Western Tidewater CSB Income Based Fees
- Substance Abuse Supports Fees
- Intellectual Disability Supports Fees
- Short Term Ability To Pay
- Long Term Ability To Pay
Western Tidewater Community Services Board Mental Health/Substance Abuse Services Fee Schedule
Effective Date 7/1/19 Financial Assistance is available to qualified consumers under the Ability To Pay (ATP) system for Short Term and Long Term Services; certain services identified below are not included
| Short Term Services – Included in ATP | Charge |
| ASAM Screening 15-30 min (ASAM) | $33.00 |
| ASAM Screening 30+ min (ASAM) | $63.00 |
| Family Psychotherapy/Counseling | $120.00 |
| Group Psychotherapy | $50.00 |
| Individual Psychotherapy/Counseling (30 mins) | $80.00 |
| Individual Psychotherapy/Counseling (45 mins) | $120.00 |
| Individual Psychotherapy/Counseling (60 mins) | $149.00 |
| Injection (Medication is charged as indicated in II below) | $25.00 |
| Intake or Screening Evaluation with LMHP | $180.00 |
| Intake or Screening Evaluation with MD | $180.00 |
| Lab Services | Various Actual Costs |
| OBOTS Intake | $140.00 |
| Physician Appointment (minimal complexity) | $50.00 |
| Physician Appointment (low complexity) | $85.00 |
| Physician Appointment (moderate complexity) | $125.00 |
| Physician Appointment (high complexity) | $165.00 |
| Psychological Testing (Admin by MD or PhD) (1 hour) | $91.00 |
| Smoking Cessation 10+ minutes | $28.00 |
| Smoking Cessation 3-9 mins | $15.00 |
| Telehealth OP | $26.15 |
| Long Term Services – Included in ATP | Charge |
| Case Management (monthly) | $326.50 |
| Child & Adolescent School Counseling Intervention Program (unit) | $36.53 |
| Crisis Intervention (unit) | $18.61 |
| Crisis Stabilization (1 hr) | $81.00 |
| Intensive Care Coordination (monthly) | $1,200.00 |
| Mental Health Support Services (unit) | $83.00 |
| Program of Assertive Community Treatment (PACT) (hour) | $139.00 |
| Psychosocial Rehabilitation/Tidewater House (unit) | $24.23 |
| Substance Abuse Case Management (monthly) | $243.00 |
| Substance Abuse Intensive Outpatient (per unit: 1 unit=lday) | $250.00 |
| Telehealth CMHRS | $25.00 |
| Transportation | Various Actual Costs |
| Urine Screen | $25.00 |
| Long Term Services NOT Included in ATP | Charge |
| ASAP Intake/Group | $25.00 |
| Assessment for Intake/Referral (up to 7 hour) | No Charge |
| Comprehensive Forensic Evaluation | $400.00 |
| Consumer Record Retrieval from Off Site Storage | $50.00 |
| Copy of Consumer Records (with written consent)* | $.50/pages 1-50; $.25/page thereafter + |
| Medications including injectables for which the CSB is charged | Various Actual Costs |
| No Show Fee (failure to cancel prior to appointment) | $20.00 |
| Purchase of Services: Inpatient | No Charge |
| Returned Check Fee | $20.00 |
| Treatment Summary Report | $90.00 |
Contract Services Contractual fees may vary depending on clinical or administrative services required, and by contractual relationship or by law; i.e. Medicaid, Medicare, Schools, Federal/State Probation, Jails/Courts, CSA Non-Mandated, etc.
* Will be provided gratis to health and mental health providers and third party payers. Payment from other sources is due within 30 days of invoice.
Western Tidewater CSB Intellectual Disability Servies
Financial assistance is available to qualified consumers under the Ability to Pay (ATP) system for long term services. Certain services identified below are not included.
| Long Term Services – Included in ATP | Charge |
| Annual Resident Review (short/long) | $25/$100 |
| Case Management (monthly) | $326.50 |
| Community Coaching | $29.24 |
| Community Engagement Tier 1 (1 hour) | $14.26 |
| Community Engagement Tier 2 (1 hour) | $16.01 |
| Community Engagement Tier 3 (1 hour) | $18.38 |
| Community Engagement Tier 4 (1 hour) | $22.61 |
| Crisis Stabilization (1 hr) | $81.00 |
| Day Rehab High Intensity (unit) | $38.02 |
| Day Rehab Regular Intensity (unit) | $26.71 |
| Developmental Disability Case Management | $242.73 |
| Developmental Disability Case Management Assessment | $300.00 |
| Elderly and Disabled Waiver Assessment | $345.00 |
| Group Day Tier 1 (1 hour) | $8.60 |
| Group Day Tier 2 (1 hour) | $11.25 |
| Group Day Tier 3 (1 hour) | $13.31 |
| Group Day Tier 4 (1 hour) | $17.34 |
| ID Center Based Crisis (1 hr) | $24.02 |
| ID Community Based Crisis (1 hr) | $24.02 |
| In-Home Residential Support (1 hr)* | various actual costs |
| Level II Screening | $525.00 |
| Part C Early Intervention Case Management (monthly) | $132.00 |
| Personal Assistance (1 hr) | $13.70 |
| Psychological Testing (Admin by MD or PhD (1 hour) | $91.00 |
| Skilled Nursing, LPN (15 minutes) | $8.05 |
| Skilled Nursing, RN (15 minutes) | $9.29 |
| Therapeutic Consultation (1 hr) | $50.00 |
| Transportation |
| Long Term Services NOT Included in ATP | Charge |
| Assessment for Intake/Referral (up to 7 hour) | No Charge |
| Comprehensive Forensic Evaluation | $400.00 |
| Consumer Record Retrieval from Off Site Storage | $50.00 |
| Copy of Consumer Records (with written consent)** | $.50/pages 1-50; $.25/page thereafter + |
| ICF/ID (per diem) *** | Various Actual Costs |
| Returned Check Fee | $20.00 |
| Waiver Home 4 bed (per diem) **** | Various Actual Costs |
| Waiver Home 5 bed (per diem) **** | Various Actual Costs |
Contract Services Contractual fees may vary depending on clinical or administrative services required, and by contractual relationship or by law; i.e. Medicaid, Medicare, Schools, Federal/State Probation, Jails/Courts, CSA Non-Mandated, etc.
