Chapter 5160-27 Community Mental Health Agency Services

5160-27-01 [Effective until 1/1/2018] 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.

Cite as Ohio Admin. Code 5160-27-01

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

5160-27-01 [Effective 1/1/2018] Eligible provider for behavioral health services.

(A) An "eligible behavioral health provider" for purposes of this chapter is a provider of a mental health or substance use disorder treatment service covered in agency 5160 of the Administrative Code and is one of the following:

(1) An entity meeting the certification requirements set forth in section 5119.36 of the Revised Code and Chapters 5122-24 to 5122-29 and Chapter 5160-1 of the Administrative Code and providing mental health or substance use disorder treatment services.

(2) An entity furnishing mental health and/or substance use disorder services operating in a bordering state and meeting the requirements set forth in rule 5160-1-11 of the Administrative Code. The entity must be an eligible and enrolled provider with the state medicaid agency in the state where the entity operates.

(3) Physician, or physician assistant, licensed by the state of Ohio medical board and practicing according to agency 4731 and agency 4730 of the Administrative Code respectively and Chapter 5160-4 of the Administrative Code, or a clinical nurse specialist or certified nurse practitioner, licensed by the Ohio board of nursing and practicing according to agency 4723 of the Administrative Code. The practitioner must be an employee or an independent contractor of an entity meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule.

(4) Registered nurse or licensed practical nurse licensed by the Ohio board of nursing and practicing according to agency 4723 of the Administrative Code. The nurse must be an employee or an independent contractor of an entity meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule. A registered nurse or licensed practical nurse must work under an order authorized by one of the practitioners listed in paragraph (A)(3) of this rule.

(5) A licensed practitioner meeting the requirements stated in rule 5160-8-05 of the Administrative Code and is an employee or an independent contractor of an entity meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule.

(6) An unlicensed practitioner meeting the following requirements as applicable:

(a) An unlicensed practitioner providing mental health services who holds a valid high school diploma or equivalent and has both work experience and training related to the service(s) being provided, and is an employee or an independent contractor of an entity meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule. These practitioners must operate under the general supervision of one of the practitioners listed in paragraphs (E)(1) to (E)(10) of this rule, in accordance with paragraph (D)(2)(b) of rule 5160-8-05 of the Administrative Code.

(b) An unlicensed practitioner providing substance use disorder services must operate under the general supervision, in accordance with paragraph (D)(2)(b) of rule 5160-8-05 of the Administrative Code, of one of the practitioners listed in paragraphs (E)(1) to (E)(10) of this rule, be an employee or an independent contractor of an entity meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule, and be one of the following provider types:

(i) A chemical dependency counselor assistant certified by the Ohio chemical dependency professionals board and practicing according to rule 5160-8-05 of the Administrative Code.

(ii) A peer recovery supporter meeting all of the following requirements:

(a) Certified as a peer recovery supporter by the Ohio department of mental health and addiction services.

(b) Be eighteen years of age or older and have a high school diploma or equivalent.

(iii) A care management specialist meeting the following requirements:

(a) Be eighteen years of age or older and have a high school diploma or equivalent.

(b) Have an understanding of substance use disorder treatment and recovery including how to engage a person in treatment and recovery.

(c) Have an understanding of health care systems, social service systems, and the criminal justice system.

(B) All practitioners shall practice within their professional scope of practice.

(C) Supervisors shall ensure that individuals whom they supervise meet the appropriate education and training qualifications for the service(s) they render.

(D) Provider agencies shall have an active provider agreement with the Ohio department of medicaid.

(E) The following practitioners shall have an active provider agreement with the Ohio department of medicaid:

(1) Physician.

(2) Physician assistant.

(3) Certified nurse practitioner.

(4) Clinical nurse specialist.

(5) Psychologist.

(6) Board licensed school psychologist.

(7) Licensed independent social worker.

(8) Licensed professional clinical counselor.

(9) Licensed independent marriage and family therapist.

(10) Licensed independent chemical dependency counselor.

(11) Licensed practical nurse.

(12) Registered nurse.

(F) An eligible provider meeting the requirements set forth in paragraph (A)(1) or (A)(2) of this rule must ensure that all contact information for their business including all physical locations where services are rendered are listed correctly in the medicaid information technology system (MITS) and updated within thirty days of any change in operations.

Cite as Ohio Admin. Code 5160-27-01

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5162.05, 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5162.371, 5119.391

5160-27-02 [Effective until 1/1/2018] 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 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.

Click to view Appendix

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Cite as Ohio Admin. Code 5160-27-02

Effective: 10/29/2015
Five Year Review (FYR) 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, 7/1/14, 7/1/15(Emer)

5160-27-02 [Effective 1/1/2018] Coverage and limitations of behavioral health services.

(A) This rule sets forth coverage and limitations for behavioral health services rendered to medicaid recipients by behavioral health provider agencies who meet all requirements found in agency 5160 of the Administrative Code unless otherwise specified.

(1) All claims for behavioral health services submitted to the Ohio department of medicaid (ODM) must include an ICD-10 diagnosis of mental illness or substance use disorder. The list of recognized diagnosis can be accessed atwww.medicaid.ohio.gov.

(2) Medicaid reimbursable behavioral health services are limited to medically necessary services defined in rule 5160-8-05 of the Administrative Code and Chapter 5160-27 of the Administrative Code. Providers shall follow the requirements in rule 5160-8-05 of the Administrative Code and Chapter 5160-27 of the Administrative Code regarding services that cannot be billed in combination with other services.

(B) The following services have limitations on the amount, scope or duration of service that can be rendered to a recipient within a certain timeframe. These limits can be exceeded with prior authorization from ODM or its designee.

(1) Screening, brief intervention and referral to treatment (SBIRT) as defined by the american medical association's current procedural terminology book. Limitation for this service is one per code, per recipient, per billing provider, per calendar year.

(2) Assertive community treatment (ACT) as defined in rule 5160-27-04 of the Administrative Code is available on or after the date as determined by prior authorization approval.

(3) Intensive home based treatment (IHBT) as defined in rule 5160-27-05 of the Administrative Code is available on or after the date as determined by prior authorization approval.

(4) 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 recipient's individualized service plan.

(b) A billable unit of service for CPST may include either face-to-face or telephone contact between the mental health professional and the recipient or an individual essential to the mental health treatment of the recipient.

(c) CPST services are not covered under this rule when provided 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.

(d) Medicaid reimbursement of CPST services is described in rule 5160-27-03 of the Administrative Code.

(C) The following services delivered to recipients with substance use disorders have limitations on the amount, scope or duration of service that can be rendered to a recipient within a certain timeframe. These limits can be exceeded with prior authorization from the ODM designated entity.

(1) Substance use disorder assessment as referenced in rule 5160-27-09 of the Administrative Code is limited to two hours per recipient, per billing provider, per calendar year.

(2) Substance use disorder urine drug screening as referenced in rule 5160-27-09 of the Administrative Code, is limited to one per day, per recipient.

