Chapter 5101:3-27 Community Mental Health Agency Services

(A) An “eligible provider” for purposes of this chapter is one of the following:

(1) The Ohio department of mental health, when providing a community mental health service that meets the requirements set forth in section 5111.022 of the Revised Code and Chapters 5122-23 to 5122-29 of the Administrative Code; or

(2) An agency meeting the requirements set forth in section 5111.022 of the Revised Code that has negotiated a contract with a community mental health board as defined in rule 5122-24-01 of the Administrative Code. For such an agency that is a government entity which receives nonfederal public funds, including but not limited to county departments of human services, county children’s services boards and local education agencies, eligibility is further contingent upon demonstration by the agency, as requested by the department of mental health, that sufficient state and/or local public funds not otherwise encumbered to match other federal funds will be committed to match Title XIX funds for reimbursement of the contracted services.

(3) In addition to the requirements of paragraph (A)(1) or (A)(2) of this rule, any medicaid covered service as set forth in rule 5101:3-27-02 of the Administrative Code must be provided.

(B) An eligible provider may subcontract for services. For such services to be billable, the services must be certified in accordance with section 5119.61 of the Revised Code and provided in accordance with the provisions set forth in Chapter 5101:3-27 of the Administrative Code.

R.C. 119.032 review dates: 4/16/2002 and 04/16/2007

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.022

Prior Effective Dates: April 20, 1982 (Temp.), August 1, 1982, March 19, 1987, September 1, 1991

(A) The following describes those services reimbursable as medicaid community mental health services when they are both rehabilitative and rendered by eligible medicaid providers. Rehabilitative services provide for the maximum reduction of mental illness and are intended to restore an individual to the best possible functional level. The services shall meet the principles set forth in rule 5101: 3-1-02 of the Administrative Code.

(1) Behavioral health counseling and therapy services as defined in rule 5122-29-03 of the Administrative Code.

(2) Mental health assessment services as defined in rule 5122-29-04 of the Administrative Code.

(3) Pharmacologic management services as defined in rule 5122-29-05 of the Administrative Code. All psychiatric/mental health medical interventions billed through this service must be used to reduce, stabilize and/or eliminate psychiatric symptoms of the person served.

(4) Partial hospitalization services as defined in rule 5122-29-06 of the Administrative Code and which meet the following requirements:

(a) Partial hospitalization services provided in social, recreational or education settings (internal or external to the partial hospitalization site) are allowable only if there are documented mental health interventions that address the specific individualized mental health treatment needs as identified in the individual service plan (ISP) of the person being served.

(b) Partial hospitalization services include activity therapies, group activities, or other services and programs which are designed to enhance skills needed for living in the least restrictive environment are allowable.

(c) Unallowable partial hospitalization activities are listed in paragraph (H)(7) of this rule.

(5) Crisis intervention mental health services as defined in rule 5122-29-10 of the Administrative Code.

(a) Crisis intervention mental health service must be face to face interventions that are responding to emergent situations with the intended result of crisis stabilization or prevention of crisis escalation.

(b) Routine monitoring of clients in a crisis residential facility is not considered a crisis intervention mental health service.

(6) Community psychiatric supportive treatment (CPST) services as defined in rule 5122-29-17 of the Administrative Code and are subject to the following limitations:

(a) All CPST services provided in social, recreational or educational settings are allowable only if they are documented mental health service interventions that address the specific individualized mental health treatment needs as identified in the ISP of the person served.

(b) A billable unit of service for CPST service may include either face-to-face or telephone contacts between the mental health professional and the client or an individual essential to the mental health treatment of the client.

(c) Consultation between staff in a multi-service agency is not a billable CPST unit of service when the client is not present. The following exceptions apply:

(i) The consultation occurs between the CPST worker and the staff of a distinct residential treatment program; and/or

(ii) The consultation occurs between the CPST worker and the staff of a distinct partial hospitalization program; and

(iii) The CPST services are not time limited or site specific.