* In Home Support rates are determined by the group size
** Records will be provided gratis to health and mental health providers and third party payers. Payment from other sources is due within 30 days of invoice.
*** ICF/IID rates are established annually via cost settlement audit
**** Waiver Home per diem rates are established by DMAS based on the size of the home and level of care
| Short Term Ability To Pay Scale – Maximum Percentage per Service |
| Effective 8/1/18 |
| Income range | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8+ |
| 0-$12,140 | 1% | 1% | 1% | 1% | 1% | 1% | 1% | 1% |
| $12,141 – $16,460 | 5% | 1% | 1% | 1% | 1% | 1% | 1% | 1% |
| $16,461 – $20,780 | 10% | 5% | 1% | 1% | 1% | 1% | 1% | 1% |
| $20,781 – $25,100 | 15% | 10% | 5% | 1% | 1% | 1% | 1% | 1% |
| $25,101 – $29,420 | 20% | 15% | 10% | 5% | 1% | 1% | 1% | 1% |
| $29,421 – $33,740 | 25% | 20% | 15% | 10% | 5% | 1% | 1% | 1% |
| $33,741 – $38,060 | 30% | 25% | 20% | 15% | 10% | 5% | 1% | 1% |
| $38,061- $42,380 | 35% | 30% | 25% | 20% | 15% | 10% | 5% | 1% |
| $42,381 – $46,700 | 40% | 35% | 30% | 25% | 20% | 15% | 10% | 5% |
| $46,701 – $51,020 | 45% | 40% | 35% | 30% | 25% | 20% | 15% | 10% |
| $51,021 – $55,340 | 50% | 45% | 40% | 35% | 30% | 25% | 20% | 15% |
| $55,341 – $59,660 | 55% | 50% | 45% | 40% | 35% | 30% | 25% | 20% |
| $59,661 – $63,980 | 60% | 55% | 50% | 45% | 40% | 35% | 30% | 25% |
| $63,981 – $68,300 | 65% | 60% | 55% | 50% | 45% | 40% | 35% | 30% |
| $68,301 – $72,620 | 70% | 65% | 60% | 55% | 50% | 45% | 40% | 35% |
| $72,621 – $76,940 | 75% | 70% | 65% | 60% | 55% | 50% | 45% | 40% |
| $76,941 – $81,260 | 80% | 75% | 70% | 65% | 60% | 55% | 50% | 45% |
| $81,261 – $85,580 | 85% | 80% | 75% | 70% | 65% | 60% | 55% | 50% |
| $85,581 – $89,900 | 90% | 85% | 80% | 75% | 70% | 65% | 60% | 55% |
| $89,901 – $94,220 | 95% | 90% | 85% | 80% | 75% | 70% | 65% | 60% |
| $94,221 – $98,540 | 100% | 95% | 90% | 85% | 80% | 75% | 70% | 65% |
| $98,541 – $102,860 | 100% | 100% | 95% | 90%00 | 85% | 80% | 75% | 70% |
| $102,861 – $107,180 | 100% | 100% | 100% | 95% | 90% | 85% | 80% | 75% |
| $107,181 – $111,500 | 100% | 100% | 100% | 100% | 95% | 90% | 85% | 80% |
| $111,501 – $115,820 | 100% | 100% | 100% | 100% | 100% | 95% | 90% | 85% |
| $115,821 – $120,140 | 100% | 100% | 100% | 100% | 100% | 100% | 95% | 90% |
| $120,141 – $124,460 | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 95% |
| $124,461+ | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Long Term Ability To Pay Scale – Maximum Monthly Amount |
| Effective 8/1/18 |
| Income range | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8+ |
| 0-$12,140 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 |
| $12,141 – $16,460 | $ 10.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 |
| $16,461 – $20,780 | $ 15.00 | $ 10.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 |
| $20,781 – $25,100 | $ 20.00 | $ 15.00 | $ 10.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 |
| $25,101 – $29,420 | $ 25.00 | $ 20.00 | $ 15.00 | $ 10.00 | $ 5.00 | $ 5.00 | $ 5.00 | $ 5.00 |
| $29,421 – $33,740 | $ 30.00 | $ 25.00 | $ 20.00 | $ 15.00 | $ 10.00 | $ 5.00 | $ 5.00 | $ 5.00 |