(3) Substance use disorder peer recovery support as referenced in rules 5160-27-09 and 5160-43-04 of the Administrative Code is limited to four hours per day per recipient.

(4) Substance use disorder partial hospitalization as described in rule 5160-27-09 of the Administrative Code is available on or after the date as determined by prior authorization approval. The prior authorization request must substantiate that the recipient meets the partial hospitalization level of care of twenty or more hours of service per week. In accordance with rule 5160-1-27 of the Administrative Code ODM reserves the right to retrospectively review the case that the number of hours of service delivered matches the approved level of care.

(5) Substance use disorder residential level of care as described in rule 5160-27-09 of the Administrative Code is available for up to thirty consecutive days without prior authorization per medicaid recipient for the first and second admission, during the same calendar year. If the stay continues beyond thirty days of the first or second stay, prior authorization is required to support the medical necessity of continued stay. If medical necessity is not substantiated and not approved by the ODM designated entity, only the initial thirty consecutive days will be reimbursed. Third and subsequent admissions during the same calendar year must be prior authorized by the ODM designated entity from the date of admission.

(D) The medications listed in the appendix to rule 5160-27-03 or appendix DD to rule 5160-1-60 of the Administrative Code are covered by ODM 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 practitioner acting within their professional scope of practice.

(E) Laboratory services, vaccines, and medications administered in a prescriber office may be administered in accordance with rule 5160-1-60 of the Administrative Code.

(F) Medical and evaluation and management services stated in the appendix to rule 5160-27-03 of the Administrative Code or appendix DD to rule 5160-1-60 of the Administrative Code are covered by ODM when rendered by a practitioner as described in paragraphs (A)(3) and (A)(4) of rule 5160-27-01 of the Administrative Code and operating within their scope of practice.

(G) CMS place of service code set descriptions may be found at www.cms.gov. The department further defines place of service 99 as "community," and this place of service may only be used when a more specific place of service is not available. Place of service 99 shall not be used to provide services to a recipient of any age if the recipient is being held in a public institution as defined in 42 C.F.R. 435.1010 (October 1, 2016).

(H) The activities that comprise or are included in the aforementioned medicaid reimbursable behavioral health services must be intended to achieve identified treatment plan goals or objectives. Providers shall maintain treatment records and progress notes as specified in rules 5160-01-27 and 5160-8-05 of the Administrative Code. A treatment plan for mental health services may only be developed by a practitioner who, at a minimum, meets the therapeutic behavioral services practitioner requirements found in paragraphs (A)(2)(a)(i) and (A)(2)(a)(ii) of rule 5160-27-08 of the Administrative Code. A treatment plan for substance use disorder services may only be developed by a practitioner who, at a minimum meets the practitioner requirements found in paragraph (A)(6)(b)(i) or (A)(6)(b)(iii) of rule 5160-27-01 of the Administrative Code.

(I) The medications and services listed in the appendix to rule 5160-27-03 of the Administrative Code or the opiate treatment service section of appendix DD to rule 5160-1-60 of the Administrative Code are reimbursed by the department when rendered and billed by an opiate treatment program as described in Chapter 5122-40 of the Administrative Code and licensed as such by the Ohio department of mental health and addiction services and/or federally certified as such as stated in 42 CFR 8.11 (October 1, 2016). Reimbursement rates are determined by the methodology described in paragraph (E) of rule 5160-4-12 of the Administrative Code or as listed in the appendix to rule 5160-27-03 of the Administrative Code or as listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(J) When permitted, provision of any service addressed in Chapter 5160-27 of the Administrative Code by interactive videoconferencing as defined in rule 5122-24-01 of the Administrative Code, must comply with the appropriate interactive videoconferencing requirement(s) found in Chapter 5122-29 of the Administrative Code.

(K) The services described in this chapter shall not substitute or supplant natural supports and do not include any of the following:

(1) Educational, vocational, or job training services.

(2) Room and board.

(3) Habilitation services including but not limited to financial management, supportive housing, supportive employment services, and basic skill acquisition services that are habilitative in nature.

(4) Services to recipients who are being held in a public institution as defined in 42 C.F.R. 435.1010 (October 1, 2016);

(5) Services to individuals residing in institutions for mental diseases as described in 42 C.F.R. 435.1010 (October 1, 2016);

(6) Recreational and social activities, including but not limited to art, music, and equine therapies;

(7) Services that are covered elsewhere in agency 5160 of the Administrative Code; and

(8) Transportation for the recipient or family.

(L) Health home services as described in rule 5122-29-33 of the Administrative Code shall be available until December 31, 2017, at which time the service shall be terminated. Until that date eligibility for health home services is determined as follows:

(1) 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 the eligibility criteria document created on May 16, 2014 and available atwww.medicaid.ohio.gov.

(2) Persons who do not meet the eligibility criteria stated in the eligibility criteria document will continue to be eligible for health home services if they meet the following criteria:

(a) 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

(b) 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.

(3) Health home services must be provided only in geographical regions approved by the centers for medicare and medicaid services (CMS).

(4) 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.

(5) Health home services must be 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. Health home services shall be documented as necessary to establish medical necessity as defined in Chapter 5160-1 of the Administrative Code.

Cite as Ohio Admin. Code 5160-27-02

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5162.05, 5164.02
Rule Amplifies: 5164.02 , 5164.03, 5164.15, 5164.76, 5164.88

5160-27-03 [Effective 1/1/2018] Reimbursement for community behavioral health services.

(A) This rule sets forth the reimbursement requirements and rates for behavioral health services as described in Chapter 5160-27 of the Administrative Code and applies to providers as described in rule 5160-27-01 of the Administrative Code.

(B) Providers rendering community behavioral health services shall abide by all applicable requirements stated in rules 5160-01-02 and 5160-27-01 of the Administrative Code.

(C) Records related to services reimbursed under this rule are subject to review in accordance with 42 C.F.R. 456.3 (October 1, 2016) and rule 5160-01-27 of the Administrative Code.

(D) Medicaid reimbursement rates for services and practitioners described in Chapter 5160-27 of the Administrative Code are listed in the appendix to this rule. Ohio medicaid shall reimburse the provider the lower of either their usual and customary charges or the reimbursement amount described in the appendix to this rule.

(1) The reimbursement rate for physicians, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is one hundred per cent of the medicaid maximum rate stated in the appendix to this rule.

(2) The reimbursement rate for clinical nurse specialists, certified nurse practitioners, and physician assistants, as described in paragraph (A)(3) of rule 5160-27-01 of the Administrative Code, is eighty-five per cent of the medicaid maximum rate stated in the appendix to this rule.

(3) The reimbursement rate for practitioners described in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code is the reimbursement rate percentage described in rule 5160-8-05 of the Administrative Code (medicaid maximum rate stated in the appendix to this rule). The reimbursement rates for services not defined in rule 5160-8-05 of the Administrative Code are stated in the appendix to this rule.

