5101:3-30-04 Reimbursement for community medicaid alcohol and other drug treatment services.

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

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

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

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

(4) "Crisis intervention" 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" 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" as defined in paragraph (S) of rule 3793:2-1-08 of the Administrative Code.

(10) "Opioid agonist administration" 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 in appendix A to this rule with the exception for case management as described in paragraph (C) of this rule.

(C) The reimbursement rate for the case management service shall be as follows:

(1) If the total number of service units rendered and billed by a provider per date of service to a unique client is less than or equal to 1.5, the medicaid payment amount is equal to the unit rate according to the department's service fee schedule (specified in appendix A to this rule) multiplied by the number of units billed or the provider billed amount based upon their established usual and customary charge, whichever is less.

(2) If the total number of service units rendered and billed by a provider per date of service to a unique client is greater than 1.5, the medicaid payment amount is equal to:

(a) The sum of:

(i) The unit rate according to the department's service fee schedule (specified in appendix A to this rule) multiplied by 1.5; and

(ii) Fifty per cent of the unit rate according to the department's service fee schedule (specified in appendix A to this rule) multiplied by the difference between the total number of units billed minus 1.5.

(D) 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 5160-1-03 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 5160-1-08 of the Administrative Code when such insurers or payers are known.

(E) The community medicaid program will not pay for more than thirty cumulative hours of the following services when provided to the same adult individual during a week, Sunday through Saturday:

(1) Group counseling,

(2) Individual counseling, and

(3) Medical/somatic.

In accordance with the early periodic screening, diagnosis, and treatment (EPSDT) program, services to children are not subject to the limit of thirty cumulative hours per week.

(F) 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.

(G) Services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456.3 , dated October 1, 2007, and rule 5160-1-27 of the Administrative Code.

(H) The reimbursement amount for injectable naltrexone as listed in appendix A to rule 5160-30-02 of the Administrative Code is the lesser of the provider's submitted charge or the maximum fee listed, described, or referenced in rule 5160-1-60 of the Administrative Code. Reimbursement for buprenorphine based medications, when administered in accordance with rule 3793:2-1-08 of the Administrative Code, shall be fifty-five cents per one milligram unit and must be billed using HCPCS code J8499. The reimbursement amount for this medication will be reviewed and updated as necessary.

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Effective: 11/10/2013
R.C. 119.032 review dates: 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02
Prior Effective Dates: 7/1/91(Emer.), 9/30/91, 9/1/05, 10/04/10, 11/1/11(Emer.), 1/30/12