Chapter 5160-30 Alcohol and Drug Addiction Services

5160-30-01 Eligible provider for alcohol and other drug treatment services.

(A) An eligible provider for purposes of this chapter is an entity that is operating a program certified in accordance with the requirements set forth in Chapters 3793:2-1 and 3793:2-2 of the Administrative Code, or certified in accordance with the requirements set forth in Chapters 3793:2-1 and 3793:2-2 of the Administrative Code and licensed according to Chapter 3793:2-3 of the Administrative Code as a methadone program ,or certified in accordance with the requirements set forth in Chapters 3793:2-1 and 3793:2-5 of the Administrative Code . For services provided prior to July 1, 2012 an eligible provider must contract with an alcohol and drug addiction services board or an alcohol, drug addiction and mental health services board to receive medicaid reimbursement for the medicaid covered services defined in rule 5101:3-30-02 of the Administrative Code. For services provided after July 1, 2012, no contract between the provider and board is required for reimbursement of medicaid covered services. Alcohol and other drug treatment services must be provided in accordance with Chapter 5101:3-30 and Chapter 5101:3-1 of the Administrative Code.

(B) For any provider that is a government entity which receives nonfederal public funds, including but not limited to county departments of human services, county children 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 service(s) and certified as representing expenditures eligible for federal financial participation.

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

Effective: 07/01/2012
R.C. 119.032 review dates: 04/16/2012 and 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 3793.06 , 3793.11 , section 5111.913 in Am. Sub. HB153 of the 129th General Assembly
Prior Effective Dates: 7/1/91 (Emer.), 9/30/91, 8/1/93

5160-30-02 Coverage and limitation policies for alcohol and other drug treatment services.

(A) The following identifies alcohol and other drug treatment services that may be covered by medicaid and the limitation policies applicable to these services.

(1) "Assessment " is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(2) "Crisis intervention " is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(3) "Individual counseling " and "group counseling " are those services defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(4) "Medical somatic " is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(5) "Laboratory urinalysis" is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter. Notwithstanding the provisions found in Chapters 3793:2-1 and 3793:2-2 of the Administrative Code, a physician must order the drug screening/urinalysis for medicaid to cover the service.

(6) "Opioid agonist administration" is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(7) "Case management " is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(8) "Intensive outpatient " is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(9) "Ambulatory detoxification" is the service defined in rule 3793:2-1-08 of the Administrative Code and provided by an eligible provider as defined in this chapter.

(B) Alcohol and other drug treatment services must be recommended by a professional who is qualified to sign an individualized treatment plan in accordance with rule 3793:2-1-06 of the Administrative Code.

(C) Alcohol and other drug treatment services must be performed by a professional who is qualified to perform the specific service. The identification of professionals qualified to perform each specific service is set forth in rule 3793:2-1-08 of the Administrative Code.

(D) 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 5101: 3-30-01 of the Administrative Code. The medication must be administered by a qualified provider acting within the provider's professional scope of practice.

Replaces: 5101:3-30-02

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Effective: 10/01/2012
R.C. 119.032 review dates: 10/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 3793.06 , 3793.11 , 5111.01 , 5111.02
Prior Effective Dates: 7/1/91 (Emer.), 9/30/91

5160-30-03 Billable services.

(A) All covered services are to be billed on a unit rate basis in accordance with definitions, standards, and eligible provider of service criteria as set forth in rules 5101:3-30-01, 5101:3-30-02, and 5101:3-30-04 of the Administrative Code.

(B) For purposes of alcohol and other drug treatment services, unless otherwise described in this chapter, a "billable unit of service" is defined as an hour-measured face-to-face contact between a client and a professional qualified to provide services delineated in rule 5101:3-30-02 of the Administrative Code as covered under the medicaid program. For an alcohol and other drug treatment service to be defined as a unit, it must meet the definition set forth in this paragraph and must be recorded in the individual client record (ICR) in accordance with rule 3793:2-1-06 of the Administrative Code.

(1) Billable units of services are limited to those which take place at the site certified as a treatment program by the Ohio department of alcohol and drug addiction services or at any other appropriate location according to the standard referenced in rule 5101:3-30-02 of the Administrative Code as relative to the covered service.

(2) Units of service with individuals other than the client (e.g., conferences and consultations with a family member) are not billable. However, individual counseling and diagnostic assessment may include face-to-face interaction with family members and/or parents, guardians and/or significant others when such intervention is part of the individualized treatment plan.

