(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 will 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, 2024).
(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
|
$68.44
|
$
9.25
|
|
T1002
|
Waiver nursing services provided by a non-agency
RN
|
$56.26
|
$7.46
|
|
T1002
|
Waiver nursing services provided by a non-agency RN
(overtime)
|
$84.39
|
$11.19
|
|
T1003
|
Waiver nursing services provided by an agency
LPN
|
$58.72
|
$7.82
|
|
T1003
|
Waiver nursing services provided by a non-agency
LPN
|
$48.00
|
$6.24
|
|
T1003
|
Waiver nursing services provided by a non-agency LPN
(overtime)
|
$72.00
|
$
9.36
|
|
T1019
|
Personal care aide services provided by an agency
personal care aide
|
$28.96
|
$7.24
|
|
T1019
|
Personal care aide services provided by a non-agency
personal care aide
|
$22.32
|
$5.58
|
|
T1019
|
Personal care aide services provided by a non-agency
personal care aide (overtime)
|
$33.48
|
$8.37
|
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
|
$0.48
|
|
S5101
|
Adult day health center services
|
Per half day
|
$53.11
|
|
S5102
|
Adult day health center services
|
Per day
|
$106.26
|
|
S5136
|
Structured family
caregiving
|
Per day
|
$102.68
|
|
S5136
|
Structured family
caregiving
|
Per half
day
|
$51.34
|
|
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
|
$8.80
|
|
S5170
|
Home delivered meal services - therapeutic or kosher
meal
|
Per meal
|
$10.61
|
|
S5135
|
Community integration services
|
Per fifteen-minute unit
|
$3.93
|
|
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 will be the lesser of the provider's
billed charge or the medicaid maximum rate.
(D) Required modifiers.
(1) The "HQ" modifier will 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 will be the
lesser of the provider's billed charge or seventy-five per cent of the medicaid
maximum.
(2) The "TU" modifier will
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 will 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 "UD" modifier
will be used when a provider submits a claim for billing code S5136 for a half
day of structured family caregiving.
(4)(5) The "U1" modifier
will 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)(6) The "U2" modifier
will 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)(7) The "U3" modifier
will 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)(8) The "U4" modifier
will 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)(9) The "U6" modifier
will be used when a provider submits a claim for billing code S5170 for a
therapeutic or kosher home delivered meal.
(E) Claims will be submitted to, and
reimbursement will be provided by, ODM in accordance with Chapter 5160-1 of the
Administrative Code.
Notes
Ohio Admin. Code
5160-46-06
Effective:
10/1/2024
Five Year Review (FYR) Dates:
7/16/2024 and
10/01/2029
Promulgated
Under: 119.03
Statutory
Authority: 5162.03,
5166.02
Rule
Amplifies: 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, 07/01/2019, 03/23/2020,
11/01/2021, 01/01/2024