(4) The reimbursement rates for practitioners decribed in rule 5160-27-01 of the Administrative Code and not otherwised addressed in paragraph (D) of this rule, are stated in the appendix to this rule.

(E) The medicaid reimbursement rate for any of the following services provided for more than ninety minutes by the same billing provider, to the same recipient, on the same calendar day will be fifty per cent of the rate listed in appendix to this rule.

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

(2) Therapeutic behavioral service as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(3) Psychosocial rehabilitation as described in rule 5160-27-08 of the Administrative Code when delivered in an office setting.

(4) Substance use disorder targeted case management as described in rule 5160-27-10 of the Administrative Code.

(F) Providers identified in rule 5160-27-01 of the Administrative Code must identify the rendering practitioner as follows:

(1) For practitioners who are eligible to enroll with Ohio medicaid and who meet the requirements of Chapter 5160-27 of the Administrative Code, list their national provider identifier number in the rendering field on the claim, or

(2) For licensed practitioners who do not have an independent professional scope or for practitioners that are unlicensed, include the modifier that accurately describes their credentials.

(G) Medicaid reimbursement is contingent upon providers maintaining complete and accurate documentation as required by Chapter 5160-27 of the Administrative Code.

(H) Medicaid behavioral health claims submitted for reimbursement must comply with the requirements of the national correct coding initiative of the centers for medicare and medicaid services.

(I) Behavioral health services that are reimbursable by medicare shall be billed first to medicare in accordance with rule 5160-1-05 of the Administrative Code. Failure to do so may result in denial of the medicaid claim.

(J) Behavioral health services that are reimbursable by a third party health care insurer shall be billed first to the third party health care insurer in accordance with rule 5160-1-08 of the Administrative Code. Failure to do so may result in denial of the medicaid claim.

(K) 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 appropriate uniform cost report principles.

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

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

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

(3) The monthly case rates calculated using the methodology in paragraphs (K)(1) and (K)(2) of this rule shall be reduced by ten percent beginning July 1, 2014.

(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.

(L) 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 (K) of this rule.

Click to view Appendix

Cite as Ohio Admin. Code 5160-27-03

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5162.05, 5162.02
Rule Amplifies: 5164.02, 5164.88, 5164.76, 5164.15, 5164.03

5160-27-04 [Effective 1/1/2018] Mental health assertive community treatment service.

(A) For the purposes of medicaid reimbursement, assertive community treatment (ACT) refers to the evidence based model of delivering comprehensive community based behavioral health services to adults with certain serious and persistent mental illnesses who have not benefited from traditional outpatient treatment. The ACT model utilizes a multidisciplinary team of practitioners to deliver services to eligible individuals.

(B) For the purposes of this rule, collateral contact occurs when the practitioner contacts individuals who play a significant role in a medicaid recipient's life. The information gained from the collateral contact can provide insight into treatment or the basic psychoeducation provided to that collateral contact can assist with the treatment of the medicaid recipient.

(C) The ACT team is the sole provider to ACT recipients of outpatient behavioral health services, including level one outpatient services as defined by the American society of addiction medicine.

(D) ACT services include but are not limited to the following:

(1) Psychiatry and primary care as related to the mental health or substance use disorder diagnoses,

(2) Service coordination,

(3) Crisis assessment and intervention,

(4) Symptom assessment and management,

(5) Community based rehabilitative services,

(6) Education, support, and consultation to families, legal custodians, and significant others who are part of the recipient's support network.

(E) The desired outcomes of ACT intervention for medicaid recipients include but are not limited to:

(1) Achieving and maintaining a stable life in a community based setting,

(2) Reducing the need for inpatient hospital admission and emergency department visits,

(3) Improving mental and physical health status, and improving life satisfaction.

(F) A medicaid recipient may receive ACT services when determined by the ODM designated entity to have met all of the following:

(1) The recipient has a diagnosis of schizophrenia spectrum, bipolar spectrum, or major depressive disorder with psychosis, and

(2) The recipient has a supplemental security income or social security disability insurance determination or has a score of two or greater on at least one of the items in the "mental health needs" or "risk behaviors" sections or a score of three on at least one of the items in the "life domain function" section of the adult needs and strengths assessment (ANSA) administered by an individual with a bachelor's degree or higher and with training in the administration of the assessment, and

(3) The recipient has one or more of the following:

(a) Two or more admissions to a psychiatric inpatient hospital setting during the past twelve months, or

(b) Two or more occasions of utilizing psychiatric emergency services during the past twelve months, or

(c) Significant difficulty meeting basic survival needs within the last twenty- four months, or

(d) History within the past two years of criminal justice involvement including but not limited to arrest, incarceration, or probation, and

(4) The recipient experiences one or more of the following:

(a) Persistent or recurrent severe psychiatric symptoms, or

(b) Coexisting substance use disorder of more than six month in duration, or

(c) Residing in an inpatient or supervised residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or

(d) At risk of psychiatric hospitalization, institutional or supervised residential placement if more intensive services are not available or,

(e) Has been unsuccessful in using traditional office-based outpatient services;and

(5) The recipient is eighteen years of age or older at the time of ACT enrollment.

(G) Prior authorization of ACT services.

(1) The provider must submit a request for prior authorization and receive approval from the ODM designated entity before ACT services can be rendered. The request for prior authorization must be accompained by the appropriate documentation which includes, but is not limited to, the ANSA results or the documentation that supports the social security determintion. The maximum amount of ACT service which may be prior authorized at any one time is twelve months.

(2) At the conclusion of the previous ACT service period, the provider agency may request additional ACT service to be prior authorized by the ODM designated entity

(3) The provider may begin submitting claims for medicaid reimbursement of ACT services for dates of service within the subsequent calendar month following the date on which prior authorization is approved by the ODM designated entity.

(H) Disenrollment of a recipient from ACT. Upon planned or unplanned disenrollment of an ACT recipient, the ACT team shall document the circumstances regarding disenrollment in the recipient's medical record.

(1) A planned disenrollment from ACT occurs when a recipient, or recipient's guardian and ACT team members mutually agree to the termination of ACT services and transition of the recipient to a different care setting, provider, or benefit package. A planned disenrollment is appropriate when:

(a) The recipient has successfully reached established goals for disenrollment and the recipient and/or their guardian and ACT team members agree to the discharge from ACT, or

(b) The recipient moves outside the geographic area of the ACT team's responsibility. In such cases, the ACT team shall arrange to transfer mental health and substance use disorder service responsibility to another ACT program or other provider wherever the recipient is moving. The ACT team shall maintain contact with the recipient until the transfer is complete, or

(c) The recipient or their guardian requests a disenrollment, or

(d) The recipient is determined by the ODM designated entity to no longer meet the eligibility or medical necessity criteria for ACT.

