Ohio Admin. Code 5160-48-01 - [Effective until 7/31/2024] Medicaid coverage of targeted case management services provided to individuals with developmental disabilities
(A) Purpose.
(1) This rule specifies the conditions for
medicaid payment of targeted case management (TCM), which is
comprised of those
associated with activities described in section
5126.15
of the Revised Code and in rule 5123:2-1-11
5123-4-02 of the Administrative Code,
but only to the extent that they are listed in paragraph (D) of this rule as
reimbursable activities for medicaid eligible individuals with developmental
disabilities.
(2) The department of
developmental disabilities (DODD), through an interagency agreement with the
department of medicaid (ODM), administers the TCM program on a daily basis in
accordance with section
5162.35
of the Revised Code.
(B)
Definitions.
(1) "IEP" means an
individualized education program and has the same meaning as described in rule
3301-51-07
of the Administrative Code.
(2)
"Institution" means a nursing facility, an intermediate care facility for
individuals with intellectual disabilities (ICF/IID), a state-operated
intermediate care facility for individuals with intellectual disabilities
(ICF/IID) or a medical institution.
(3) "ISP" means an individual service plan as
defined in rule 5123:2-1-11
5123-4-02
of the Administrative Code.
(4)
"Major unusual incident" (MUI) has the same meaning as defined in rule
5123:2-17-02
5123-17-02 of the Administrative Code.
(5) "Medical necessity" for the purposes of
this rule medically necessary has the same meaning as medical necessity as
defined in rule
5160-1-01
of the Administrative Code.
(6)
"Service and support administration" has the same meaning as described in
section
5126.15
of the Revised Code.
(7) "Targeted
case management" means services which will assist individuals in gaining access
to needed medical, social, educational and other services as described in this
rule in accordance with section 1915(g) of the Social Security Act
(42 U.S.C.
1396n(g)(2)) as effective
October 1, 2015
2021 . Targeted case management is also referred to as
medicaid case management.
(8)
"Unusual incident" has the same meaning as defined in rule
5123:2-17-02
5123-17-02 of the Administrative Code.
(C) Eligible individuals.
(1) Individuals eligible for medicaid
coverage of TCM services are:
(a) Medicaid
eligible individuals, regardless of age, who are enrolled on home and
community-based service (HCBS) waivers administered by the DODD, and
(b) All other medicaid eligible individuals,
age three or above, who are determined to have mental retardation or other
a developmental disability according to section
5126.01
of the Revised Code.
(D) Reimbursable activities.
(1) Medicaid services listed in paragraph (D)
of this rule are reimbursable only if provided to or on behalf of a medicaid
eligible individual as defined in paragraph (C) of this rule and by qualified
providers as defined in paragraph (E) of this rule. Payment for targeted case
management services may not duplicate payments made to public agencies or
private entities under other program authorities for this same purpose.
Medicaid reimbursable TCM services are:
(a)
Assessment. Activities reimbursable under the assessment category are limited
to the following:
(i) Activities performed to
make arrangements to obtain from therapists and appropriately qualified persons
the initial and on-going assessments of an eligible individual's need for any
medical, educational, social, and other services which includes
technology and employment-related.
(ii) Eligibility assessment activities that
provide the basis for the recommendation of an eligible individual's need for
HCBS waiver services administered by DODD.
(iii) Activities related to recommending an
eligible individual's initial and on-going need for services and associated
costs for those individuals eligible for HCBS waiver services administered by
DODD.
(b) Care planning.
Activities reimbursable under the care planning category are limited to the
following:
Activities related to ensuring the active participation of the eligible individual and working with the eligible individual and others to develop goals and identify a course of action to respond to the assessed needs of the eligible individual. These activities result in the development, monitoring, and on-going revision of an individualized service plan (ISP).
(c) Referral and
linkage. Activities reimbursable under the referral and linkage category are
limited to the following:
Activities that help link eligible individuals with medical,
social, educational providers and/or other programs and services that are
capable of providing needed services including
(d) Monitoring
and follow-up. Activities reimbursable under the monitoring and follow-up
category are limited to the following:
(i)
Activities and contacts that are necessary to ensure that the ISP is
effectively implemented and adequately addresses the needs of the eligible
individual.
(ii) Reviewing the
individual trends and patterns resulting from reports of investigations of
unusual incidents and MUIs and integrating prevention plans into amendments of
an ISP.
(iii) Ensuring that
services are provided in accordance with the ISP and ISP services are
effectively coordinated through communication with service providers.
(iv) Activities and contacts that are
necessary to ensure that guardians and eligible individuals receive appropriate
notification and communication related to unusual incidents and MUIs.
(e) State hearings: Activities
reimbursable under the state hearing category are limited to the following:
Activities performed to assist an eligible individual in preparing for a state hearing related to the reduction, termination or denial of a service on an ISP.
