(A) This rule defines coverage and
payment for providers who meet the provisions in sections 5103.60, 5103.602,
5103.603, 5103.6010, 5103.6011, 5103.6017 and 5103.6018 of the Revised Code and
the provisions described in this rule.
(B) Definitions. For the purpose of this
rule the following definitions apply:
(1) "Clinical
Director" is a practitioner of physician services who supervises
day-to-day clinical operations of the pediatric recovery center (PRC) including
clinical practice standards and quality improvement in collaboration with the
medical director. The clinical director will also be responsible for
coordinating outreach and education to referring entities.
(2) "Direct care
costs" are costs for services delivered to an infant treated at a PRC
through a PRC employee or contractual arrangement with a PRC. Direct care costs
include wages, supervision, staff development, contracting, and consulting
services.
(3) "Eligible
provider" has the same meaning as in rule 5160-1-17 of the Administrative
Code.
(4) "Medical
Director" means a practitioner of physician services who assumes
responsibility for administering all medical services performed by the PRC,
either by performing them directly or by delegating specific responsibility to
authorized program physicians and health care professionals functioning under
the medical director's supervision. The medical director will have
hospital admitting privileges.
(5) "Non-pharmacological care" means
evidence-based treatment, excluding the use of pharmacological interventions,
for withdrawal that is recognized by the American academy of pediatrics or
another nationally recognized organization with expertise in withdrawal
treatment.
(6) "Pediatric
recovery center (PRC)" has the same meaning as "residential infant
care center" in section 5103.60 of the Revised Code.
(7) "Pharmacological
care" means the use of prescribed medications indicated to relieve
moderate to severe signs of withdrawal and to prevent complications such as
fever, weight loss, and seizures that is recognized by the American academy of
pediatrics or another nationally recognized organization with expertise in
withdrawal treatment.
(C) Providers:
(1) Billing
("pay-to") provider. The following eligible providers may receive
medicaid payment for submitting a claim for a covered PRC service:
(a) PRCs.
(b) Professional medical groups with a PRC
specialty.
(D) Staffing:
(1) In addition to the
operational requirements in section 5103.6010 of the Revised Code, a PRC will
employ or contract with the following providers:
(a) Medical director with hospital admitting privileges;
and
(b) Clinical director to establish, supervise and evaluate
clinical services.
(2) The PRC will ensure
all clinical and professional staff who provide direct care to or interact with
patients and families complete training in trauma-informed care annually and
for new employees within thirty calendar days of start date.
(E) Coverage:
(1) Payment may be made
only for a PRC service for which the following conditions are met:
(a) The service is medically necessary in accordance with
rule 5160-1-01 of the Administrative Code.
(b) For admission to a PRC, the following criteria are
met:
(i) The infant is
recommended or referred by a practitioner of physician services, a public
children services agency, a parent, guardian, or legal custodian.
(ii) The infant is
considered medically stable as determined by hospital or other facility
discharge; and
(iii) The infant's
parent or caregiver would benefit from additional education and support
services regarding care for the patient.
(c) The PRC develops and implements a program for parents
and caregivers of the infant, either individually or in a group setting to
address:
(i) Activities to
encourage caregiver-infant bonding.
(ii) Advising on caring
for infants with physical withdrawal symptoms.
(iii) Referrals for
services and counseling; and
(iv) Training on caring
for infants.
(F) Payment:
(1) The medicaid base per
diem rate includes medically necessary PRC services provided to the infant
during their stay at the PRC for up to thirty consecutive days.
(2) PRC per diem payments
in excess of thirty days may be made through the prior authorization (PA)
process described in rule 5160-1-31 of the Administrative Code. If treatment
goals are not accomplished within a consecutive thirty day timeframe, it is the
PRC's responsibility to justify why a longer stay is needed.
(a) The justification for a continued stay should be
directly related to the physical withdrawal symptoms of the infant which have
not improved and should include the following:
(i) A documented medical
diagnosis related to significant substance exposure resulting in
withdrawal.
(ii) A description of the
infant's condition including on-going physical withdrawal symptoms and
additional unimproved symptoms requiring medically necessary care in this
setting; and
(iii) A detailed care
plan with the anticipated period of time for treatment goals to be met.
(b) A lack of post-discharge options alone will not be
considered a valid basis for a continued stay at a PRC.
(3) The per diem rate
includes the following:
(a) Activities to encourage caregiver-infant
bonding.
(b) Advising on caring for infants with physical withdrawal
symptoms.
(c) Referrals for services and counseling.
(d) Direct care costs.
(e) Discharge planning.
(f) Non-pharmacological care for infants with significant
substance exposure resulting in withdrawal.
(g) Pediatric medical services including but not limited to
prescribing medication, administering rectal or intravenous medication,
outpatient laboratory services, sick visits, and onsite well child
exams.
(h) Pharmacological care for infants with significant
substance exposure resulting in withdrawal; and
(i) Training on caring for infants.
(4) Services not included
in the PRC per diem reimbursement rate for which a separate medicaid payment
may be made include, but are not limited to:
(a) Direct services provided to medicaid eligible parents
or caregivers.
(b) Healthcare-related transportation services defined in
Chapter 5160-15 of the Administrative Code.
(c) Services rendered by a practitioner of physician
services.
(d) Other services specifically authorized in rule
promulgated under agency 5160 of the Administrative Code.
(5) For any covered PRC
service, payment is the lesser of the provider's submitted charge or the
maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative
Code.