(2) As part of a planned disenrollment, the ACT team shall document that the recipient has actively participated in disenrollment activities by documenting in the recipient's medical record the following information:

(a) The reason(s) for the recipient's disenrollment as stated by both the recipient and the ACT team,

(b) The recipient's progress toward the goals set forth in the treatment plan,

(c) Documentation that the recipient's behavioral health care is being linked and transfered to a provider other than the ACT team,

(d) The signature of the recipient or their guardian, the ACT team leader, and the psychiatric prescriber.

(3) A recipient's disenrollment from ACT may be unplanned and due to circumstances facilitated by:

(a) The inability of the ACT team to locate the recipient for more than forty- five days, or

(b) The recipient's incarceration, hospitalization or admission to a residential substance use disorder treatment facility. In these circumstances, the primary responsibility for the recipient's health care is transferred to the aforementioned setting.

(i) The ACT team is expected to maintain contact with the recipient to assist with transition between settings if the recipient is likely to be discharged and resume service from the ACT team within two months.

(ii) If the recipient's stay is predicted to be longer than two months, the recipient shall be disenrolled from the ACT team.

(iii) The recipient may be re-enrolled with the ACT team when discharged from the incarcerated, inpatient or residential setting. Any re-enrollment shall follow the eligibility determination criteria described in paragraph (F) of this rule.

(4) Except for services found in paragraph (O) of this rule, a recipient may not obtain behavioral health services from a provider other than the ACT team unless the recipient is disenrolled from ACT services.

(5) The provider must inform the ODM designated entity of disenrollment within three business days of the discharge date. The ODM designated entity shall deactivate the authorization for the ACT service. Failure to timely disenroll the recipient from ACT may result in claim denial for other mental health or substance use disorder services.

(I) A provider furnishing ACT services must meet both of the following criteria:

(1) Meets the eligibility requirements found in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and

(2) Employs one or more teams of mental health and substance use disorder practitioners who comprise the ACT treatment team.

(J) Each team must meet the following criteria:

(1) Completed an on-site fidelity review within the previous twelve months by an independent validation entity recognized by ODM. In year one of an ACT team's participation with Ohio medicaid the team must achieve an average fidelity score of at least 3.0 on the dartmouth assertive community treatment scale (DACTS) as determined via an on-site fidelity review performed by an independent validation entity recognized by ODM. The DACTS fidelity scale and protocol can be found atwww.medicaid.ohio.gov.

(a) Fidelity reviews of ACT teams must be repeated every twelve months from the report date of the previous fidelity review.

(b) In year three and subsequent years of ACT team participation with the Ohio medicaid program, each ACT team must achieve and maintain an average fidelity score of at least 4.0.

(c) An ACT team must have documented evidence of fidelity compliance prior to submitting any prior authorization requests for recipients of ACT services.

(2) Each team shall have a designated full-time team leader who may serve in that capacity with only one team.

(a) An ACT team leader shall have a national provider identification number and be actively enrolled as an Ohio medicaid provider.

(b) A team leader shall have psychiatric training and shall hold one of the following valid licenses from the appropriate Ohio professional licensure board or licensure equivalents for ACT teams located in other states:

(i) Licensed independent social worker.

(ii) Licensed independent marriage and family therapist.

(iii) Licensed professional clinical counselor.

(iv) Licensed psychologist.

(v) Physician - medical doctor, psychiatrist, doctor of osteopathy.

(vi) Clinical nurse specialist

(vii) Certified nurse practitioner.

(viii) Physician assistant.

(ix) Registered nurse.

(c) Team leaders who are licensed in accordance with paragraph (A)(5) of rule 5160-27-01 of the Administrative Code but do not have independent licensure status from one of the boards referenced in paragraph (A)(5) of rule 5160-27-01 of the Administrative Code must receive approval from ODM before the ACT team to which they are assigned can begin billing Ohio medicaid.

(3) ACT teams that employ peer recovery supporters must ensure that they meet the criteria and requirements for the peer recovery support services set forth in rule 5160-43-09 of the Administrative Code.

(4) ACT teams must have a caseload no greater than one hundred and twenty and must maintain an average caseload ratio of one practitioner for every ten ACT recipients. Upon request from the ODM, the ACT team must provide to the ODM or its designated entity the ACT team caseload size and composition of medicaid and non-medicaid enrollees.

(K) ODM reserves the right to suspend or terminate the payment of ACT services and to require subsequent review of an ACT team's fidelity rating if ODM has reason to believe that the ACT team's fidelity to the DACTS model described in paragraph (J) (1) of this rule may be in question. ODM may, at its discretion, suspend payment of ACT medicaid claims from the provider agency employing the ACT team until such time as ODM receives documentation from its independent validation entity that the team does meet the fidelity criteria described in paragraph (J)(1) of this rule.

(L) A provider employing an ACT team may bill up to four ACT units per month per recipient when all clinical and billing requirements for each unit are met. The billing of ACT units are subject to the following limits per provider category, per recipient, per month:

(1) Not more than one unit may be billed per medicaid recipient per month for services rendered by the ACT team medical prescriber including physician, clinical nurse specialist, certified nurse practitioner, or physician assistant operating within their respective scopes of practice.

(2) Not more than one unit per medicaid recipient per month may be billed for services rendered by any one of the following ACT team members: psychologist, licensed independent social worker, licensed social worker, licensed clinical social worker, licensed professional counselor, licensed professional clinical counselor, licensed independent clinical counselor, licensed independent marriage and family therapist, licensed marriage and family therapist, licensed practical nurse, registered nurse, licensed independent chemical dependency counselor, licensed chemical dependency counselor II or licensed chemical dependency counselor III.

(3) Not more than two units per medicaid recipient per month may be billed by an ACT team member not listed in paragraph (L)(1) or (L)(2) of this rule. This unit category includes bachelor degree practitioners, and peer recovery practitioners.

(M) The medicaid payment rates for ACT are stated in the appendix to rule 5160-27-03 of the Administrative Code. Payment for services provided by authorized ACT teams is only available for dates of services on or after January 1, 2018.

(N) ACT teams shall maintain regular contact and deliver all medically necessary outpatient mental health and substance use disorder services and supports to ACT recipients enrolled with their team. However, only services and supports rendered in person, face-to-face, by an ACT team member are billable to Ohio Medicaid according to the requirements stated in paragraph (L) of this rule. While ACT teams are encouraged to utilize the delivery of services and supports via telephone or secure video conference, these services and supports are not billable to the Ohio medicaid program.

(O) When a recipient is enrolled on an ACT team, no other medicaid community behavioral health services, as defined in Chapter 5160-27 of the Administrative Code, are eligible for reimbursement except:

(1) Supported employment as identified on a recipient's specialized recovery services program treatment plan if applicable, as described in rule 5160-43-01 of the Administrative Code.

(2) Substance use disorder services that are not considered part of the benefit package encompassed under level one of the american society of addiction medicine (ASAM) as defined in rule 5160-27-09 of the Administrative Code. Prior authorization from the ODM designated entity is required.

(3) Crisis services furnished by a provider other than the billing provider agency employing the ACT team.

(P) Documentation requirements for ACT.

