Lawriter - OAC - 5160-12-05 Reimbursement: home health services.

5160-12-05 Reimbursement: home health services.

(A) Definitions of terms used for billing home health services rates set forth in appendix A to this rule are:

(1) "Base rate", as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid:

(a) For the initial thirty-five to sixty minutes of home health aide service delivered;

(b) For the initial thirty-five to sixty minutes of home health nursing service delivered; or

(c) Up to the first four units of initial home health skilled therapy service delivered.

(2) "Unit rate", as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid for each fifteen minutes of service delivered when the initial visit is:

(a) Greater than sixty minutes in length for any home health service delivered; or

(b) Less than or equal to thirty-four minutes in length for home health aide and/or home health nursing service delivered.

(B) Home health services are delivered and billed in accordance with this chapter by medicare certified home health agencies (MCHHA).

(C) The amount of reimbursement for a home health visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and/or unit rate found in appendix A as applicable to this rule using the number of units of service that were provided during a visit in accordance with this chapter as follows:

(1) Each visit must be less than or equal to four hours.

(2) For a home health aide and/or a home health nursing visit that is less than thirty-five minutes in total, Ohio medicaid will reimburse a maximum of only one unit if the service is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(3) For a home health aide and/or a home health nursing visit thirty-five minutes to one hour in length in total, the medicaid maximum is the amount of the base rate.

(4) For a home health aide, home health nursing, or home health skilled therapy visit in length beyond the initial hour of service, the base rate plus the rate amount for each unit over the initial one hour may be claimed, not to exceed four hours.

(D) The amount of reimbursement for a visit shall be the lesser of the provider's billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (C) of this rule when billing with the modifier HQ "group setting" for group visits conducted in accordance with rule 5160-12-04 of the Administrative Code.

(E) The modifiers set forth in appendix B to this rule must be used to provide additional information in accordance with this chapter. A visit made for the purpose of home infusion therapy in accordance with 5160-12-01 of the Administrative Code must be billed using the U1 modifier.

(F) A visit conducted by a registered nurse (RN) for the provision of home health nursing services must be billed to Ohio medicaid using the billing code G0299 as found in appendix A to this rule. A visit conducted by a licensed practical nurse (LPN) for the provision of home health nursing services must be billed to Ohio medicaid using the billing code G0300 as found in appendix A to this rule.

(G) An MCHHA will not be reimbursed for home health services provided to an individual that duplicates same or similar services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplement recipient or individual receiving medicaid resides, such as an adult foster home, adult family home, adult group home, residential care facility, or other facility is paid to provide personal care or nursing services, home health services are not reimbursable by medicaid.

(H) An MCHHA may be reimbursed for home health services provided to an individual residing in a facility/home if the provider has written documentation from the facility/home stating that it is not responsible for providing the same or similar home health services to the individual.

(I) Home health services provided to an individual enrolled on an assisted living home and community based services waiver in accordance with rule 5160-1-06 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

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Effective: 1/1/2017
Five Year Review (FYR) Dates: 07/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.77
Rule Amplifies: 5164.70, 5164.77
Prior Effective Dates: 5/01/87, 4/01/88, 5/15/89, 7/01/98, 7/01/06, 7/01/08, 1/01/10 , 10/01/11, 7/01/15, 01/01/16, 10/01/16.