Chapter 5101:3-30 Alcohol and Drug Addiction Services

(A) An eligible provider for purposes of this chapter is an entity that is operating a program certified in accordance with the requirements set forth in Chapters 3793:2-1 and 3793:2-2 of the Administrative Code, or certified in accordance with the requirements set forth in Chapters 3793:2-1 and 3793:2-2 of the Administrative Code and licensed according to Chapter 3793:2-3 of the Administrative Code to provide a methadone program. An eligible provider must contract with an alcohol and drug addiction services board or an alcohol, drug addiction and mental health services board to receive medicaid reimbursement for the medicaid covered services defined in rule 5101:3-30-02 of the Administrative Code. Alcohol and drug addiction treatment services must be provided in accordance with Chapter 5101:3-30 of the Administrative Code.

(B) For any provider that is a government entity which receives nonfederal public funds, including but not limited to county departments of human services, county children services boards and local education agencies, eligibility is further contingent upon demonstration by the agency, as requested by the department of alcohol and drug addiction services, 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 service(s) and certified as representing expenditures eligible for federal financial participation.

HISTORY: Eff 7-1-91 (Emer.); 9-30-91; 8-1-93

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5111.02

Rule amplifies: RC 3793.06, 3793.11, 5111.01, 5111.02

(A) The following identifies alcohol and drug addiction treatment services that may be covered by medicaid and the limitation policies applicable to these services.

(1) “Assessment services” are those services defined in rule 3793:2-1-08 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(2) “Crisis intervention services” are those services defined in rule 3793:2-1-09 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(3) “Individual counseling services” and “group counseling services” are those services defined in rule 3793:2-1-11 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(4) “Medical somatic services” are those services defined in rule 3793:2-1-13 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(5) “Drug screening/urinalysis services” are those services defined in rule 3793:2-1-14 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code. Notwithstanding the provisions found in Chapters 3793:2-1 and 3793:2-2 of the Administrative Code, a physician must order the drug screening/urinalysis for medicaid to cover the service.

(6) “Methadone administration services” are those services defined in rule 3793:2-1-15 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code and licensed in accordance with Chapter 3793:2-3 of the Administrative Code.

(7) “Case management services” are those services defined in rule 3793:2-1-16 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(8) “Intensive outpatient services” are those services defined in rule 3793:2-1-17 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(9) “Ambulatory medical” or “social detoxification services” are those services defined in paragraph (F) of rule 3793:2-1-10 of the Administrative Code and provided in accordance with Chapters 3793:2-1 and 3793:2-2 of the Administrative Code.

(B) Services meeting the requirements identified in paragraphs (A)(1) to (A)(9) of this rule are covered when recommended by an individual who has one of the following credentials:

(1) Certified chemical dependency counselor three;

(2) Licensed physician;

(3) Licensed psychologist;

(4) Licensed professional clinical counselor with a declared scope of practice of alcohol and drug addiction counseling;

(5) Licensed professional counselor with a declared scope of practice of alcohol and drug addiction counseling;

(6) Licensed independent social worker with a declared scope of practice of alcohol and drug addiction counseling; or

(7) Registered nurse with a declared scope of practice of alcohol and drug addiction nursing.

HISTORY: Eff 7-1-91 (Emer.); 9-30-91

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5111.02

Rule amplifies: RC 3793.06, 3793.11, 5111.01, 5111.02

(A) All covered services are to be billed on a unit rate basis in accordance with definitions, standards, and eligible providers of service set forth in rule 5101:3-30-02 of the Administrative Code.

(B) For purposes of alcohol and drug addiction treatment services unless otherwise noted, a “billable unit of service” is defined as an hour-measured face-to-face contact between a client and a professional authorized to provide services delineated in rule 5101:3-30-02 of the Administrative Code as covered under the medicaid program. For an alcohol and drug addiction treatment service to be defined as a unit, it must meet the definition set forth in this paragraph and must be recorded in the individual client record (ICR). Case management services can be delivered face-to-face or by telephone and be a “billable unit of service.” Billable case management services may include face-to-face or telephone contact with persons other than the client; such services must be recorded in the clients ICR.

(1) Billable units of services are limited to those which take place at the site certified for participation in the alcohol and drug addiction treatment program or at a site deemed appropriate according to the standard referenced in rule 5101:3-30-02 of the Administrative Code as relative to the covered service.

(2) Units of service with individuals other than the client (e.g., conferences and consultations with a family member) are not billable. However, counseling and diagnostic assessment may include face-to-face interaction with family members and/or parent, guardian and significant other of a child or adolescent when the intended outcome is improved functioning of the child or adolescent and when such intervention is part of the individualized treatment plan. It is recognized also that case management services include contact with individuals other than the client and is billable as a unit of service.