(B) All medicaid community mental health services are to be billed on a unit rate basis in accordance with definitions, standards and eligible providers of service requirements as set forth in Chapter 5101:3-27 of the Administrative Code.

(C) Medicaid community mental health services must be recommended by an individual who is qualified to supervise the specific service. The identification of individuals qualified to supervise each specific service is set forth in each applicable rule of Chapter 5122-29 of the Administrative Code and as defined in rule 5122-24-01 of the Administrative Code. Provisions set forth in rule 5122-25-06 of the Administrative Code do not affect the provisions of this paragraph.

(D) Medicaid community mental health services must be performed by an individual who is qualified to perform the specific service. The identification of individuals qualified to perform each specific service is set forth in each applicable rule of Chapter 5122-29 of the Administrative Code and as defined in rule 5122-24-01 of the Administrative Code. Provisions set forth in rule 5122-25-06 of the Administrative Code do not affect the provisions of this paragraph.

(E) With the exception of the limitations in paragraphs (C) and (D) of this rule, the provisions set forth in rule 5122-25-06 of the Administrative Code apply.

(F) For the purposes of medicaid community mental health services, a billable unit of service is defined as the following:

(1) A face-to-face contact between a client and a professional authorized to provide medicaid reimbursable services as described in this rule; or

(2) A face-to-face contact with family members, parent, guardian and/or significant others as defined in rule 5122-24-01 of the Administrative Code for children or adolescents receiving behavioral health counseling and therapy, pharmacologic management, mental health assessment, or crisis intervention mental health services, when the purpose of the contact is directed to the exclusive benefit of the medicaid eligible beneficiary; or

(3) A face-to-face contact with family members or significant others of adults receiving crisis intervention mental health services, when the purpose of the contact is directed to the exclusive benefit of the medicaid eligible beneficiary; or

(4) Community psychiatric supportive treatment interventions provided to individuals other than the client as allowed in paragraphs (A)(6)(b) and (A)(6)(c)of this rule; or

(5) Services rendered via interactive video conferencing as described in rules 5122-29-03, 5122-29-04, 5122-29-05, and 5122-29-17 of the Administrative Code.

(G) All medicaid community mental health services contacts must be documented in the individual client record (ICR) of the person served and clearly relate to the mental health assessment, crisis assessment, or psychiatric diagnostic interview. Such documentation shall include the following:

(1) The date of the service contact; and

(2) The time of day of the service contact; and

(3) The duration of the service contact; and

(4) The signature and discipline of the provider of the service and the date of the signature; and

(5) The description of the activities of the service; and

(6) The therapeutic interventions, as defined in rule 5122-24-01 of the Administrative Code, rendered by the provider; and

(7) The behavior and the response to the intervention of the person served.

(H) Non-reimbursable community mental health services include:

(1) Community meetings or group sessions that are not designed to provide specific mental health treatment services to clients. Examples of such activities include, but are not limited to, orientation sessions for new clients, mental health presentations to community groups (high school classes, parent teacher associations, etc.), and informal presentations about the community mental health program.

(2) Monitoring clients while they are sleeping.

(3) Observing clients when not performing a therapeutic intervention (e.g., when client is watching television, resting, eating, etc.)

(4) Transportation in and of itself.

(5) Unallowable vocational job training activities include, but are not limited to, job shadowing, job coaching, teaching computer skills, math skills, or other trade skills.

(6) Services which are considered mental health residential treatment facility services as set forth in Chapter 5122-30 of the Administrative Code.

(7) Unallowable partial hospitalization activities include, but are not limited to, crafts, general non-therapeutic art projects, recreational outings purely for recreational purposes, exercise groups, etc.

(8) Other than consultation authorized in paragraph (A)(6)(c) of this rule, consultation between staff of the same agency without the client present is not reimbursable.

