Ohio Admin. Code 5160-46-06.1 - Ohio home care waiver program: home care attendant services reimbursement rates and billing procedures
(A) Definitions of terms used for billing and
calculating home care attendant services (HCAS) rates.
(1) "Base rate," as set forth in column 3 of
tables A and B of this rule, means the amount reimbursed by Ohio medicaid for
the first thirty-five to sixty minutes of assistance with self-administration
of medications and the performance of nursing tasks provided during a single
visit.
(2) "Continuous nursing"
means nursing services (waiver nursing and/or private duty nursing) that are
more than four hours in length and during which personal care aide service
tasks as described in paragraph (A)(1) of rule
5160-46-04 of the Administrative
Code may be provided incidental to nursing services.
(3) "Group rate" means the amount that HCAS
providers shall
will be reimbursed when the service is provided in a
group setting.
(4) "Group setting"
means a situation in which an HCAS provider furnishes HCAS in accordance with
rule 5160-44-27 of the Administrative
Code, and as authorized by the Ohio department of medicaid (ODM), to two or
three individuals who reside at the same address.
(5) "HCAS visit" is a visit during which HCAS
is provided in accordance with rule
5160-44-27 of the Administrative
Code. An HCAS visit shall
will not exceed twelve hours or forty-eight units
in duration.
(6) "Intermittent
nursing" means nursing services (waiver nursing and/or home health nursing)
that are four hours or less in length.
(7) "Medicaid maximum rate" means the maximum
amount that shall
will be paid by the Ohio medicaid program for the
service rendered. The base rate in column 3 and the unit rate in column 4 of
table A of this rule, and the base rate in column 3 and the unit rates in
column 5 of table B of this rule represent the medicaid maximum rates for
HCAS.
(8) "Modifier", as set forth
in column 4 of table A of this rule and column 4 of table B of this rule, means
the additional two-alpha-numeric-digit billing code as set forth in paragraph
(G) of this rule that HCAS providers shall
will use to provide additional information
regarding service delivery.
(9)
"Unit rate," as set forth in column 5 of table A of this rule and column 5 of
table B of this rule, means the amount reimbursed by Ohio medicaid for each
fifteen minutes of HCAS delivered when the visit is:
(a) Greater than sixty minutes in
length.
(b) Less than or equal to
thirty-four minutes in length. Ohio medicaid will reimburse a maximum of only
one unit if HCAS 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)
Providers shall
will bill for reimbursement using table A when HCAS is
provided in lieu of continuous nursing as described in paragraph (A)(2) of this
rule. Personal care aide tasks are included in the unit rate.
Table A
|
Column 1 |
Column 2 |
Column 3 |
Column 4 |
Column 5 |
|
Billing code |
Home care attendant service description |
Base rate |
Modifier |
Unit rate |
|
S5125 |
Assistance with self-administration of medications and/or the performance of nursing tasks (HCAS/N) |
$27.53 |
N/A |
|
|
S5125 |
HCAS/N (overtime) |
$35.11 |
TU or UA |
|
(C)
Providers shall
will bill for reimbursement using table B when HCAS is
provided in lieu of intermittent nursing as described in paragraph (A)(6) of
this rule. The first four units of HCAS shall
will be billed
for at the base rate. Beginning with the fifth unit of HCAS, assistance with
self-administration of medications and the performance of nursing tasks
(HCAS/N) shall
will be billed at the HCAS/N unit rate; and personal
care aide service tasks (HCAS/PC) shall
will be billed at the HCAS/PC unit rate using the
U8 modifier. There is no base rate for HCAS/PC. The HCAS/PC service can only be
rendered in conjunction with an HCAS/N service.
Table B
|
Column 1 |
Column 2 |
Column 3 |
Column 4 |
Column 5 |
|
Billing code |
Home care attendant service description |
Base rate |
Modifier |
Unit rate |
|
S5125 |
HCAS/N |
$27.53 |
N/A |
|
|
S5125 |
HCAS/PC |
N/A |
U8 |
|
|
S5125 |
HCAS/N (overtime) |
$35.11 |
TU or UA |
|
|
S5125 |
HCAS/PC (overtime) |
N/A |
either TU or UA, and U8 |
|
(D) The
amount of reimbursement for a service shall
will be the lesser of the provider's billed
charge or the medicaid maximum rate.
(E) When HCAS/N and HCAS/PC are provided
during an uninterrupted period of time, the visit shall
will be
considered a single HCAS visit. An HCAS provider is entitled to only one base
rate during an HCAS visit.
(F) HCAS
providers shall
will be limited to a maximum of twelve hours or
forty-eight units of HCAS during a twenty-four-hour period, regardless of the
number of individuals enrolled on an ODM-administered waiver who are
served.
(G) Required modifiers.
(1) The "HQ" modifier
must
will be
used when a provider submits a claim if HCAS was delivered in a group setting.
Reimbursement at a group rate shall
will be the lesser of the provider's billed
charge or seventy-five per cent of the medicaid maximum rate.
(2) The "TU" modifier
must
will be
used when a provider submits a claim for billing code S5125 and the entire
visit is being billed as overtime.
(3) The "UA" modifier
must
will be
used when a provider submits a claim for billing code S5125 and only a portion
of the visit is being billed as overtime.
(4) The "U2" modifier
must
will be
used when a provider submits a claim for a second HCAS visit to an individual
enrolled on the Ohio home care waiver for the same date of service.
(5) The "U3" modifier
must
will be
used when the same provider submits a claim for three or more HCAS visits to an
individual enrolled on the Ohio home care waiver for the same date of
service.
(6) The "U8" modifier
must
will be
used when a provider submits a claim for an HCAS visit that is in lieu of
intermittent nursing as described in paragraph (A)(6) of this rule, and for
units of service that are HCAS/PC.
(H) Claims shall
will be
submitted to, and reimbursement shall
will be provided by, the ODM in accordance with
Chapter 5160-1 of the Administrative Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 5166.02, 5166.30
Rule Amplifies: 5162.03, 5164.02, 5166.30, 5166.301, 5166.302, 5166.303, 5166.304, 5166.305, 5166.306, 5166.307, 5166.308, 5166.309, 5166.3010
Prior Effective Dates: 07/01/2010, 10/01/2011, 08/01/2015, 01/01/2017, 11/01/2021
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