(2) Coverage exclusions.
(a) Activities performed on behalf of an
eligible individual residing in an institution are not billable for medicaid
TCM reimbursement except for the last one hundred eighty consecutive days of
residence when the activities are related to moving the eligible individual
from an institution to a non-institutional community setting.
(b) Emergency response systems as described
in paragraph (Q)
(G) of rule 5123:2-1-11
5123-4-02
of the Administrative Code. This does not preclude those activities covered in
paragraph (D)(1) of this rule when responding to an emergency and provided by a
certified or registered service and support administrator.
(c) Conducting investigations of abuse,
neglect, unusual incidents, or major unusual incidents.
(d) The provision of direct services
(medical, educational, vocational, transportation, or social services) to which
the eligible individual has been referred and with respect to the direct
delivery of foster care services, including but not limited to those described
in paragraph (A)(iii) of section 1915(g) of the Social Security Act
(42 U.S.C.
1396n(g)(2)) as effective
October 1, 2015
2021 .
(e)
Services provided to individuals who have been determined to not have
mental retardation or another
a developmental disability according to section
5126.01
of the Revised Code, except for individuals eligible for coverage of TCM
services pursuant to paragraph (C)(1)(a) of this rule.
(f) Payment or coverage for establishing
budgets for services outside of the scope of individual assessment and care
planning.
(g) Activities related to
the development, monitoring or implementation of an individualized education
program (IEP).
(h) Services
provided to groups of individuals.
(i) Habilitation management.
(j) Eligibility determinations for county
board of developmental disabilities (CBDD) services.
(E) Qualified providers.
Qualified providers of medicaid TCM services are CBsDD as established under Chapter 5126. of the Revised Code. Only those eligible activities as defined in this rule performed by CBsDD employees or CBsDD sub-contractors meeting the registration or certification standards contained in rule 5123:2-5-02 of the Administrative Code are eligible for payment.
(F) Documentation requirements.
To receive medicaid reimbursement for TCM activities provided under this rule, documentation must include, but is not limited to, the following elements:
(1) The date that
the activity was provided, including the year;
(2) The name of the person for whom the
activity was provided;
(3) A
description of the activity provided and location of the activity delivery (may
be in case notes or a coded system with a corresponding key);
(4) The duration in minutes or time in/time
out of the activity provided. Duration in minutes is acceptable if the
provider's schedule is maintained on file;
(5) The identification of the activity
provider by signature or initials on each entry of service delivery. Each
documentation recording sheet must contain a legend that indicates the service
provider's name (typed or printed), title, signature, and initials to
correspond with each entry's identifying signature or initials.
(G) Reimbursement and claims
submission.
(1) Each CBDD shall maintain a
current fee schedule of usual and customary charges. Records of fee schedules
must be maintained for a period of six years. The CBDD shall bill DODD its
usual and customary charge for a TCM covered service. TCM services will be
reimbursed the lesser of the CBDD's usual and customary charge or the rate
found in appendix A
DD to this rule
5160-1-60 of the Administrative Code . Without
regard to the rate of reimbursement that may be identified in appendix
A
DD to
this rule 5160-1-60
of the Administrative Code , no provider of TCM shall receive
reimbursement at a rate in excess of the rate in the federally approved state
plan amendment.
(2) Each CBDD is
responsible for instituting collection efforts against third parties liable for
the payment of TCM services as required by rule
5160-1-08
of the Administrative Code. The CBDD must maintain sufficient documentation to
substantiate collection activities and any payments received. Sufficient
documentation includes a written confirmation every twelve months from any
known possible third party, if applicable, which states that the TCM service is
not covered under that program or policy.
(3) If any of the TCM services provided by a
CBDD are paid or attributable to another federal program, the costs of such
services should be allocated in accordance with 2 CFR Part 200 as in effect on
September 1, 2016
2021 .
(4)
A CBDD shall not alter or adjust usual and customary rates charged to the
medicaid program if such adjustments will result in a direct or indirect charge
for costs of uncompensated care being charged to the medicaid
program.
(5) A CBDD is required to
submit claims to DODD within three hundred thirty days from the date of service
in accordance with the format specified by DODD. Failure to submit claims
within the specified three hundred thirty days may result in the CBDD not being
reimbursed for such claims. The CBDD shall have no recourse to recover such
non-reimbursed claims.
(6) Medicaid
reimbursement for TCM services shall constitute payment in full. Medicaid
recipients may not be billed for medicaid covered services.
(7) Payment for TCM services must not
duplicate payments made to CBDD under other programs.
(8) To support the provision of providing TCM
through fee for service, utilization review procedures will be incorporated to
assure compliance with " 42 C.F.R. Part 456 " as in effect on October 1,
2014
2021 .