(I) Services rendered via interactive video conferencing technology must be provided in accordance with rules established by Ohio department of mental health (ODMH). All services rendered via interactive video conferencing technology must also meet the following conditions:

(1) The services rendered via interactive video conferencing technology are consistent with rules 5122-29-03, 5122-29-04, 5122-29-05, and 5122-29-17 of the Administrative Code; and

(2) The documentation requirements of the interactive video conferencing technology contacts remain the same as the face-to-face contacts; and

(3) The purpose of the interactive video conferencing technology contact is not the scheduling of appointments.

(J) The provisions contained in this rule will be effective July 1, 2008.

Effective: 07/01/2008

R.C. 119.032 review dates: 06/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.02, 5111.023, 5111.025

Prior Effective Dates: 4/30/82(Temp), 8/1/82, 7/1/84, 1/1/86, 3/19/87, 7/1/91, 11/1/93, 6/30/95 (Emer.), 9/28/95, 7/15/01, 6/1/07

Rescinded eff 6-1-07

(A) This rule sets forth the reimbursement and rate setting for the following medicaid covered community mental health services:

(1) “Behavioral health counseling and therapy services” as described in rule 5122-29-03 of the Administrative Code.

(2) “Community psychiatric support treatment services” as described in rule 5122-29-17 of the Administrative Code.

(3) “Crisis intervention mental health services” as described in rule 5122-29-10 of the Administrative Code.

(4) “Mental health assessment services” as described in rule 5122-29-04 of the Administrative Code.

(5) “Partial hospitalization services” as described in rule 5122-29-06 of the Administrative Code.

(6) “Pharmacologic management services” as described in rule 5122-29-05 of the Administrative Code.

(B) Each agency shall maintain a fee schedule of usual and customary charges for all community mental health medicaid services it provides. The agency shall bill the community medicaid program it’s usual and customary charge for a medicaid-covered service. The reimbursement rate to each agency shall be the lesser of the agency’s usual and customary charge or the amount established per paragraph (E)(2) of this rule.

(C) The community medicaid program will not pay for community mental health medicaid services for medicaid clients when those same services are routinely provided to non-medicaid clients at no charge, except when medicaid reimbursement for such services are prescribed by federal law or in rule 5101:3-1-03 of the Administrative Code. If a reduced charge or no charge is made, the lowest charge made becomes the medicaid rate for that service. The community mental health medicaid services are not considered to be provided to non-medicaid clients at no charge or at a reduced charge if all of the following requirements are met:

(1) The agency establishes a fee schedule of usual and customary charges (UCC) for each service available and the agency utilizes a sliding fee schedule whereby individuals without third party insurance are charged; and

(2) The agency collects third-party insurance information from all medicaid and non-medicaid clients; and

(3) The agency bills other responsible third party insurers or payers in accordance with rule 5101:3-1-08 of the Administrative Code where such insurers or payers are known.

(D) The agency may enter into arrangements with insurers and other responsible payers for reimbursement at levels that may differ from the published usual and customary fee schedule.

(E) Methods and standards for establishing prospective cost based unit rates for community mental health medicaid services.

(1) A prospective unit rate for each covered service will be calculated in accordance with the uniform cost report as established in rule 5122-26-19 of the Administrative Code and thus may vary from agency to agency.

(2) The prospective unit rate for covered community medicaid mental health services will be the lesser of an agency’s unit rate calculated on the budgeted uniform cost report as established in rule 5122-26-19 of the Administrative Code or the individual service rate ceiling as established below.

(a) Pharmacological management: two hundred ten dollars and eighty-seven cents per unit. One unit of pharmacological management is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(b) Mental health assessment (nonphysician): one hundred twenty-nine dollars and ninety-nine cents per unit. One unit of mental health assessment is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(c) Mental health assessment (physician): two hundred ten dollars and eightyseven cents per unit. One unit of mental health assessment is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(d) Behavioral health counseling and therapy (individual): twenty-two dollars and fifty cents per unit. One unit of behavioral health counseling and therapy is fifteen minutes and there are no fractions of units of this service allowed.

