Chapter 5160-27 Community Mental Health Agency Services

5160-27-01 Eligible providers for community mental health 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 5111.023 of the Revised Code and Chapters 5122-24 to 5122-29 of the Administrative Code; or

(2) For services provided prior to July 1, 2012, an agency meeting the requirements set forth in section 5111.023 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, 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) For services provided on or after July 1, 2012, a community mental health agency or facility that has its community mental health services certified by the Ohio department of mental health under section 5119.611 of the Revised 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 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 services.

(B) In addition to the requirements of paragraphs (A)(1), (A)(2), and (A)(3) of this rule, an eligible provider must provide one or more of the medicaid covered services as set forth in rule 5101:3-27-02 of the Administrative Code.

(C) An eligible provider may subcontract for services. For such services to be billable, the services must be certified in accordance with section 5119.611 of the Revised Code and provided in accordance with the provisions set forth in Chapter 5101:3-27 of the Administrative Code.

(D) An eligible provider must have a valid Ohio health plans provider agreement approved by and on file with the Ohio department of job and family services.

Effective: 07/01/2012
R.C. 119.032 review dates: 04/16/2012 and 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , section 5111.912 in Am. Sub. HB153 of the 129th General Assembly
Prior Effective Dates: 4/20/82 (Temp.), 8/1/82, 3/19/87, 9/1/91, 3/15/93

5160-27-02 Coverage and limitations of medicaid community mental health services.

(A) The following describes those services reimbursable as medicaid community mental health services when rendered by eligible medicaid providers as defined in rule 5160-27-01 of the Administrative Code. For the purposes of this rule, a twelve month period means the time period from July first of any given year to June thirtieth of the subsequent year.

(1) Behavioral health counseling and therapy services as defined in rule 5122-29-03 of the Administrative Code. A combined maximum of fifty-two hours of individual and group behavioral health counseling and therapy services are allowed per twelve month period. In accordance with the requirements of "Healthchek" (Ohio's early periodic screening, diagnosis, and treatment (EPSDT) benefit), children up to the age of twenty-one may receive services beyond established limits when medically necessary.

(2) Mental health assessment services as defined in rule 5122-29-04 of the Administrative Code. Psychological testing, when performed as a component of the mental health assessment, must be face-to-face. A provider billing for or receiving medicaid reimbursement for psychological testing as a component of a mental health assessment under this rule shall not bill for or be reimbursed for that same psychological testing under other medicaid programs.

(a) A maximum of two hours of psychiatric diagnostic interview services are allowed per twelve month period. In accordance with the "Healthchek" benefit, children up to the age of twenty-one may receive services beyond established limits when medically necessary.

(b) A maximum of four hours of mental health assessment services are allowed per twelve month period. In accordance with the "Healthchek" benefit, children up to the age of twenty-one may receive services beyond established limits when medically necessary.

(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. A maximum of twenty-four hours of pharmacologic management services are allowed per twelve month period. In accordance with the "Healthchek" benefit, children up to the age of twenty-one may receive services beyond established limits when medically necessary. Pharmacologic management services, as defined in this rule, are not covered during an inpatient stay in a hospital.

(4) Partial hospitalization services as defined in rule 5122-29-06 of the Administrative Code and 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 includes activity therapies, group activities, or other services and programs 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 and meet the following requirements:

(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 meet the following requirements:

(a) All CPST services provided in social, recreational, vocational, or educational settings are allowable only if they are documented mental health service interventions addressing 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) A combined maximum of one-hundred and four hours of individual and group CPST services are allowed per twelve month period. In accordance with the "Healthchek" benefit, children up to age of twenty-one may receive services beyond established limits when medically necessary and approved through the prior authorization process. Adults may receive services beyond established limits when medically necessary and approved through the prior authorization process.

(d) CPST services are not covered under this rule when provided to an adult or child in a hospital setting, except for the purpose of coordinating admission to the inpatient hospital or facilitating discharge to the community following inpatient treatment for an acute episode of care.

(7) Eligibility for health home services is determined as follows:

(a) Health home enrollment is restricted to persons with serious and persistent mental illness as defined in rule 5122-29-33 of the Administrative Code and in accordance with additional eligibility criteria defined by the Ohio department of medicaid in collaboration with the Ohio department of mental health and addiction services as stated in appendix B to this rule.

(b) Persons who do not meet the eligibility criteria in appendix B to this rule will continue to be eligible for health home services until July 1, 2015 if they meet the following criteria:

(i) They are enrolled in a health home located in Adams, Butler, Lawrence, Lucas, or Scioto counties for an effective date prior to July 1, 2014, and

(ii) The health home in which they were enrolled prior to July 1, 2014 delivered a health home service to the person during the month of June 2014.

(c) Health home services shall be covered only in geographical regions approved by the centers for medicare and medicaid services (CMS).

(d) When a health home enrollee or the parent or guardian requests to disenroll from the health home, the health home must process the disenrollment within three business days. The request for disenrollment, including the date the request was made, must be recorded in the client record.

(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 5160-27 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 paragraph (I) of this rule, and in rules 5122-29-03 , 5122-29-04 , 5122-29-05 and 5122-29-17 of the Administrative Code.

(6) Health home services provided in accordance with rule 5122-29-33 of the Administrative Code. Health home services performed after the development of the single, person-centered, integrated care plan must be directly linked to the goals and actions documented in the single, person-centered integrated care plan.

(G) All medicaid community mental health services contacts, other than health home services, must be documented in the individual client record (ICR) of the person served and satisfy the requirements in rule 5122-27-06 of the Administrative Code. Health home services shall be documented as necessary to establish medical necessity as defined in Chapter 5160-1 of the Administrative Code.

