Western Tidewater CSB Income Based Fees

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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

Download the Fee Structure

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

Download the Fee Structure

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%

Download the Fee Structure

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

Download the Fee Structure

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