(1) Documentation in the recipient's medical record of the services provided by the ACT team must meet the requirements stated in this paragraph as well as those stated in rules 5160-1-27 and 5160-8-05 of the Administrative Code

(2) The ACT team must develop a specific treatment plan for each enrolled recipient. The treatment plan must, at a minimum, meet the requirements of rule 5160-8-05 of the Administrative Code plus the following additional requirements:

(a) The treatment plan shall be individualized based on the recipient's needs, strengths, and preferences and shall set measurable long-term and short-term goals and specify approaches and interventions necessary for the recipient to achieve the recipient goals. The treatment plan shall also identify who will carry out the approaches and interventions.

(b) The treatment plan shall address, at a minimum, the following key areas:

(i) Psychiatric illness or symptom reduction.

(ii) Stable, safe, and affordable housing.

(iii) Activities of daily living.

(iv) Daily structure and activities, including employment if appropriate.

(v) Family and social relationships.

(c) The treatment plan shall be reviewed and revised by a member of the ACT team with the recipient whenever a change is needed in the recipient's course of treatment or at least every six months. In conjunction with a treatment plan review, the ACT team member shall prepare a summary of the recipient's progress, goal attainment, effectiveness of the intervention and recipient's satisfaction with the ACT team interventions since enactment of the previous treatment plan.

(d) The treatment plan, and all subsequent revisions of it, shall be reviewed and signed by the recipient and the ACT team practitioner.

(Q) The following activities performed by members of the ACT team are not eligible for reimbursement:

(1) Time spent attending or participating in recreational activities.

(2) Services provided to teach academic subjects or as a substitute for educational personnel, including but not limited to a teacher, teacher's aide, or an academic tutor.

(3) Habilitative services for the recipient to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings.

(4) Child care services or services provided as a substitute for the parent or other individuals responsible for providing care and supervision.

(5) Respite care.

(6) Transportation for the recipient or family.

(7) Services provided to children, spouse, parents, or siblings of the eligible recipient under treatment or others in the eligible recipient's life to address problems not directly related to the eligible recipient's issues and not listed in the eligible recipient's ACT treatment plan.

(8) Art, movement, dance, or drama therapies.

(9) Services provided to collaterals of the recipient.

(10) Contacts that are not medically necessary.

(11) Any service outside the responsibility of the ACT team.

(12) Vocational training and supported employment services, unless the recipient is enrolled in the specialized recovery services program as described in rule 5160-43-01 of the Administrative Code.

(13) Crisis intervention provided by the provider agency employing the ACT team.

Cite as Ohio Admin. Code 5160-27-04

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5162.05, 5162.02
Rule Amplifies: 5164.02, 5164.03

5160-27-05 [Effective until 1/1/2018] 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 beginning July 1, 2014.

(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.

Click to view Appendix

Cite as Ohio Admin. Code 5160-27-05

Effective: 10/29/2015
Five Year Review (FYR) Dates: 08/14/2015 and 10/29/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5164.03, 5164.15, 5164.76, 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, 7/1/14, 7/1/15(Emer)

5160-27-05 [Effective 1/1/2018] Mental health intensive home based treatment service.

(A) For the purposes of medicaid reimbursement, intensive home based treatment (IHBT), is the service and activities as set forth by the Ohio department of mental health and addiction services in paragraphs (A) to (C) of rule 5122-29-28 of the Administrative Code.

(B) To be eligible for IHBT, a medicaid recipient must meet the following:

(1) The requirements as established in paragraph (E) of rule 5122-29-28 of the Administrative Code; and

(2) Score the following on the life functioning domain, child behavioral/emotional needs, and child risk behaviors dimensions of the child and adolescent needs and strengths (CANS) assessment tool available atwww.medicaid.ohio.gov:

(a) A rating of "three" on one of the following items or a rating of at least "two" on two of the following life functioning domain items, and;

(i) Family;

(ii) Legal;

(iii) Social functioning;

(iv) Living situation;

(v) School behavior; or

(vi) School attendance.

(b) A rating of "two" or higher on one or more items within the child behavioral/ emotional needs criteria, or:

(i) Psychosis;

(ii) Impulse/hyperactivity;

(iii) Depression;

(iv) Anxiety;

(v) Oppositional;

(vi) Conduct;

(vii) Adjustment to trauma;

(viii) Anger control; or

(ix) Substance use.

(c) A rating of "two" or higher on one or more items within the child risk behaviors criteria:

(i) Suicide risk;

(ii) Self-mutilation;

(iii) Other self-harm;

(iv) Danger to others;

(v) Sexual aggression;

(vi) Runaway;

(vii) Delinquency;

(viii) Judgment;

(ix) Fire setting; or

(x) Social behavior.

(3) The recipient must have at least one adult family member or other adult individual who is a part of the recipient's home who authorizes IHBT services to be provided, and actively participates in the provision of IHBT. "Home" has the same meaning as in rule 5122-29-28 of the Administrative Code.

(C) Prior authorization of IHBT services.

(1) The provider must submit a request for prior authorization and receive approval from the Ohio department of medicaid designated entity before ODM will reimburse for IHBT services. The maximum amount of IHBT service which may be prior authorized at any one time is seventy-two hours.

(2) The provider agency may request additional IHBT service to be prior authorized by the ODM designated entity.

(D) Disenrollment from IHBT

(1) A recipient or their guardian may request to end receipt of IHBT services at their discretion. The IHBT provider will notify ODM or its designee of the disenrollment. Failure to timely notify ODM or its designee may result in claims denial for other mental health services.

(2) Disenrollment of a recipient from IHBT is necessary to ensure that the recipient may obtain medicaid reimbursed behavioral health services from a provider other than the IHBT team. Upon disenrollment of an IHBT recipient, the IHBT team shall document the circumstances regarding disenrollment in the recipient's treatment plan. The provider must inform the ODM designated entity of disenrollment within three business days of the discharge date. Either the provider or the ODM designated entity shall deactivate the authorization for the IHBT service. Failure to timely disenroll the recipient from IHBT may result in claims denial for other mental health or substance use disorder services.

(E) A provider of IHBT must meet all of the following criteria:

(1) Meets the eligibility requirements found in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and

(2) Employment of one or more IHBT practitioners licensed by the counselor, social worker, and marriage and family therapist board or Ohio board of psychology working within their scope of practice, and

(3) Have documentation of completion, within the previous twelve months, of an on site fidelity review performed by an ODM designated entity. Information concerning fidelity standards and requirements is available atwww.medicaid.ohio.gov; and

(4) Receive a minimum rating of three on the following items on the IHBT fidelity rating tool (dated September 23, 2016); and

(a) Intensity of service;

(b) Strength-based assessment and treatment planning;

(c) Comprehensive system collaboration and service coordination;

(d) Cultural responsiveness;

(e) Professional training and development;

(f) Treatment partnerships and youth and family engagement;

(g) Team composition;

(h) Accessible and flexible services and scheduling:

(i) Must meet items listed in paragraphs (E)(4)(b) and (E)(4)(c) of this rule; and

(ii) Meet one additional item.