(H) Non-covered medicaid 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.

(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 medications listed in appendix A to this rule are covered by the department when rendered and billed by an eligible provider as described in rule 5160-27-01 of the Administrative Code. The medication must be administered by a qualified provider acting within the provider's professional scope of practice.

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Effective: 07/01/2014
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5164.03 , 5164.15 , 5164.76 , 5164.88
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, 7/1/08, 11/1/11(Emer.), 1/30/12, 10/1/12

5160-27-05 Reimbursement for community mental health medicaid services.

(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" as described in rule 5122-29-03 of the Administrative Code.

(2) "Community psychiatric supportive treatment" as described in rule 5122-29-17 of the Administrative Code.

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

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

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

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

(7) "Health home services for persons with serious and persistent mental illness" as described in rule 5122-29-33 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 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 community psychiatric supportive treatment (CPST) as described in paragraph (C) of this rule and health home services for persons with serious and persistent mental illness as described in paragraphs (H) to (J) of this rule. Reimbursement for community mental health medicaid services is considered payment in full .

(C) The reimbursement rate for CPST shall be as follows:

(1) For CPST services not rendered in a group setting, the medicaid maximum amount is calculated as follows:

(a) If the total number of service units rendered by a provider per date of service is less than or equal to six, the medicaid maximum amount is equal to the unit rate according to the department's service fee schedule multiplied by the number of units rendered.

(b) If the total number of services units rendered by a provider per date of service is greater than six, the medicaid maximum amount is equal to the sum of:

(i) The unit rate according to the department's service fee schedule multiplied by six; and

(ii) Fifty per cent of the unit rate according to the department's service fee schedule multiplied by the difference between the total number of units rendered minus six.

(2) For CPST services rendered in a group setting, the medicaid maximum amount is calculated as follows:

(a) If the total number of service units rendered by a provider per date of service is less than or equal to six, the medicaid maximum amount is equal to the unit rate according to the department's service fee schedule multiplied by the number of units rendered.

(b) If the total number of services units rendered by a provider per date of service is greater than six, the medicaid maximum amount is equal to the sum of:

(i) The unit rate according to the department's service fee schedule multiplied by six; and

(ii) Fifty per cent of the unit rate according to the department's service fee schedule multiplied by the difference between the total number of units rendered minus six.

(D) 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 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 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, including medicare, in accordance with rules 5160-1-05 and 5160-1-08 of the Administrative Code where such insurers or payers are known.

(E) 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.

(F) Services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456.3, as in effect on October 1, 2013, and rule 5160-1-27 of the Administrative Code.

(G) Notwithstanding the provisions set forth in paragraph (G) of rule 5160-27-02 of the Administrative Code the agency shall be deemed to be in compliance with paragraph (G) of rule 5160-27-02 of the Administrative Code if it satisfies all the requirements in rule 5122-27-06 of the Administrative Code.

(H) Health home services for persons with serious and persistent mental illness, as defined in rule 5122-29-33 of the Administrative Code, are reimbursed using a monthly case rate specific to the health home service providers located in Ohio counties Adams, Butler, Lawrence, Lucas, and Scioto, and shall be calculated as follows:

(1) Annual costs must be compiled in accordance with the uniform cost report principles and cost categories described in rule 5122-26-19 of the Administrative Code.

(2) Calculation of the monthly case rate is as follows:

(a) Divide the annual cost as developed in accordance with paragraph (H)(1) of this rule by the caseload, then

(b) Divide the result of the calculation in paragraph (H)(2)(a) of this rule by twelve.

(3) .The monthly case rates calculated using the methodology in paragraphs (H)(1) and (H)(2) of this rule shall be reduced by ten percent for the period of July 1, 2014 through June 30, 2015.

(4) Reimbursement for health home services is considered payment in full for all components of the service as defined in rule 5122-29-33 of the Administrative Code, including service components that may otherwise be reimbursable as CPST.

(I) Beginning July 1, 2014, reimbursement for health home service providers located in Ohio counties Cuyahoga, Erie, Franklin, Hamilton, Portage, and Summit will be made using the base rate as stated in appendix A to this rule. Rates will remain in effect until changed by the Ohio department of medicaid in consultation with the Ohio department of mental health and addiction services and certified health home providers.

(J) Beginning July 1, 2014, health home service providers located in Cuyahoga, Franklin, Hamilton, Portage, and Summit counties that render health home services to individuals enrolled in a "MyCare Ohio" plan, as specified in rule 5160-58-01 of the Administrative Code, shall bill the "MyCare Ohio" plan for the monthly case rate stated in appendix A to this rule. Health home service providers located in Butler and Lucas counties that render health home services to individuals enrolled in a "MyCare Ohio" plan, as specified in rule 5160-58-01 of the Administrative Code, shall bill the "MyCare Ohio" plan for the monthly case rate outlined in paragraph (H) of this rule.

(K) The reimbursement amount for an injectable or provider-administered medication listed in appendix A to rule 5160-27-02 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.

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Effective: 07/01/2014
R.C. 119.032 review dates: 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5164.03 , 5164.15 , 5164.88
Prior Effective Dates: 8/1/82, 12/22/86(Emer.), 7/1/91, 9/1/05, 2/15/10, 10/4/10, 7/1/11(Emer.), 9/29/11, 10/1/12

5160-27-07 Cost reconciliation requirements for medicaid covered community mental health services.

(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.

The cost reconciliation process described in this rule is no longer applicable to medicaid covered community mental health 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) "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 community 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.

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 , 5111.022
Prior Effective Dates: 8/1/82, 12/22/86(Emer.), 7/1/91, 9/1/05