Ohio Admin. Code 5160-12-05 - Reimbursement: home health services
(A) Definitions of terms used for billing
home health services rates set forth in appendix A to this rule are:
(1) "Base rate, ", as used in
this rule and appendix A to this rule, means the amount reimbursed by Ohio
medicaid:
(a) For the initial thirty-five to
sixty minutes of home health aide service delivered;
(b) For the initial thirty-five to sixty
minutes of home health nursing service delivered; or
(c) Up to the first four units of initial
home health skilled therapy service delivered.
(2) "Unit rate, ", as used in
this rule and appendix A to this rule, means the amount reimbursed by Ohio
medicaid for each fifteen minutes of service delivered when the initial visit
is:
(a) Greater than sixty minutes in length
for any home health service delivered; or
(b) Less than or equal to thirty-four minutes
in length for home health aide and/ or home health nursing service
delivered.
(B) Home health services are delivered and
billed in accordance with this chapter by medicare certified home health
agencies (MCHHA).
(C) The amount of
reimbursement for a home health visit shall be the lesser of the provider's
billed charge or the medicaid maximum rate. The medicaid maximum rate is
determined by using a combination of the base rate and/or unit rate found in
appendix A as applicable to this rule using the number of units of service that
were provided during a visit in accordance with this chapter as follows:
(1) Each visit must be less than or equal to
four hours.
(2) For a home health
aide and/or a home health nursing visit that is less than thirty-five minutes
in total, Ohio medicaid 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.
(3) For a home health aide
and/or a home health nursing visit thirty-five minutes to one hour in length in
total, the medicaid maximum is the amount of the base rate.
(4) For a home health aide, home health
nursing, or home health skilled therapy visit in length beyond the initial hour
of service, the base rate plus the rate amount for each unit over the initial
one hour may be claimed, not to exceed four hours.
(D) The amount of reimbursement for a visit
shall be the lesser of the provider's billed charge or seventy-five per cent of
the total medicaid maximum as specified in paragraph (C) of this rule when
billing with the modifier HQ "group setting" for group visits conducted in
accordance with rule
5160-12-04
of the Administrative Code.
(E) The
modifiers set forth in appendix B to this rule must be used to provide
additional information in accordance with this chapter. A visit made for the
purpose of home infusion therapy in accordance with 5160-12-01 of the
Administrative Code must be billed using the U1 modifier.
(F) The "place of service" code "02" will be
used to indicate a visit was completed using telehealth.
(G) A visit conducted by a registered nurse
(RN) for the provision of home health nursing services must be billed to Ohio
medicaid using the billing code G0299 as found in appendix A to this rule. A
visit conducted by a licensed practical nurse (LPN) for the provision of home
health nursing services must be billed to Ohio medicaid using the billing code
G0300 as found in appendix A to this rule.
(H) An MCHHA will not be reimbursed for home
health services provided to an individual that duplicates same or similar
services already paid by medicaid or another funding source. For example, if
the facility/home where a residential state supplement recipient or individual
receiving medicaid resides, such as an adult foster home, adult family home,
adult group home, residential care facility, or other facility is paid to
provide personal care or nursing services, home health services are not
reimbursable by medicaid.
(I) An
MCHHA may be reimbursed for home health services provided to an individual
residing in a facility/home if the provider has written documentation from the
facility/ home stating that it is not responsible for providing the same or
similar home health services to the individual.
(J) Home health services provided to an
individual enrolled on an assisted living home and community based services
waiver in accordance with rule
5160-1-06
and Chapter 173-39 of the Administrative Code do not constitute a duplication
of services.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 05/01/1987, 04/01/1988, 05/15/1989, 07/01/1998, 07/01/2006, 07/01/2008, 01/01/2010, 10/01/2011, 07/01/2015, 01/01/2016, 10/01/2016, 01/01/2017, 06/12/2020 (Emer.), 03/07/2021
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