(i) Treatment durations and continuity of care: items listed in paragraphs (E)(4)(b), (E)(4)(c), and (E)(4)(d) of this rule must be met.

(5) Receive a minimum rating of four on the following items on the IHBT fidelity rating tool (dated September 23, 2016); and

(a) Location of service;

(b) Caseload;

(c) Crisis response and availability;

(d) Safety planning;

(e) Outcomes monitoring and quality improvement;

(f) Fidelity monitoring.

(6) Receive a minimum rating of five on the following items on the IHBT fidelity rating tool (dated September 23, 2016); and

(a) Comprehensive and integrated behavioral health treatment approach;

(b) Supervisory support and availability.

(7) An IHBT provider must have documented evidence of fidelity compliance prior to submitting any prior authorization requests for recipients of IHBT services.

(F) ODM reserves the right to suspend or terminate the payment of IHBT services and to require subsequent review of an IHBT practitioner's fidelity rating if ODM has reason to believe that the IHBT practitioner's fidelity to the model may be in question. ODM may, at its discretion, suspend the payment of IHBT claims from the provider agency employing the IHBT practitioner until such time as ODM receives documentation from its independent validation entity that the practitioner does meet the minimum fidelity criteria described in paragraph (E) of this rule.

(G) All IHBT services must be rendered in person by an IHBT practitioner to the recipient or his/her family members who are participating in the treatment. While IHBT practitioner services rendered via telephone or video conference are not prohibited, they are not considered in person services and therefore do not qualify as a billable Medicaid-covered IHBT service.

(H) Documentation requirements.

(1) Documentation in the recipient's client record of the services provided by the IHBT practitioner must meet the requirements stated in paragraph (H) of this rule as well as those stated in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

(2) The IHBT practitioner must develop a specific treatment plan for each recipient receiving IHBT. The treatment plan must, at a minimum, meet the requirements stated in rule 5160-8-05 of the Administrative Code as well as the following:

(a) The treatment plan shall be individualized based on the recipient's needs, strengths, and preferences and shall set measurable long-term and short-term goals and specify approaches and interventions necessary for the recipient to achieve the individual goals. The treatment plan shall also identify who will carry out the approaches and interventions.

(b) The treatment plan shall address, at a minimum, the following key areas:

(i) Behavioral health symptom reduction.

(ii) Risk reduction and safety planning.

(iii) Family and interpersonal relationship.

(iv) Functioning in relevant life domains.

(c) The treatment plan shall be reviewed and updated by an IHBT practitioner with the recipient or guardian whenever there is a significant change in condition or at least every three months. The treatment plan update shall include a summary of the recipient's progress, goal attainment, effectiveness of the intervention and the recipient's satisfaction with the IHBT practitioner's intervention(s).

(d) The treatment plan, and all subsequent revisions of it, shall be reviewed and signed by the recipient and the adult as described in paragraph (B)(3) of this rule, and the IHBT practitioner.

(I) The following activities are not reimbursable as part of IHBT:

(1) Time spent doing, attending, or participating in recreational activities.

(2) Child care services or services provided as a substitute for the parent or other individuals responsible for providing care and supervision.

(3) Respite care.

(4) Transportation for the beneficiary or family.

(5) Any art, movement, dance, or drama therapies.

(6) Services provided to teach academic subjects or as a substitute for educational personnel including, but not limited to, a teacher, teacher's aide, or an academic tutor.

(J) Medicaid payment will not be made for any of the following services or treatments while the recipient is enrolled in IHBT services:

(1) Assessments, screenings, and diagnostic evaluations.

(2) Mental health day treatment.

(3) Individual, group, or family psychotherapy and counseling.

(4) Therapeutic behavioral services.

(5) Community psychiatric supportive treatment.

(6) Psychosocial rehabilitation.

(7) Substance use disorder residential treatment services.

(8) Assertive community treatment.

(9) Crisis intervention provided by the provider agency employing the IHBT practitioner.

(K) Substance use disorder (SUD) targeted case management requires prior authorization from the ODM designated entity while a recipient is enrolled in IHBT.

(L) The medicaid payment rate for IHBT is stated in appendix DD to rule 5160-1-60 of the Administrative Code. Payment for services provided by authorized IHBT teams is only available for dates of services on or after January 1, 2018.

Cite as Ohio Admin. Code 5160-27-05

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5162.05, 5162.02
Rule Amplifies: 5162.02 , 5162.03

5160-27-06 [Effective 1/1/2018] Therapeutic behavioral group service-hourly and per diem.

(A) For the purpose of medicaid reimbursement, therapeutic behavioral (day treatment), group service-hourly and per diem, is defined as an intensive, structured, goal-oriented, distinct and identifiable group treatment service that addresses the individualized mental health needs of the client. The therapeutic behavioral group service-hourly and per diem is clinically indicated by assessment. The environment at this level of treatment is highly structured, and has an appropriate staff-to-client ratio to guarantee sufficient therapeutic services and professional monitoring, control, and protection. The purpose and intent of therapeutic behavioral group service-hourly and per diem is to stabilize, increase or sustain the highest level of functioning.

(1) Therapeutic behavioral group service-hourly and per diem must be a group treatment service that includes but is not limited to the following:

(a) Skills development of interpersonal and social competency, problem solving, conflict resolution, and emotions/behavior management,

(b) Developing of positive coping mechanisms,

(c) Managing mental health and behavioral symptoms to enhance independent living, and

(d) Psychoeducational services including instruction and training of persons served in order to increase their knowledge and understanding of their psychiatric diagnosis(es), prognosis(es), treatment, and rehabilitation in order to enhance their acceptance, increase their cooperation and collaboration with treatment and rehabilitation, and favorably affect their outcomes.

(B) Service requirements.

(1) When the service is provided for less than 2.5 hours per day, the therapeutic behavioral group service hourly billing code must be used.

(2) When the service is provided for 2.5 or more hours per day, the therapeutic behavioral group service per diem must be used and the service must:

(a) Be delivered at a nationally-accredited program and must be provided by a licensed practitioner, or an unlicensed mental health practitioner as described in paragraph (A)(2) of rule 5160-27-08 of the Administrative Code.

(b) The staff to client ratio cannot exceed 1:12.

(C) Limitations.

(1) Reimbursement for therapeutic behavioral group service-hourly and per diem will not be made while the patient is enrolled in assertive community treatment (ACT), intensive home based treatment (IHBT) or a substance use disorder (SUD) residential treatment facility.

(2) For adults, reimbursement for the following medically necessary behavioral health group services will be limited to no more than four fifteen-minute units, or one hour per day on the same day as the therapeutic behavioral group service (hourly, or per diem).

(a) Mental health group psychotherapy.

(b) SUD group psychotherapy.

(c) Mental health counseling.

(d) SUD group counseling.