(3) Covered services delineated in rule 5101:3-30-02 of the Administrative Code, with the exception of intensive outpatient services, are considered hour-measured billable services. Intensive outpatient services are considered day-measured billable services and drug screening/urinalysis services are considered a per screening billable unit for purposes of the alcohol and drug addiction treatment services program.

(4) The billable unit of service criterion is not met nor is coverage available under medicaid for costs involved when a provider participates in community meetings or group sessions which are not designed to provide alcohol and drug addiction treatment services to program users. Examples of such activities include orientation sessions for new clients, presentations to community groups (high school classes, PTA, etc.), and informal presentations about alcohol and drug addiction treatment programs.

(C) It is recognized that eligible providers may wish to augment staff delivered services through contractual arrangements. Such arrangements are recognized to the extent that the conditions set forth in paragraphs (C)(1) and (C)(2) of this rule are met. Services provided by contract may either be included as a cost item in determining the prospective rates or may be billed independently by the contract provider. If the contract provider bills independently, any such services will not be subject to prospective cost-related reimbursement, but will instead be reimbursed in accordance with methods established under 5101:3 of the Administrative Code other than the provisions set forth in Chapter 5101:3-30 of the Administrative Code (e.g., physician psychiatric services will be reimbursed under provisions set forth in Chapter 5101:3-4 of the Administrative Code). In order for contractual arrangements to be recognized, eligible providers must provide the following information to Ohio department of alcohol and drug addiction services at the point of entry into the program and any subsequent point when new contracts are negotiated or when existing contracts are revised:

(1) Identification by name and, where applicable, medicaid provider number of each individual practitioner providing services under contractual arrangements. Where the contract is let with a legal entity other than the individual practitioner, both the name of the legal entity and the name(s) of any individual practitioner(s) involved must be furnished.

(2) A written statement indicating, for each legal entity or individual practitioner, whether the contracted services are:

(a) To be included as a cost item and reimbursed under the applicable prospective rate for the type of service provided; or

(b) To be billed independently by the legal entity or individual practitioner under contract.

HISTORY: Eff 7-1-91 (Emer.); 9-30-91

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5111.02

Rule amplifies: RC 3793.06, 3793.11, 5111.01, 5111.02

(A) This rule sets forth the reimbursement and rate setting for the following community medicaid alcohol and other drug treatment services:

(1) “Ambulatory detoxification services” as defined in paragraph (X) of rule 3793:2-1-08 of the Administrative Code.

(2) “Assessment services” as defined in paragraph (K) of rule 3793:2-1-08 of the Administrative Code.

(3) “Case management services” as defined in paragraph (M) of rule 3793:2-1-08 of the Administrative Code.

(4) “Crisis intervention services” as defined in paragraph (L) of rule 3793:2-1-08 of the Administrative Code.

(5) “Group counseling” as defined in paragraph (O) of rule 3793:2-1-08 of the Administrative Code.

(6) “Individual counseling” as defined in paragraph (N) of rule 3793:2-1-08 of the Administrative Code.

(7) “Intensive outpatient services” as defined in paragraph (Q) of rule 3793:2-1-08 of the Administrative Code.

(8) “Laboratory urinalysis” as defined in paragraph (R) of rule 3793:2-1-08 of the Administrative Code.

(9) “Medical/somatic services” as defined in paragraph (S) of rule 3793:2-1-08 of the Administrative Code.

(10) “Methadone administration services” as defined in paragraph (T) of rule 3793:2-1-08 of the Administrative Code.

(B) Each agency shall maintain a fee schedule of usual and customary charges for all community medicaid alcohol and other drug treatment services it provides. The agency shall bill the community medicaid program its 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 medicaid alcohol and other drug treatment 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 medicaid alcohol and other drug treatment 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 when 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 medicaid alcohol and other drug treatment services.

(1) A prospective unit rate for each community medicaid alcohol and other drug treatment service will be calculated in accordance with the uniform cost report as established in rule 3793:2-1-09 of the Administrative Code and thus may vary from agency to agency.

(2) The prospective unit rate for covered community medicaid alcohol and other drug treatment services will be the lesser of an agency’s unit rate calculated on the budgeted uniform cost report as established in rule 3793:2-1-09 of the Administrative Code or the individual service rate ceiling as established below.

(a) Ambulatory detoxification: one hundred ninety-three dollars and eightyseven cents per unit. One unit of ambulatory detoxification is one day, there are no fractions of this unit.