(9)
Records relating to TCM services shall be made available to DODD, ODM, centers
for medicare and medicaid services (CMS) or any of their representatives to
verify actual units of service provided are in compliance with federal
requirements and are adequately supported.
(10) For the purpose of this rule, a unit of
service is equivalent to fifteen minutes. Minutes of service provided to a
specific eligible individual can be accrued over one calendar day. The number
of units that may be billed during a day is equivalent to the total number of
minutes of TCM provided during the day for a specific individual divided by
fifteen plus one additional unit if the remaining number of minutes is eight or
greater minutes.
(11) Billable
units of service are those tasks/contacts made with the eligible individual or
on behalf of the eligible individual. Activities which are not performed on
behalf of or are not specific to an eligible individual are not
billable.
(H)
Reimbursement on and after January 1, 2015
2022 .
(1) A CBDD shall receive an interim rate as
defined in the appendix DD to
this rule 5160-1-60
of the Administrative Code for each fifteen minute unit of providing TCM
services to medicaid eligible individuals as defined in paragraph (C) of this
rule.
(2) A CBDD shall be
reimbursed for the actual incurred costs of providing TCM to eligible medicaid
beneficiaries. Each CBDD must certify its expenditures as eligible for federal
financial participation in order to settle to actual incurred costs for
medicaid TCM.
(3) Each CBDD shall
submit their actual incurred costs as described in paragraph (G) (1) of this
rule on an annual cost report as established in section
5126.131
of the Revised Code.
(4) Each CBDD
shall receive an interim rate in the amount of fifteen dollars and forty-eight
cents per fifteen minute unit for providing TCM services to medicaid eligible
individuals as defined in paragraph (C) of this rule.
(5) DODD shall conduct a final settlement
once all cost reports are received audited. Payments shall be paid to each
provider in an amount based on the provider's reconciled costs for providing
TCM services to medicaid eligible recipients less any amounts previously paid
to the provider for proving TCM services under the state plan.
(6) Reconciled costs shall be calculated by
using a methodology approved by the centers for medicare and
medicaid.
(I) Record
requests and retention.
(1) CBDD shall make
available all records including but not limited to work papers, supporting
reports, medical reports, progress notes, charges, journals, ledgers, computer
tapes, computer disks, and fiscal reports for review by representatives from
ODM, ODM's designee, CMS, or DODD at the discretion and request of these
representatives.
(2) Documentation
will be retained for a period of six years from the date of receipt of final
payment or until such time as a lawsuit or audit finding has been resolved,
whichever is longer. The records shall be provided to ODM or its designee upon
request in a timely manner. Records produced electronically must be produced at
the provider's expense, in the format specific by state or federal authorities.
A retrospective program review shall not be required on or after January 1,
2015.
(J) Monitoring,
compliance and sanctions.
(1) DODD shall
conduct periodic monitoring and compliance reviews related to TCM as authorized
by the Revised Code. Reviews may consist of, but are not limited to, physical
inspections of records and sites where services are provided, interviews of
providers, recipients, and administrators. Qualified providers as defined in
paragraph (E) of this rule, in accordance with the medicaid provider agreement
and DODD, shall furnish to DODD, ODM, CMS, and the medicaid fraud control unit
or their designees any records related to the administration and/or provision
of TCM services.
(2) ODM will
monitor the activities of DODD, as necessary, to ensure that funding applicable
to the TCM program is used for authorized purposes in compliance with laws,
regulations, and the provisions of the interagency agreement.
(3) In the event a fiscal review reveals that
an overpayment has been made, and/or there is a disallowance of medicaid
payments, the amount of the overpayment and/or disallowance shall be recovered
from the CBDD.
(K) Due
process.
(1) Medicaid eligible individuals
whose TCM services either affect the provision of services or whose TCM
services are affected by any decision may appeal that decision at a state
hearing pursuant to division 5101:6 of the Administrative Code. CBDDs must
provide notice to the individual of their right to request a state hearing
pursuant to Chapter 5101:6-2 of the Administrative Code.
(2) If an eligible individual requests a
hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative
Code, the participation of DODD, and/or ODM and the CBDD is required during the
hearing proceedings to justify the decision under appeal.
(3) All rules related to due process shall be
interpreted in a manner consistent with section
1.11
of the Revised Code, which requires that they be liberally construed in order
to promote their objective and assist the individual in obtaining justice. All
rules relating to the right to a hearing and limitations on that right shall be
interpreted in favor of the right to a hearing.
(L) Nonfederal share.
A CBDD is responsible for payment of the nonfederal share of
medicaid expenditures in accordance with section
5126.057
Notes
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5162.02, 5162.021
Prior Effective Dates: 07/01/2005, 12/30/2005 (Emer.), 03/30/2006, 04/03/2006 (Emer.), 07/05/2006 (Emer.), 10/04/2006, 07/01/2011, 04/01/2015, 12/05/2016
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