(3) Case management services can be billable units of service delivered face-to-face or by telephone and may include contact with a client or with individuals other than the client; such services must be recorded in the client's ICR.

(4) Covered services delineated in rule 5101:3-30-02 of the Administrative Code, with the exception of ambulatory detoxification, intensive outpatient services, laboratory urinalysis and opioid agonist administration are considered hour-measured billable services. Ambulatory detoxification and intensive outpatient services are considered day-measured billable services and, the laboratory urinalysis service is considered a per screening (independent of the number of panels) billable unit and opioid agonist administration is considered a per dose billable unit of service.

(C) Eligible providers may augment staff delivered services through contractual arrangements. Such arrangements are recognized to the extent that the conditions set forth in paragraphs (C)(1) and (C)(2) of this rule are met. In order for contractual arrangements to be recognized, eligible providers must provide upon request the following information to the Ohio department of alcohol and drug addiction and/or the Ohio department of job and family services :

(1) Identification by name and, where applicable, Ohio medicaid provider number of each individual practitioner providing services under contractual arrangements. Where the contract is let with a legal entity other than the individual practitioner, both the name of the legal entity and the name(s) of any individual practitioner(s) involved must be furnished.

(2) A written statement indicating, for each legal entity or individual practitioner, whether the contracted services are:

(a) To be included as billable services by the participating Ohio department of alcohol and drug addiction services certified treatment program; or

(b) To be billed independently by the legal entity or individual practitioner under contract.

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 , 3793.06 , 3793.11
Prior Effective Dates: 7/1/91 (Emer.), 9/30/91

5160-30-04 Reimbursement for community medicaid alcohol and other drug treatment services.

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

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

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

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

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

(5) "Group counseling" as defined in paragraph (O) of rule 3793:2-1-08 of the Administrative Code.

(6) "Individual counseling" as defined in paragraph (N) of rule 3793:2-1-08 of the Administrative Code.

(7) "Intensive outpatient" as defined in paragraph (Q) of rule 3793:2-1-08 of the Administrative Code.

(8) "Laboratory urinalysis" as defined in paragraph (R) of rule 3793:2-1-08 of the Administrative Code.

(9) "Medical/somatic" as defined in paragraph (S) of rule 3793:2-1-08 of the Administrative Code.

(10) "Opioid agonist administration" as defined in paragraph (T) of rule 3793:2-1-08 of the Administrative Code.

(B) Each agency shall maintain a fee schedule of usual and customary charges for all community medicaid alcohol and other drug treatment services it provides. The agency shall bill the community medicaid program its usual and customary charge for a medicaid-covered service. The reimbursement rate to each agency shall be the lesser of the agency's usual and customary charge or the amount established in appendix A to this rule with the exception for case management as described in paragraph (C) of this rule.

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

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

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

(a) The sum of:

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

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

(D) The community medicaid program will not pay for community medicaid alcohol and other drug treatment services for medicaid clients when those same services are routinely provided to non-medicaid clients at no charge, except when medicaid reimbursement for such services are prescribed by federal law or in rule 5160-1-03 of the Administrative Code. If a reduced charge or no charge is made, the lowest charge made becomes the medicaid rate for that service. The community medicaid alcohol and other drug treatment services are not considered to be provided to non-medicaid clients at no charge or at a reduced charge if all of the following requirements are met:

(1) The agency establishes a fee schedule of usual and customary charges (UCC) for each service available and the agency utilizes a sliding fee schedule whereby individuals without third party insurance are charged; and

(2) The agency collects third-party insurance information from all medicaid and non-medicaid clients; and

(3) The agency bills other responsible third party insurers or payers in accordance with rule 5160-1-08 of the Administrative Code when such insurers or payers are known.

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

(1) Group counseling,

(2) Individual counseling, and

(3) Medical/somatic.

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

(F) The agency may enter into arrangements with insurers and other responsible payers for reimbursement at levels that may differ from the published usual and customary fee schedule.

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

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

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

5160-30-06 Cost reconciliation requirements for medicaid covered alcohol and other drug treatment services.

(A) Purpose: this rule sets forth the cost reconciliation calculation method to be used by the Ohio department of alcohol and drug addiction services, the notification of overpayment requirement to and the repayment for medicaid participating alcohol and other drug programs.

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

(B) Definitions:

(1) "Actual uniform cost report" means the uniform cost report completed retrospectively after the close of the state fiscal year (SFY) using actual cost data.

(2) "Actual unit rate" means the unit cost found in column twelve of the actual uniform cost report.