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

(c) Case management: seventy-eight dollars and seventeen cents per unit. One unit of case management is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(d) Crisis intervention: one hundred twenty-nine dollars and fifty-nine cents per unit. One unit of crisis intervention is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(e) Group counseling: nine dollars and fifty-two cents per unit. One unit of group counseling is fifteen minutes and there are no fractions of units of this service allowed.

(f) Individual counseling: twenty-one dollars and eighty-two cents per unit. One unit of individual counseling is fifteen minutes and there are no fractions of units of this service allowed.

(g) Intensive outpatient: one hundred thirty-six dollars and ninety cents per unit. One unit of intensive outpatient is one day, there are no fractions of this unit.

(h) Laboratory urinalysis: sixty dollars per unit. One unit of laboratory urinalysis is defined as a screen, regardless of the number of panels and there are no fractions of units of this service allowed.

(i) Medical/somatic: one hundred seventy-six dollars and twenty-eight cents per unit. One unit of medical/somatic is one hour, fractions of this unit are allowed, reportable in six minute increments represented by tenths.

(j) Methadone administration: sixteen dollars and thirty-eight cents per unit. One unit of methadone administration is one dose and there are no fractions of units of this service allowed.

(3) Individual service unit rates shall be established at the beginning of each state fiscal year. The unit rate shall be established consistent with the guidelines for determining these costs contained in rule 3793:2-1-09 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 alcohol and drug addiction services (ODADAS) and simultaneously send a copy to the ADAMHS/ADAS board for the service district in which the AOD program owner’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 ODADAS and simultaneously send a copy to the ADAMHS/ADAS board for the service district in which the AOD program owner’s primary place of business is located. Budgeted uniform cost reports for adjusted rates will not be accepted by ODADAS 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 ODADAS or a later date if requested by the agency. Retroactive rate adjustments will not occur.

(6) Rates for 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 uniform 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: 5101:3-30-04

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, 3793.06, 3793.11

Prior Effective Dates: 7/1/91 (Emer.), 9/30/91

Rescinded eff 7-1-09

(A) Purpose: this rule sets forth the cost reconciliation calculation method to be used by the Ohio department of alcohol and drug addiction services, the notification of overpayment requirement to and the repayment for medicaid participating alcohol and other drug programs.

(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) “AOD program” means an alcohol and drug addiction program as defined in section 3793:01 of the Revised Code which has been certified by the Ohio department of alcohol and drug addiction services in accordance with the requirements of section 3793.06 of the Revised Code or has been issued a license from the Ohio department of alcohol and drug addiction services in accordance with the requirements of section 3793.11 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 AOD program” means an AOD program that has met the requirements of rule 5101:3-30-01 of the Administrative Code and has received payment for medicaid covered AOD treatment services as defined in rule 5101:3-30-02 of the Administrative Code.

(10) “ODADAS” means the Ohio department of alcohol and drug addiction services.

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

(12) “Rate ceiling” means the maximum amount per unit of service a medicaid participating AOD program may be paid for a medicaid covered AOD treatment service listed in rule 5101:3-30-04 of the Administrative Code.

(13) “Uniform cost report” means the cost report as contained in rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled.

(14) “Unit of service” means the length of time as defined in rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled. For each medicaid covered AOD treatment service as defined in rule 5101:3-30-02 of the Administrative Code on the uniform cost report.

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

(C) Each medicaid participating AOD program shall complete all the budgeted uniform cost reports and the actual uniform cost report for any given SFY in accordance with rule 3793:2-1-09 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 5101:3-30-04 of the Administrative Code for a SFY must be the same methods the medicaid participating AOD program 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 AOD program could have received for medicaid covered AOD treatment services for the state fiscal year being reconciled shall be determined by ODADAS 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 unit 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 the medicaid participating AOD program fails to submit an actual uniform cost report in accordance with rule 3793:2-1-09 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 AOD program received medicaid payment. If a medicaid participating AOD program fails to submit an actual uniform cost report in accordance with rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled, the medicaid participating AOD program’s ODADAS certification/license may be revoked in accordance with rule 3793:2-1-09 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 AOD program 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 AOD program for the SFY being reconciled.

(2) The actual amount of medicaid payment paid to the medicaid participating AOD program 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 the rule.

(a) If the result of this calculation is greater than zero, the medicaid participating AOD program 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 for the service exists.

(4) The medicaid participating AOD program is required to repay the full amount of the sum of all overpayments identified in paragraph (D)(3)(a) to ODADAS.

(E) ODADAS shall send the medicaid participating AOD program a notification, by certified mail, of the overpayment amount calculated. ODADAS will send a copy to ODJFS.

Replaces: 5101:3-30-04

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, 3793.06, 3793.11

Prior Effective Dates: 7/1/91 (Emer.), 9/30/91