5101:3-30-06 Cost reconciliation requirements for medicaid covered alcohol and other drug treatment services.

(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.

The cost reconciliation process described in this rule is no longer applicable to medicaid covered alcohol and other drug treatment services provided on or after October 4, 2010 due to the fee schedule payment methodology implemented in rule 5101:3-27-05 of the Administrative Code.

(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.

Effective: 10/04/2010
R.C. 119.032 review dates: 07/20/2010 and 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 3793.06 , 3793.11
Prior Effective Dates: 7/1/1/91(Emer.), 9/30/91, 9/1/05