(3) "AOD program" means an alcohol and drug addiction program as defined in section 3793.01 of the Revised Code which has been certified by the Ohio department of alcohol and drug addiction services in accordance with the requirements of section 3793.06 of the Revised Code or has been issued a license from the Ohio department of alcohol and drug addiction services in accordance with the requirements of section 3793.11 of the Revised Code.

(4) "Budgeted uniform cost report" means a uniform cost report completed prospectively using anticipated budgeted cost data for an upcoming SFY.

(5) "Full payment" means federal financial participation and match participation.

(6) "Interim unit rate" means the unit cost found in column twelve of a budgeted uniform cost report.

(7) "MACSIS" means multi-agency community services information system.

(8) "Medicaid paid claims" means claims sourced from MACSIS which were submitted to and approved for reimbursement by ODJFS.

(9) "Medicaid participating AOD program" means an AOD program that has met the requirements of rule 5101:3-30-01 of the Administrative Code and has received payment for medicaid covered AOD treatment services as defined in rule 5101:3-30-02 of the Administrative Code.

(10) "ODADAS" means the Ohio department of alcohol and drug addiction services.

(11) "ODJFS" means the Ohio department of job and family services.

(12) "Rate ceiling" means the maximum amount per unit of service a medicaid participating AOD program may be paid for a medicaid covered AOD treatment service listed in rule 5101:3-30-04 of the Administrative Code.

(13) "Uniform cost report" means the cost report as contained in rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled.

(14) "Unit of service" means the length of time as defined in rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled. For each medicaid covered AOD treatment service as defined in rule 5101:3-30-02 of the Administrative Code on the uniform cost report.

(15) "UPI" means the unique provider identification number. This number represents an ODADAS certified community alcohol and drug addiction program and owner (indicated by a single federal tax identification number) operating at a discrete physical location.

(C) Each medicaid participating AOD program shall complete all the budgeted uniform cost reports and the actual uniform cost report for any given SFY in accordance with rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled. The methods of cost reporting selected when completing the first budgeted uniform cost report submitted in accordance with rule 5101:3-30-04 of the Administrative Code for a SFY must be the same methods the medicaid participating AOD program shall use when completing and submitting any subsequent budgeted uniform cost report and the actual uniform cost report for that same SFY.

(D) Cost reconciliation process:

(1) The actual allowable amount a medicaid participating AOD program could have received for medicaid covered AOD treatment services for the state fiscal year being reconciled shall be determined by ODADAS as follows:

(a) For each service, the maximum allowable rate will be determined by selecting the lower of the following: the medicaid rate ceiling in effect for the SFY being reconciled or the actual unit cost. The total allowable payment shall be determined by multiplying the number of service units from MACSIS associated with the medicaid paid claims by the maximum allowable rate. If the medicaid participating AOD program fails to submit an actual uniform cost report in accordance with rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled, the number of service units from MACSIS associated with the medicaid paid claims shall be multiplied by the lowest actual unit cost as documented on all filed actual uniform cost reports for the SFY being reconciled for each service the medicaid participating AOD program received medicaid payment. If a medicaid participating AOD program fails to submit an actual uniform cost report in accordance with rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled, the medicaid participating AOD program's ODADAS certification/license may be revoked in accordance with rule 3793:2-1-09 of the Administrative Code as in effect for the SFY being reconciled.

(b) From each of the calculations described in paragraph (D)(1)(a) of this rule the value of third party payments, as reported by the medicaid participating AOD program associated with the service specific medicaid paid claims shall be deducted. The result is the actual allowable amount of medicaid payment for each service for the medicaid participating AOD program for the SFY being reconciled.

(2) The actual amount of medicaid payment paid to the medicaid participating AOD program for each service for the SFY being reconciled shall be determined by summing the net amount from MACSIS claims detail associated with medicaid paid claims for that service.

(3) For each service, subtract the result of paragraph (D)(1)(b) of this rule from paragraph (D)(2) of the rule.

(a) If the result of this calculation is greater than zero, the medicaid participating AOD program has been overpaid for the service for the SFY being reconciled.

(b) If the result of this calculation is equal to or less than zero, no overpayment for the service exists.

(4) The medicaid participating AOD program is required to repay the full amount of the sum of all overpayments identified in paragraph (D)(3)(a) to ODADAS.

(E) ODADAS shall send the medicaid participating AOD program a notification, by certified mail, of the overpayment amount calculated. ODADAS will send a copy to ODJFS.

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