Ohio Admin. Code 5160-59-03.6 - Psychiatric residential treatment facility (PRTF) service

(A) This rule sets forth provisions governing coverage for the psychiatric residential treatment facility (PRTF) service furnished as part of the Ohio resilience through integrated systems and excellence (OhioRISE) program.

(B) Definitions. For purposes of this rule, the following definitions apply:

(1) "Bed hold day" means a day for which a bed is reserved for a resident of a PRTF through medicaid reimbursement while the resident is temporarily absent from the PRTF for hospitalization, therapeutic leave, or a family visit. A youth on bed hold day status is not considered discharged from the PRTF.

(2) "Direct care costs" are costs for services delivered to a resident of a PRTF through a PRTF employee or contractual arrangement with a PRTF. Direct care costs include wages, taxes, supervision, staff development, contracting, and consulting services.

(3) "Family visit" means an authorized overnight absence from the PRTF that allows the youth to spend time with friends or relatives.

(4) "Hospitalization" means transfer of a youth receiving PRTF services to a hospital as defined in Chapter 5160-2 of the Administrative Code. The youth is considered hospitalized if admitted to the hospital as an inpatient or is in an observation status in a hospital.

(5) "PRTF services" include the service and activities described in Chapter 5122-41 of the Administrative Code.

(6) "Therapeutic leave" means a youth is temporarily absent from the PRTF and is in a setting in which the youth is receiving a regimen of therapeutic services that is not duplicative of PRTF services or are services related to facilitating transition planning.

(C) Eligible providers.

(1) A "PRTF provider" for purposes of Chapter 5160-59 of the Administrative Code is an entity covered in agency 5160 of the Administrative Code that provides psychiatric services to individuals twenty years of age or younger in an inpatient setting; and

(a) Meets the provisions in 42 CFR Part 441 Subpart D and 42 CFR Part 483 Subpart G (October 1, 2023), including participating in survey and certification activities with the Ohio department of health; and

(b) Has current behavioral health accreditation by the joint commission, the commission on accreditation of rehabilitation facilities, or the council on accreditation of services for families and children; and is one of the following:

(i) An entity that is certified as a PRTF in accordance with section 5119.36 of the Revised Code and Chapter 5122-41 of the Administrative Code.

(ii) An entity operating in another state and meeting the provisions set forth in rule 5160-1-11 of the Administrative Code. The entity has to:

(a) Maintain licensure to provide relevant services in the state where the entity operates; and

(b) Provide evidence that the facility is an eligible and enrolled PRTF provider with another state medicaid agency.

(2) A PRTF provider has to be an eligible provider, as defined in rule 5160-1-17 of the Administrative Code.

(a) A PRTF provider will notify the Ohio department of medicaid (ODM) if its license, certification, or accreditation is terminated, suspended, or not renewed within five business days of the action taken against its license or accreditation.

(i) The PRTF provider will be disenrolled as an ODM PRTF provider, effective the license termination date, at least until such time as the license, certification, or accreditation is restored.

(ii) Once the PRTF provider's license, certification, or accreditation is restored by the appropriate agency, the provider will notify ODM for potential reenrollment.

(iii) A PRTF provider will be held liable for recoupment of any monies paid for services during the time that the provider did not possess a valid license, certification, or accreditation.

(b) A provider enrolling or revalidating as an ODM PRTF provider will inform and make available to the department any cited deficiencies issued by, or plans of correction submitted to, any local, state, or federal licensure, accreditation, or certification authorities within the preceding three years.

(c) No facility can enroll or revalidate as an ODM PRTF provider or receive medicaid funds for services furnished before the date on which the facility director signs an attestation that the facility is in compliance with centers for medicare and medicaid services (CMS) provisions regarding restraint, seclusion, and death reporting policies, in accordance with 42 CFR Parts 441 and 483 (October 1, 2023).

(d) A PRTF provider will report incidents and notify the department of any local, state, or federal civil (including licensure, accreditation, or certification) or criminal investigation of the provider related to allegations that, if true, could impact the health, safety, or welfare of youth at the facility, in accordance with paragraph (F) of rule 5160-44-05 of the Administrative Code.

(e) Provide ODM, the resident and guardian (as applicable), and anyone designated by the resident or guardian, written notice at least ninety calendar days prior to a facility closure or voluntary termination of the provider agreement.

(D) Coverage.

(1) Services and activities provided in accordance with Chapter 5122-41 of the Administrative Code to individuals twenty years of age or younger in a PRTF are covered services.

(2) PRTF services do not include hospital services covered in Chapter 5160-2 of the Administrative Code.

(3) PRTF services may continue when a youth is receiving PRTF services upon turning twenty-one years of age until the individual meets discharge or transition criteria or reaches twenty-two years of age, whichever occurs first.

(E) Reimbursement.