| $33,741 – $38,060 | $ 35.00 | $ 30.00 | $ 25.00 | $ 20.00 | $ 15.00 | $ 10.00 | $ 5.00 | $ 5.00 |
| $38,061- $42,380 | $ 40.00 | $ 35.00 | $ 30.00 | $ 25.00 | $ 20.00 | $ 15.00 | $ 10.00 | $ 5.00 |
| $42,381 – $46,700 | $ 45.00 | $ 40.00 | $ 35.00 | $ 30.00 | $ 25.00 | $ 20.00 | $ 15.00 | $ 10.00 |
| $46,701 – $51,020 | $ 50.00 | $ 45.00 | $ 40.00 | $ 35.00 | $ 30.00 | $ 25.00 | $ 20.00 | $ 15.00 |
| $51,021 – $55,340 | $ 55.00 | $ 50.00 | $ 45.00 | $ 40.00 | $ 35.00 | $ 30.00 | $ 25.00 | $ 20.00 |
| $55,341 – $59,660 | $ 60.00 | $ 55.00 | $ 50.00 | $ 45.00 | $ 40.00 | $ 35.00 | $ 30.00 | $ 25.00 |
| $59,661 – $63,980 | $ 65.00 | $ 60.00 | $ 55.00 | $ 50.00 | $ 45.00 | $ 40.00 | $ 35.00 | $ 30.00 |
| $63,981 – $68,300 | $ 70.00 | $ 65.00 | $ 60.00 | $ 55.00 | $ 50.00 | $ 45.00 | $ 40.00 | $ 35.00 |
| $68,301 – $72,620 | $ 75.00 | $ 70.00 | $ 65.00 | $ 60.00 | $ 55.00 | $ 50.00 | $ 45.00 | $ 40.00 |
| $72,621 – $76,940 | $ 80.00 | $ 75.00 | $ 70.00 | $ 65.00 | $ 60.00 | $ 55.00 | $ 50.00 | $ 45.00 |
| $76,941 – $81,260 | $ 85.00 | $ 80.00 | $ 75.00 | $ 70.00 | $ 65.00 | $ 60.00 | $ 55.00 | $ 50.00 |
| $81,261 – $85,580 | $ 90.00 | $ 85.00 | $ 80.00 | $ 75.00 | $ 70.00 | $ 65.00 | $ 60.00 | $ 55.00 |
| $85,581 – $89,900 | $ 95.00 | $ 90.00 | $ 85.00 | $ 80.00 | $ 75.00 | $ 70.00 | $ 65.00 | $ 60.00 |
| $89,901 – $94,220 | $ 100.00 | $ 95.00 | $ 90.00 | $ 85.00 | $ 80.00 | $ 75.00 | $ 70.00 | $ 65.00 |
| $94,221 – $98,540 | Full Fee | $ 100.00 | $ 95.00 | $ 90.00 | $ 85.00 | $ 80.00 | $ 75.00 | $ 70.00 |
| $98,541 – $102,860 | Full Fee | Full Fee | $ 100.00 | $ 95.00 | $ 90.00 | $ 85.00 | $ 80.00 | $ 75.00 |
| $102,861 – $107,180 | Full Fee | Full Fee | Full Fee | $ 100.00 | $ 95.00 | $ 90.00 | $ 85.00 | $ 80.00 |
| $107,181 – $111,500 | Full Fee | Full Fee | Full Fee | Full Fee | $ 100.00 | $ 95.00 | $ 90.00 | $ 85.00 |
| $111,501 – $115,820 | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | $ 100.00 | $ 95.00 | $ 90.00 |
| $115,821 – $120,140 | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | $ 100.00 | $ 95.00 |
| $120,141 – $124,460 | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | $ 100.00 |
| $124,461+ | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee | Full Fee |
- Substance Abuse Supports Fees
- Intellectual Disability Supports Fees
- Short Term Ability To Pay
- Long Term Ability To Pay
Western Tidewater Community Services Board Mental Health/Substance Abuse Services Fee Schedule
Effective Date 7/1/19 Financial Assistance is available to qualified consumers under the Ability To Pay (ATP) system for Short Term and Long Term Services; certain services identified below are not included
Please click the image to open and read the pdf
Western Tidewater CSB Intellectual Disability Servies
Financial assistance is available to qualified consumers under the Ability to Pay (ATP) system for long term services. Certain services identified below are not included.
Click the image below to open and read the pdf
| Short Term Ability To Pay Scale – Maximum Percentage per Service |
| Effective 8/1/18 |
Click the image below to open and read the pdf
| Long Term Ability To Pay Scale – Maximum Monthly Amount |
| Effective 8/1/18 |
Click the image below to open and read the pdf