(e) Behavioral health counseling and therapy (group): nine dollars and eightyseven cents per unit. One unit of behavioral health counseling and therapy is fifteen minutes and there are no fractions of units of this service allowed.

(f) Crisis intervention behavioral health services: one hundred fifty-four dollars and thirty-five cents per unit. One unit of crisis intervention behavioral health services is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(g) Partial hospitalization: one hundred sixteen dollars and eighty-one cents per unit. One unit of partial hospitalization is a program day as defined by the provider consistent with standards established by rule 5122-26-19 of the Administrative Code and there are no fractions of units of this service allowed.

(h) Community psychiatric supportive treatment (individual): twenty-one dollars and thirty-three cents per unit. One unit of community psychiatric supportive treatment is fifteen minutes and there are no fractions of units of this service allowed.

(i) Community psychiatric supportive treatment (group): nine dollars and eighty-one cents per unit. One unit of community psychiatric supportive treatment is fifteen minutes and there are no fractions of units of this service allowed.

(3) Individual service unit rates shall be established at the beginning of the state fiscal year. The unit rate shall be established consistent with the guidelines for determining these costs contained in rule 5122-26-19 of the Administrative Code. All agencies are required to file the budgeted version of the uniform cost report for medicaid rate setting purposes no later than June first of each calendar year with the Ohio department of mental health (ODMH) and simultaneously send a copy to the ADAMHS/CMH board for the service district in which the agency’s primary place of business is located. The unit rates reported on the budgeted version of the uniform cost report will be used as the agency’s prospective rates for the subsequent state fiscal year. Failure to file a budgeted uniform cost report will result in no change to the prospective unit rates for the stated time period. Any budgeted uniform cost report received after June first will be considered untimely. The untimely budgeted uniform cost report may be resubmitted as a request for rate adjustments in accordance with paragraph (E) (4) of this rule.

(4) Agencies may make rate adjustments to the unit rates within the state fiscal year by submitting a revised budgeted uniform cost report to ODMH and simultaneously send a copy to the ADAMHS/CMH board for the service district in which the agency owner’s primary place of business is located. Budgeted uniform cost reports for adjusted rates will not be accepted by ODMH until on or after July first of any calendar year. Rate adjustments to the current period will not be accepted after May first of any calendar year.

(5) Adjustments to the rate(s) will become effective within ten business days of receipt by ODMH or a later date if requested by the agency. Retroactive rate adjustments will not occur.

(6) Rates for additional services not previously contracted for and listed in paragraph (A) of this rule may be added by an agency at any time during the state fiscal year. The prospective unit rate(s) for additional services will be based upon a budgeted uniform cost report amended to include the additional services.

(a) If the budgeted cost report reflects rate adjustment(s) for existing unit rates, paragraphs (E)(4) and (E)(5) of this rule apply.

(b) An agency must specify a rate effective date for services not previously contracted for and listed in paragraph (A) of this rule. For new services this effective date can be up to three hundred and sixty-five days prior to submission. This is not considered a retroactive rate adjustment.

Replaces: 5101:3-27-05

Effective: 09/01/2005

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.022

Prior Effective Dates: 8/1/82, 12/22/86 (Emer.), 7/1/91

Rescinded eff 1-19-09

(A) Purpose: this rule sets forth the cost reconciliation calculation method to be used by the Ohio department of mental health, the notification of overpayment requirement to and the repayment for medicaid participating mental health agencies.

(B) Definitions:

(1) “Actual uniform cost report” means the uniform cost report completed retrospectively after the close of the state fiscal year (SFY) using actual cost data.

(2) “Actual unit rate” means the unit cost found in column twelve of the actual uniform cost report.

(3) “Agency” means a community mental health provider as defined in section 5122:01 of the Revised Code which has been certified by the Ohio department of mental health in accordance with the requirements of section 5119.611 of the Revised Code.

(4) “Budgeted uniform cost report” means a uniform cost report completed prospectively using anticipated budgeted cost data for an upcoming SFY.

(5) “Full payment” means federal financial participation and match participation.

