Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-46 - Ohio home care waiver › Section 5160-46-06 - Ohio home care waiver program: reimbursement rates and billing procedures

Current through all regulations passed and filed through July 1, 2024
(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.