(e) Group community psychiatric supportive treatment.

(3) A therapeutic behavioral group service per diem and therapeutic behavioral group service hourly reimbursement will not be made on the same day with the same provider for the same individual.

(4) Other behavioral health individual services may be reimbursed on the same day as therapeutic behavioral group service-hourly and therapeutic behavioral group service per diem.

(5) A medicaid recipient can receive one therapeutic behavioral group service per diem service per day. Prior authorization may be approved for a different billing provider furnishing an additional therapeutic behavioral group service per diem on the same day.

(D) Providers must adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

Cite as Ohio Admin. Code 5160-27-06

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5162.05, 5162.02
Rule Amplifies: 5164.02, 5164.03

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.

Cite as Ohio Admin. Code 5160-27-07

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

5160-27-08 [Effective 1/1/2018] Mental health therapeutic behavioral services and psychosocial rehabilitation.

(A) For the purposes of medicaid reimbursement, therapeutic behavioral services (TBS) are goal-directed supports and solution-focused interventions.

(1) Activities included must be intended to achieve the identified goals or objectives as set forth in the individual's treatment plan. Activities include but are not limited to the following:

(a) Treatment planning. Participating in and utilizing strengths based treatments/planning which may include assisting the individual and family members or other collaterals with identifying strengths and needs.

(b) Identification of strategies or treatment options. Assisting the individual and family members or other collaterals to identify strategies or treatment options associated with the individual's mental illness.

(c) Developing and providing solution focused interventions and emotional and behavioral management drawn from evidence-based psychotherapeutic treatments.

(d) Restoration of social skills. Rehabilitation and support with the restoration of social and interpersonal skills to increase community tenure, enhance personal relationships, establish support networks, increase community awareness, develop coping strategies, and promote effective functioning in the individual's social environment including home, work and school.

(e) Restoration of daily functioning. Assisting the individual to restore daily functioning specific to managing their own home including managing their money, medications, and using community resources and other self-care requirements; and

(f) Crisis prevention and amelioration. Assisting the individual with effectively responding to or avoiding identified precursors or triggers that would risk their remaining in a community setting or that result in functional impairments, including assisting the individual and family members or other collaterals with identifying a potential psychiatric or personal crisis, developing a crisis management plan, and/or, as appropriate, seeking other supports to restore stability and functioning.

(2) Eligible providers must be an unlicensed mental health practitioner in accordance with rule 5160-27-01 of the Administrative Code who have at a minimum:

(a) A bachelor's or a master's degree in social work, psychology, nursing, or in related human services, or

(b) A high school diploma with a minimum of three years of relevant experience as determined by the employing agency and documented in the employee's record.

(B) For the purposes of this rule, collateral/collateral supports contact occurs with the practitioner contacts individuals who play a significant role in a medicaid recipient's life. The information gained from the collateral contact can provide insight into treatment or basic psychoeducation provided to that collateral contact can assist with the treatment of the medicaid recipient.

(C) For the purposes of medicaid reimbursement, psychosocial rehabilitation (PSR) assists individuals with implementing interventions outlined on a treatment plan to compensate for or eliminate functional deficits and interpersonal and/or behavioral health barriers associated with an individual's behavioral health diagnosis.

(1) Activities include:

(a) Restoration, rehabilitation and support of daily functioning to improve self- management of the negative effects of psychiatric or emotional symptoms that interfere with a person's daily functioning.

(b) Supporting the individual with restoration and implementation of daily functioning and daily routines critical to remaining successful in home, school, work, and community.

(c) Rehabilitation and support to restore skills to function in a natural community environment.

(2) Eligible providers are unlicensed mental health practitioners in accordance with rule 5160-27-01 of the Administrative Code, are at least eighteen years of age and who have, at a minimum, a high school diploma with appropriate mental health training as determined by the employing agency and documented in the employee's record.

(D) Limitations.

(1) TBS and PSR will not be reimbursed when a patient is enrolled in assertive community treatment (ACT), intensive home based treatment (IHBT), or receiving residential substance use disorder treatment services.

(2) TBS must be delivered as an individual or group face-to-face intervention with the individual, family/caregiver and/or other collateral supports.

(3) PSR must be delivered as a face-to-face intervention with the individual, not in a group setting.

(E) Providers shall adhere to documentation requirements set forth in rules 5160-01-27 and 5160-8-05 of the Administrative Code.

Cite as Ohio Admin. Code 5160-27-08

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5162.05, 5164.02
Rule Amplifies: 5164.02 , 5164.03

5160-27-09 [Effective 1/1/2018] Substance use disorder treatment services.

(A) For the purpose of medicaid reimbursement, substance use disorder treatment services shall be defined by and shall be provided according to the American society of addiction medicine also known as the ASAM treatment criteria for addictive, substance related and co-occurring conditions for admission, continued stay, discharge, or referral to each level of care (LOC).

(B) Medicaid will reimburse for the services provided under the following ASAM levels of care:

(1) LOC 1: outpatient services. LOC 1 services are designed to treat the recipient's level of clinical severity and function. These services may be delivered in a variety of settings. Addiction, mental health, or general health care treatment personnel provide professionally directed screening, evaluation, treatment, and ongoing recovery and disease management services. Such services are provided in regularly scheduled sessions and follow a defined set of policies and procedures or medical protocols. Service provision is limited to less than nine hours per week for adults and less than six hours per week for adolescents.

(2) LOC 2: intensive outpatient/partial hospitalization including LOC 2 withdrawal management (WM). LOC 2 services are capable of meeting the complex needs of people with addiction and co-occurring conditions. They can be rendered during the day, before or after work or school, in the evening, and/or on weekends.

(3) LOC 3: residential services/inpatient services including LOC 3 WM. These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. The following services are included in the residential treatment service and will not be reimbursed separately:

(a) Ongoing assessments and diagnostic evaluations.

(b) Crisis intervention.

(c) Individual, group, family psychotherapy and counseling.

(d) Case management.

(e) Substance use disorder peer recovery services.

(f) Urine drug screens.

(g) Medical services.

(4) The following services are considered non-covered for individuals in residential treatment:

(a) Therapeutic behavioral services.

(b) Psychosocial rehabilitation.

(c) Community psychiatric supportive treatment.

(d) Mental health day treatment.

(e) Assertive community treatment.

(f) Intensive home based treatment.

(C) Individuals in residential treatment may receive medically necessary services from practitioners who are not affiliated with the residential treatment program. Examples include, but are not limited to, psychiatry, medication assisted treatment, or other medical treatment that is outside the scope of the residential level of care as defined by the American society of addiction medicine. Medicaid will reimburse providers of these services outside the per diem rate paid to residential treatment programs. All treatment services, regardless of whether they are rendered by the residential treatment program or unaffiliated billing practitioners or agencies must be documented in the client's treatment plan maintained by the residential treatment provider.

(D) The entity providing a residential service must ensure that the medicaid recipient has access to the appropriate practitioner for receipt of clinical services as stated in the ASAM treatment criteria.