(6) “Interim unit rate” means the unit cost found in column twelve of a budgeted uniform cost report.

(7) “MACSIS” means multi-agency community services information system.

(8) “Medicaid paid claims” means claims sourced from MACSIS which were submitted to and approved for reimbursement by ODJFS.

(9) “Medicaid participating mental health agency” means an agency that has met the requirements of rule 5101:3-27-01 of the Administrative Code and has received payment for medicaid covered mental health services as defined in rule 5101:3-27-02 of the Administrative Code.

(10) “ODJFS” means the Ohio department of job and family services.

(11) “ODMH” means the Ohio department of mental health.

(12) “Rate ceiling” means the maximum amount per unit of service a medicaid participating mental health agency may be paid for a medicaid covered mental health service listed in rule 5101:3-27-05 of the Administrative Code.

(13) “Uniform cost report” means the cost report as contained in rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled.

(14) “Unit of service” means the length of time defined in rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled for each medicaid covered mental health service as defined in rule 5101:3-27-02 of the Administrative Code.

(15) “UPI” means the unique provider identification number. This number represents an ODMH certified community mental health program and owner (indicated by a single federal tax identification number) operating at a discrete physical location.

(C) Each medicaid participating mental health agency shall complete all the budgeted uniform cost reports and the actual uniform cost report for any given SFY in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled. The methods of cost reporting selected when completing the first budgeted uniform cost report submitted in accordance with rule 5101:3-27-05 of the Administrative Code for a SFY must be the same methods the medicaid participating mental health agency shall use when completing and submitting any subsequent budgeted uniform cost report and the actual uniform cost report for that same SFY.

(D) Cost reconciliation process:

(1) The actual allowable amount a medicaid participating mental health agency could have received for medicaid covered mental health services for the state fiscal year being reconciled shall be determined by ODMH as follows:

(a) For each service, the maximum allowable rate will be determined by selecting the lower of the following: the medicaid rate ceiling in effect for the SFY being reconciled or the actual cost. The total allowable payment shall be determined by multiplying the number of service units from MACSIS associated with the medicaid paid claims by the maximum allowable rate. If a medicaid participating mental health agency fails to submit an actual uniform cost report in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled, the number of service units from MACSIS associated with the medicaid paid claims shall be multiplied by the lowest actual unit cost as documented on all filed actual uniform cost reports for the SFY being reconciled for each service the medicaid participating mental heath agency received medicaid payment. If a medicaid participating mental health agency fails to submit an actual uniform cost report in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled, the medicaid participating mental health agency’s ODMH certification/license may be revoked in accordance with rule 5122-26-19 of the Administrative Code as in effect for the SFY being reconciled.

(b) From each of the calculations described in paragraph (D)(1)(a) of this rule the value of third party payments, as reported by the medicaid participating mental health agency associated with the service specific medicaid paid claims shall be deducted. The result is the actual allowable amount of medicaid payment for each service for the medicaid participating mental health agency for the SFY being reconciled.

(2) The actual amount of medicaid payment paid to the medicaid participating mental health agency for each service for the SFY being reconciled shall be determined by summing the net amount from MACSIS claims detail associated with medicaid paid claims for that service.

(3) For each service, subtract the result of paragraph (D)(1)(b) of this rule from paragraph (D)(2) of this rule.

(a) If the result of this calculation is greater than zero, the medicaid participating mental health agency has been overpaid for the service for the SFY being reconciled.

(b) If the result of this calculation is equal to or less than zero, no overpayment of the service exists.

(4) The medicaid participating mental health agency is required to repay the full amount of the sum of all overpayments identified in paragraph (D)(3)(a) of the rule to ODMH.

(E) ODMH shall send the medicaid participating mental health agency a notification, by certified mail, of the overpayment amount calculated. ODMH will send a copy to ODJFS.

Replaces: 5101:3-27-05

Effective: 09/01/2005

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.022

Prior Effective Dates: 8/1/82, 12/22/86 (Emer.), 7/1/91