5101:3-51-06    HOME Choice ("Helping Ohioans Move, Expanding Choice") Demonstration Program: Reimbursement Rates and Billing Procedures

CSTL 09-02

Effective Date: June 1, 2009

Most Current Prior Effective Date:   July 1, 2008

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or upon the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

(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 paid for up to the first four units of service delivered.

(2)      "Billing unit," as used in table B, column 3 of paragraph (B) of this rule, means a single fixed item or amount of time.

(3)      "Classroom rate" is the amount that HOME choice independent living skills training service providers are reimbursed when the service is provided in a classroom setting. The rate is equivalent to fifty per cent of the reimbursement rate set forth in paragraph (B), table (B) of this rule that is paid to a provider for furnishing HOME choice independent living skills training services to a single individual.

(4)      "Classroom setting" is a situation in which a HOME choice independent living skills training service provider furnishes the same type of services to four or more individuals at the same address, during the same visit. The services provided in the classroom setting can be either the same type of HOME choice independent living skills training service, or a combination of HOME choice independent living skills training services and similar independent living skills training services.

(5)      "Group rate," as used in paragraph (E)(1) of this rule, is the amount that HOME choice nursing providers, or HOME choice independent living skills training services are reimbursed when the service is provided in a group setting. The rate is equivalent to seventy-five per cent of the reimbursement rate set forth in paragraph (B), table (A) of this rule for HOME choice nursing services, and in paragraph (B), table (B) of this rule for HOME choice independent living skills training services that is paid to a provider for delivering the HOME choice nursing services or HOME choice independent living skills training services to a single individual.

(6)      "Group setting" is a situation in which a HOME choice nursing, service provider, or a HOME choice independent living skills training service provider furnishes the same type of services to two or three individuals at the same address, during the same visit. The services provided in the group setting can be either the same type of HOME choice nursing service or HOME choice independent living skills training service, or a combination of HOME choice nursing services and similar nursing services, or HOME choice independent living skills training services and similar independent living skills training services.

(7)      "Maximum hours/days usage amounts," as used in table B, column 6 of paragraph (B) of this rule, means the maximum number of hours or days, or the maximum dollar amount that a

HOME choice demonstration program service can be reimbursed either monthly or annually, and as set forth on the HOME choice demonstration program participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(8)      "Maximum hours per month," as used in table A, column 5 of paragraph (B) of this rule, means the maximum number of hours that a HOME choice demonstration program service can be reimbursed per month, and as set forth on the HOME choice participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(9)      "Maximum rate" means the maximum amount that will be paid for the HOME choice demonstration program service rendered.

(a)      For the billing codes in table B of paragraph (B) of this rule, the HOME choice demonstration program maximum rate is set forth in column (4).

(b)      For the billing codes in table A of paragraph (B) of this rule, the HOME choice demonstration program 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)(10) of this rule for each additional unit of service delivered.

(10)    "Unit rate," as used in table A, column 4 of paragraph (B) of this rule, and in table B, column 5 of paragraph (B) of this rule, means the amount paid for each fifteen minute unit following the base rate paid for the first four units of service provided.

(B)      Billing code tables.

-Table A-

-Table B-

(C)      In order for a provider to submit a claim for HOME choice demonstration program services, the services must be provided in accordance with Chapter 5101:3-51 of the Administrative Code.

(D)      The amount of reimbursement for a service shall be the lesser of the provider's billed charge or the HOME choice demonstration program maximum rate.

(E)      Required modifiers.

(1)      The "GS" modifier must be used when a provider submits a claim for HOME choice nursing services, or HOME choice independent living skills training services, if the service was delivered in a group setting. Reimbursement as a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the HOME choice demonstration program maximum for the specific service.

(2)      The "CS" modifier must be used when a provider submits a claim for HOME choice independent living skills training services if the service was delivered in a classroom setting. Reimbursement as a classroom rate shall be the lesser of the provider's billed charge or fifty per cent of the HOME choice demonstration program maximum.

(3)      The "N2" modifier must be used when the same provider submits a claim for HOME choice nursing services for a second visit to a participant for the same date of service.

(4)      The "N3" modifier must be used when the same provider submits a claim for HOME choice nursing services for three or more visits to a participant for the same date of service.

(5)      The "N4" modifier must be used when a provider submits a claim for HOME choice nursing services for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(F)      Reimbursement will be provided in accordance with paragraphs (A) to (D) of rule 5101:3-1-60 of the Administrative Code. Reimbursement will be provided in accordance with the following:

(1)      Except as stated in paragraph (F)(2) of this rule, claims must be received by the financial management service provider (FMS) within ninety calendar days of the actual date the HOME choice demonstration service was provided.

(2)      Reimbursement requests for community transition services must be received by the FMS within fourteen calendar days of the actual date goods and services were purchased. Reimbursement requests must be in the form of either an invoice, a receipt or a purchase order.

(3)      The payment for a covered HOME choice demonstration program service constitutes payment-in-full and shall not be construed as a partial payment when the reimbursement amount is less than the provider's charge. The provider may not collect and/or bill the participant for any difference between the HOME choice demonstration program payment and the provider's charge, or request the participant to share in the cost through a deductible, coinsurance, co-payment or other similar charge.

(4)      Except for as stated in paragraphs (F)(5) and (F)(6) of this rule, HOME choice demonstration program reimbursement is not available for non-covered services, or for similar waiver or administrative services available on the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or the medicaid state plan.

(5)      When the HOME choice demonstration program participant is enrolled on an HCBS waiver, HOME choice demonstration program reimbursement is available for communication aid services only after the participant has received and exhausted same or similar waiver services.

(6)      When the HOME choice demonstration program participant is enrolling on an ODA-administered waiver, the participant may use HOME choice community transition services in lieu of, but not in addition to, the community transition service available through the ODA-administered waiver.

(7)      Reimbursement is made only for those HOME choice demonstration program services that are set forth in the participant's all services plan, service plan, individual service plan or non-waiver HOME choice demonstration program service plan, as appropriate. The amount of payment is determined in accordance with federal and state laws and regulations. In establishing HOME choice demonstration program maximums, ODJFS must assure that the maximum reimbursement is consistent with efficiency, economy and quality of care.

(8)      The state's appropriation determines the total amount of funds that may be expended for HOME choice demonstration program services. The maximums used by ODJFS may be less than the maximums permitted under federal law for same or similar services, but may not be more. Providers are expected to bill the FMS provider their usual and customary charge (i.e., the amount the provider charges the general public). If the amount billed to the FMS exceeds the maximum set forth in this rule, the amount paid will automatically be reduced to the maximum permitted.

Effective: 06/01/2009

R.C. 119.032 review dates: 07/01/2013

Certification: CERTIFIED ELECTRONICALLY

Date: 05/11/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am.

Sub. H.B. 119, 127th G.A.

Prior Effective Dates: 07/01/2008