(1) The medicaid base per diem reimbursement rate includes medically necessary PRTF services. The per diem rate includes the following:

(a) Room and board;

(b) Treatment, therapeutic, and other services described in rule 5122-41-07 of the Administrative Code;

(c) Direct care costs;

(d) Staffing to support increases in acuity, extending to the provision of individual supports when necessary;

(e) The services of PRTF staff as attendants during transportation; and

(f) Transportation of the youth to and from family visits or community outings, as is included in the youth's individual plan of care.

(2) The PRTF per diem medicaid rate will be reimbursed for up to three consecutive bed hold days, as defined in paragraph (B) of this rule.

(a) Temporary absences will first be approved by the youth's treatment team, included in the individual plan of care, and planned in consultation with the youth's child and family team as described in rule 5160-59-01 of the Administrative Code.

(b) Payment for bed hold days may be made only if the youth has the intent and ability to return to the same PRTF.

(c) If the therapeutic leave is related to an acute need, the facility will notify the OhioRISE plan within twenty-four hours of the leave event.

(d) Extensions to bed hold days will be authorized in accordance with rule 5160-59-03.1 of the Administrative Code.

(3) Distinct base per diem rates are established for the following types of PRTFs:

(a) Serving youth with cooccurring behavioral health and intellectual or developmental disabilities.

(b) Serving youth in a separate, detached building of six or fewer beds.

(c) Serving youth with cooccurring behavioral health and intellectual or developmental disabilities in a separate, detached building of six or fewer beds.

(d) Serving youth in a facility that does not meet the provisions in paragraph (E)(3)(a), (E)(3)(b) or (E)(3)(c) of this rule.

(4) Services not included in the PRTF per diem reimbursement rate for which a separate medicaid payment may be made include, but are not limited to:

(a) Medical, ancillary, and specialty healthcare services that a nurse is unable to provide onsite rendered by providers who bill medicaid directly.

(b) Direct-care services provided by a practitioner of physician services or hospital services as described in Chapter 5160-2 of the Administrative Code when performed outside of the PRTF.

(c) Community behavioral health services, as defined in Chapter 5160-27 and rule 5160-8-05 of the Administrative Code, rendered by a provider outside of the PRTF, when identified in the child and family-centered care plan as necessary for the youth's successful transition to a lower level of care.

(d) Care coordination activities, including administration of the CANS assessment, provided by a care management entity, in accordance with rule 5160-59-03.2 of the Administrative Code, will be reimbursed as described in Chapter 5160-59 of the Administrative Code.

(e) Mobile response and stabilization services provided by a behavioral health provider in accordance with rule 5160-27-13 of the Administrative Code will be reimbursed as described in Chapter 5160-27 of the Administrative Code when it is provided prior to admission to the PRTF or while the youth is on a family visit described in paragraph (B)(3) of this rule.

(f) Drugs and take-home drugs billed in accordance with Chapter 5160-9 of the Administrative Code.

(g) Dental services provided by licensed dentists in accordance with Chapter 5160-5 of the Administrative Code.

(h) Laboratory and x-ray procedures in accordance with Chapter 5160-11 of the Administrative Code.

(i) Vision care services, including examinations, dispensing, and the fitting of eyeglasses, are paid directly to vision care providers in accordance with Chapter 5160-6 of the Administrative Code.

(j) Transportation:

(i) Emergency and non-emergency transportation to and from other healthcare facilities.

(ii) Of the youth's family or guardian to and from the PRTF facility.

(iii) Of a youth transitioning into or out of a PRTF.

(5) Payments for PRTF services will be paid the lesser of billed charges or at the OhioRISE plan contracted per diem rate. The OhioRISE plan contracted per diem rate will be no less than the rate listed on the PRTF fee schedule in effect on the date of services rendered. The PRTF fee schedule is published on the department's website, http://medicaid.ohio.gov/ .

(F) Limitations.

(1) PRTF admissions will:

(a) Be requested by the OhioRISE care coordinator upon recommendation of the child and family team;

(b) Document the certification of need described in 42 CFR 441.152; and

(c) Meet the medical necessity provisions in rule 5122-41-01 of the Administrative Code.

(2) Except as described in paragraph (E) of this rule, separate medicaid payment will not be made for community behavioral health services, as defined in Chapter 5160-27 and rule 5160-8-05 of the Administrative Code, by a provider outside of the PRTF, unless the service is prior authorized by the OhioRISE plan.

(3) A PRTF may not accept preadmission payment to reserve a bed from a medicaid-eligible prospective resident or from any other source on the prospective resident's behalf as a precondition for admission.

(4) Educational services and transportation to or from educational services are not reimbursable as a PRTF service.

(5) When the OhioRISE plan denies, reduces, terminates or suspends PRTF services, this constitutes an adverse benefit determination, and can be appealed in accordance with rule 5160-26-08.4 of the Administrative Code.

Notes

Ohio Admin. Code 5160-59-03.6

Effective: 10/1/2023
Five Year Review (FYR) Dates: 10/01/2028
Promulgated Under: 119.03
Statutory Authority: Revised Code Sections 5167.02 and 5164.02
Rule Amplifies: Revised Code Sections 5162.02, 5164.70, 5167.03, 5167.10, 5167.12, and 5167.13