Lawriter - OAC - 5160-46-06 Ohio home care waiver program: reimbursement rates and billing procedures.

5160-46-06 Ohio home care waiver program: reimbursement rates and billing procedures.

(A) Definitions of terms used for billing and calculating rates.

(1) "Base rate," as used in table A, column 3 of paragraph (B) of this rule, means the amount reimbursed by the Ohio department of medicaid (ODM) for the first thirty-five to sixty minutes of service delivered.

(2) "Bid rate," as used in table B, column 3 of paragraph (B) of this rule, means the per job bid rate negotiated between the provider and the individual's case manager.

(3) "Billing unit," as used in table B, column 3 of paragraph (B) of this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(4) "Caretaker relative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(5) "Group rate," as used in paragraph (D)(1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting.

(6) "Group setting" means a setting in which:

(a) A personal care aide service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(b) A waiver nursing service provider furnishes the same type of services to either:

(i) Two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(ii) Two to four individuals at the same address if all of the individuals receiving ODM-administered waiver nursing services are:

(a) Medically fragile children, and

(b) Siblings, and

(c) Residing together in the home of their caretaker relative. The services provided in the group setting must be ODM-administered waiver nursing services.

(7) "Medicaid maximum rate" means the maximum amount that will be paid by medicaid for the service rendered.

(a) For the billing codes in table B of paragraph (B) of this rule, the medicaid maximum rate is set forth in column (4).

(b) For the billing codes in table A of paragraph (B) of this rule, the medicaid maximum rate is:

(i) The base rate as defined in paragraph (A)(1) of this rule, or

(ii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A) (7) of this rule for each additional unit of service delivered, or

(iii) The unit rate as defined in paragraph (A)(7)(b) of this rule.

(8) "Medically fragile child" means an individual who is under eighteen years of age, has intensive health care needs, and is considered blind or disabled under section 1614(a)(2) or (3) of the "Social Security Act," ( 42 U.S.C. 1382c(a)(2) or (3) ) (as in effect on January 1, 2018).

(9) "Modifier," as used in paragraph (D) of this rule, means the additional two-alpha-numeric-digit billing codes that providers are required to use to provide additional information regarding service delivery.

(10) "Unit rate," as used in table A, column 4 of paragraph (B) of this rule, means the amount reimbursed by ODM for each fifteen minutes of service delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. ODM will reimburse a maximum of only one unit if the service is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(B) Billing code tables.

Table A

Column 1

Column 2

Column 3

Column 4

Billing code

Service

Base rate

Unit rate

T1002

Waiver nursing services provided by an agency RN

$ 47.40

$ 8.72

T1002

Waiver nursing services provided by a non-agency RN

$ 38.95

$ 7.03

T1002

Waiver nursing services provided by a non-agency RN (overtime)

$ 50.82

$ 10.01

T1003

Waiver nursing services provided by an agency LPN

$ 40.65

$ 7.37

T1003

Waiver nursing services provided by a non-agency LPN

$ 33.20

$ 5.88

T1003

Waiver nursing services provided by a non-agency LPN (overtime)

$ 43.00

$ 8.33

T1019

Personal care aide services provided by an agency personal care aide

$ 23.12

$ 3.84

T1019

Personal care aide services provided by a non-agency personal care aide

$ 18.64

$ 2.95

T1019

Personal care aide services provided by a non-agency personal care aide (overtime)

$ 22.59

$ 4.16

Table B

Column 1

Column 2

Column 3

Column 4

Billing code

Service

Billing unit

Medicaid maximum rate

H0045

Out-of-home respite services

Per day

$ 199.82

S0215

Supplemental transportation services

Per mile

$ 0.38

S5101

Adult day health center services

Per half day

$ 32.48

S5102

Adult day health center services

Per day

$ 64.94

S5160

Personal emergency response systems

Per installation and testing

$ 32.95

S5161

Personal emergency response systems

Per monthly fee

$ 32.95

S5165

Home modification services

Per item

Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year

T2029

Supplemental adaptive and assistive device services

Per item

Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year

S5170

Home delivered meal services - standard meal

Per meal

$ 6.50

S5170

Home delivered meal services - therapeutic or kosher meal

Per meal

$ 8.68

S5135

Community integration services

Per fifteen-minute unit

$ 3.50

T2038

Community transition services

Per job

$2,000 per waiver enrollment

S5121

Home maintenance and chore services

Per job

Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year

(C) The amount of reimbursement for a service shall be the lesser of the provider's billed charge or the medicaid maximum rate.

(D) Required modifiers.

(1) The "HQ" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement as a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "TU" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 and the entire claim is being billed as overtime.

(3) The "UA" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 and only a portion of the claim is being billed as overtime.

(4) The "U1" modifier must be used when a provider submits a claim for billing code T1002 and the individual enrolled on the Ohio home care waiver is receiving infusion therapy.

(5) The "U2" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to an individual enrolled on the Ohio home care waiver for the same date of service.

(6) The "U3" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to an individual enrolled on the Ohio home care waiver for the same date of service.

(7) The "U4" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(8) The "U6" modifier must be used when a provider submits a claim for billing code S5170 for a therapeutic or kosher home delivered meal.

(E) Claims shall be submitted to, and reimbursement shall be provided by, ODM in accordance with Chapter 5160-1 of the Administrative Code.


Effective: 7/1/2019
Five Year Review (FYR) Dates: 1/1/2022
Promulgated Under: 119.03
Statutory Authority: 5162.03, 5166.02
Rule Amplifies: 5162.03, 5164.70, 5164.77, 5166.01, 5166.02 , 5166.041
Prior Effective Dates: 01/01/2004, 07/01/2006, 07/01/2008, 01/01/2010, 04/01/2011, 10/01/2011, 07/01/2015, 01/01/2017, 01/01/2019