(E) Eligible practitioners of substance use disorder treatment services must meet all applicable requirements stated in rule 5160-27-01 of the Administrative Code. Qualified mental health specialists are not eligible to be a residential treatment team practitioner.

(F) Limitations.

(1) Residential levels of care are mutually exclusive, therefore a patient can only receive services through one level of care at a time.

(2) Prior authorization is required for LOC 2.5 (partial hospitalization) which requires a minimum of twenty hours of services per week. If, after the first four consecutive weeks of treatment, the amount of services provided is less than twenty hours, the prior authorization will be rescinded but services may still be reimbursed at a lower level of care not to exceed 19.9 hours per week.

(3) Prior authorization is required for LOC 3 residential treatment according to the following:

(a) Up to thirty consecutive days without prior authorization per medicaid enrollee for the first and second admission in a calendar year. If the stay continues beyond the thirty days of the first or second stay, prior authorization is required to support the medical necessity of the continued stay. If medical necessity is not substantiated and approved by the ODM designated entity, only the initial thirty consecutive days will be reimbursed.

(b) Third and subsequent admissions during the same calendar year must be prior authorized from the first day of admission.

(G) The patient's medical record must substantiate the medical necessity of services performed. Providers shall adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

Cite as Ohio Admin. Code 5160-27-09

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5162.05, 5164.02
Rule Amplifies: 5164.02 , 5164.03

5160-27-10 [Effective 1/1/2018] Substance use disorder targeted case management.

(A) Targeted case management assists an individual within the eligible target population to gain access to needed medical, social, educational and other services.

(1) Targeted case management services shall include, at a minimum, the following activities:

(a) Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or other services. Assessment activities include taking client history; identifying the individual's needs and completing related documentation and gathering information from other sources such as family members, medical providers, social workers and educators to form a complete assessment of the eligible individual.

(b) Development and periodic revision of a specific care plan that is based on the information gathered through the assessment. The care plan must include the following requirements:

(i) Goals and actions to address the medical, social, educational and other services needed by the individual; and

(ii) A plan to ensure the active participation of the eligible individual and or their authorized health care decision maker; and

(iii) A course of action to respond to the assessed needs of the eligible individual.

(c) Referral and related activities to help the eligible individual obtain needed services

(d) Monitoring and follow-up activities or contacts that are necessary to ensure that the care plan is implemented and adequately addresses the eligible individual's needs. Changes in needs or status must be reflected in the care plan. Monitoring shall be performed no less frequently than annually. Monitoring may be performed in person or by electronic communication.

(B) In order to provide targeted case management, practitioners must meet the requirements in paragraph (A)(6) of rule 5160-27-01 of the Administrative Code. For the purposes of this rule, the following unlicensed practitioners are excluded: qualified mental health specialists and peer recovery supporters.

(C) The following activities or contacts do not constitute targeted case management and are ineligible for reimbursement as targeted case management:

(1) Transportation.

(2) Waiting with an individual for appointments at social service agencies, court hearings and similar activities does not, in and of itself, constitute case management.

(3) Direct services to which the client has been referred such as medical, educational or social services.

(4) Internal quality assurance activities, such as clinical supervisory activities and/or case review/staffing sessions.

(D) Targeted case management services will not be separately reimbursed when a recipient is enrolled in a substance use disorder (SUD) residential treatment facility.

(E) Targeted case management services require prior authorization from the Ohio department of medicaid (ODM) designated entity when a recipient is enrolled in an assertive community treatment (ACT) or intensive home based treatment (IHBT) team.

(F) Providers shall adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

Cite as Ohio Admin. Code 5160-27-10

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5162.05, 5164.02
Rule Amplifies: 5164.02 , 5164.03

5160-27-11 [Effective 1/1/2018] Behavioral health nursing services.

(A) Behavioral health nursing services are mental health and substance use disorder (SUD) nursing services performed by registered nurses or licensed practical nurses. They include those activities that are performed within professional scope of practice and in authorized settings by staff that are licensed by the Ohio board of nursing and are intended to address the behavioral and other physical health needs of individuals receiving treatment for psychiatric symptoms or substance use disorders.

(B) Activities may include but are not limited to performance of the following:

(1) Health care screenings

(2) Nursing assessments

(3) Nursing exams

(4) Checking vital signs

(5) Monitoring the effects of medication

(6) Monitoring symptoms

(7) Behavioral health education

(8) Collaboration with the individual and/or family as clinically indicated

(9) Group nursing services

(C) Eligible providers.

(1) Registered nurse (RN) as described in rule 5160-27-01 of the Administrative Code.

(2) Licensed practical nurse (LPN) as described in rule 5160-27-01 of the Administrative Code.

(D) Limitations.

(1) Group nursing services and nursing assessments must be provided by an RN.

(2) When behavioral health nursing services are provided, medication administration will not be reimbursed when provided by the same practitioner, to the same recipient, on the same day.

(3) Behavioral health nursing services will not be reimbursed when a recipient in enrolled in assertive community treatment (ACT) or in a SUD residential treatment facility.

(E) Providers shall adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

Cite as Ohio Admin. Code 5160-27-11

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5162.05, 5162.02
Rule Amplifies: 5164.02, 5164.03

5160-27-12 [Effective 1/1/2018] Behavioral health crisis intervention provided by unlicensed.

(A) For the purpose of medicaid reimbursement, behavioral health crisis intervention is a timely face to face intervention with medicaid recipients who are experiencing a life threatening or complex emergent situation related to mental illness or a substance use disorder.

(1) The goals of crisis intervention are to ease the crisis, re-establish safety and institute interventions to minimize psychological trauma.

(2) Activities may include but are not limited to: emergent care, assessment, immediate stabilization, de-escalation, counseling, care planning and resolution.

(B) In order to provide behavioral health crisis intervention, practitioners must meet the requirements in paragraph (A)(6) of rule 5160-27-01 of the Administrative Code.

(1) For the purposes of this rule, the following unlicensed practitioners are excluded: care management specialist and peer recovery supporter

(2) Practitioners may only provide crisis intervention if they have previously met and provided services to the recipient.

(3) Practitioners of crisis intervention shall have current certification in first aid and cardio-pulmonary resuscitation (CPR).

(C) Limitations: crisis intervention will not be reimbursed when a recipient is enrolled in assertive community treatment (ACT), intensive home based treatment (IHBT) or receiving services in a substance use disorder (SUD) residential treatment facility.

(D) Providers shall adhere to documentation requirements set forth in rules 5160-1-27 and 5160-8-05 of the Administrative Code.

(E) Crisis psychotherapy rendered by licensed practitioners is authorized in rule 5160-8-05 of the Administrative Code and as defined by the american medical association's current procedural terminology book.

Cite as Ohio Admin. Code 5160-27-12

Effective: 1/1/2018
Five Year Review (FYR) Dates: 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5162.05, 5164.02
Rule Amplifies: 5164.03, 5164.02