if no 6/30/24 rate: $6.02 per 15-minute unit; daily not-to-exceed example $139.18.

Day Habilitation (T2021) — unit: 15-minute; fee schedule effective 08/01/25: provider's rate in effect 07/31/25 plus 0.9% converted to 15-minute; if no 7/31/25 rate: $3.97 per 15-minute unit.

Supported Employment (T2018 UC, H2025 U4, etc.) — unit: monthly limit; published fee schedule applies; monthly cap example: $3,692.34.

Enabling Technology Assessment (T2029 UA) — unit: per assessment; example upper rate: $442.43 per assessment; Enabling Technology (BI and ID waivers) — per-member annual limit $4,500.00.

Procedure Codes, Units, and Caps

Adult Day Care codesHCPCSCovered

S5100	Adult Day Care (15-minute)
S5101	Adult Day Care (half day)
S5102	Adult Day Care (full day)

Adult Day Care (intellectual disability waiver) - half day variantHCPCSCovered

S5101

Adult Day Care (Half Day - ID waiver acuity tier / half-day rate $35.14)

Nursing care codesCPTCovered

T1030	Nursing Care (RN) per visit
T1031	Nursing Care (LPN) per visit

Attendant care and counselingmixedCovered

S5125	Attendant Care (15-minute)
H0004	Counseling Individual

Representative HCBS service codes and descriptorsmixedCovered

H0004	Counseling Individual
S5125 U3	Skilled Attendant Care (provider-specific rate reference)
T1016	Case management 15-minute
H2016	Supported Community Living
T2021	Day Habilitation
T2029 UA	Enabling Technology assessment
T2018 UC	Individual Supported Employment

Daily maximum for respite/group services

Daily maximum (respite/group/facility)$356.93 per day

Per 15-minute fallback example$3.94 per 15-minute unit if no 07/31/25 rate

Applies toRespite (group), facility care, camps, and adult day care daily limits

Mental Health Outreach annual unit cap

Annual unit cap1,440 units per year

Rate fallbackProvider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units; if no 6/30/24 rate, on-site Medicaid reimbursement rate applies

Service codeH0036 (Mental Health Outreach)

Supported Employment monthly cap

Monthly cap (supported employment)$3,692.34 per month

Applies toIndividual Supported Employment, Long-Term Job Coaching, Small-Group Supported Employment, IPS (see published fee schedule for detail)

Reference codesT2018 UC; H2025 U4; H2023 U3; T2018 U3-U6

Enabling Technology assessment limit

Per-assessment limit$442.43 per assessment

ServiceEnabling Technology Assessment (T2029 UA)

Fee scheduleFee Schedule effective; published amounts shown in fee schedule table

Enabling Technology per member annual limit (BI and ID waivers)

Per-member annual limit (BI and ID waivers)$4,500.00 per member per year

Applies toEnabling Technology for Remote Support (T2029 UA/T2029 UB) under Brain Injury and Intellectual Disability waivers

ReferenceSee published fee schedule entries for Enabling Technology — per member annual cap listed

Provider Billing, Conversion, and Actionable Limits

Documentation Required

Mental Health Outreach annual unit cap (1,440 units)

Maximum of 1,440 units per year when using the on-site Medicaid reimbursement rate fallback for Mental Health Outreach (H0036, 15-minute units).

Billing Rule

Rate conversion — use 6/30/24 rate +4.1% or specified fallback per-15-minute amounts

Provider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units is the primary conversion method.
If no 6/30/24 rate exists, use the specified fallback per-15-minute rates (e.g., $10.43 for IMMT/SCL; $3.97 per 15-minute for Day Habilitation if no 7/31/25 rate).

Unit Definitions, Fallback Rates, and Fee Schedule Rules

Fee Schedule fallback rule

Fallback typesPer 15-minute unit, per half-day, per full-day, or applicable Medicare/Veterans Administration contract rate as specified per service

Conversion noteWhen prior rates exist, provider's rate in effect on the prior date is increased (e.g., +4.1% or +0.9%) then converted to the relevant unit (15-minute, half-day, full-day)

Unit definitions and conversion

Unit conversion conventionMany services are converted to 15-minute units or to per-visit/per-day rates to establish upper rate limits

ExamplesProvider's rate in effect 6/30/24 plus 4.1% converted to 15-minute units (mental health outreach); Medicare/Medicaid rates in effect 7/31/25 plus .9% converted to 15-minute rates (respite)

Daily/visit capsSome services additionally have per-day caps (e.g., $356.93) applied after unit conversion

Fallback rate

ApplicationUsed when provider's prior-date rate (e.g., 6/30/24 or 7/31/25) is not available for conversion to 15-minute units

Not to exceedSome fallback per-unit rates are subject to daily or program-specific maximums (e.g., per-day $356.93)

Acuity-tier fee schedule

Acuity-tier fee scheduleCertain services use a fee schedule for the member's acuity tier; rates vary by acuity tier and are published on the department's website

Services using acuity tiersHome- and community-based habilitation services (e.g., H2016 UA-UC) and adult day care for intellectual disability waiver

ImplementationFor services using acuity tiers, use the published fee schedule rates (daily or per-unit) as determined pursuant to the member's acuity tier