Section 5160-46-06 - Ohio home care waiver program: reimbursement rates and billing procedures(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(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.(B) Billing code tables. Table A
Column 1 | Column 2 | Column 3 | Column 4 |
Billing code | Service | Base rate | Unit rate |
T1002 | Waiver nursing services provided by an agency RN | $68.44 | $ 9.25 |
T1002 | Waiver nursing services provided by a non-agency RN | $56.26 | $7.46 |
T1002 | Waiver nursing services provided by a non-agency RN (overtime) | $84.39 | $11.19 |
T1003 | Waiver nursing services provided by an agency LPN | $58.72 | $7.82 |
T1003 | Waiver nursing services provided by a non-agency LPN | $48.00 | $6.24 |
T1003 | Waiver nursing services provided by a non-agency LPN (overtime) | $72.00 | $ 9.36 |
T1019 | Personal care aide services provided by an agency personal care aide | $28.96 | $7.24 |
T1019 | Personal care aide services provided by a non-agency personal care aide | $22.32 | $5.58 |
T1019 | Personal care aide services provided by a non-agency personal care aide (overtime) | $33.48 | $8.37 |
Table B
Column 1 | Column 2 | Column 3 | Column 4 |
Billing code | Service | Billing unit | Medicaid maximum rate |
H0045 | Out-of-home respite services | Per day | $199.82 |
S0215 | Supplemental transportation services | Per mile | $0.48 |
S5101 | Adult day health center services | Per half day | $53.11 |
S5102 | Adult day health center services | Per day | $106.26 |
S5136 | Structured family caregiving | Per day | $102.68 |
S5136 | Structured family caregiving | Per half day | $51.34 |
S5160 | Personal emergency response systems | Per installation and testing | $32.95 |
S5161 | Personal emergency response systems | Per monthly fee | $32.95 |
S5165 | Home modification services | Per item | Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year |
T2029 | Supplemental adaptive and assistive device services | Per item | Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year |
S5170 | Home delivered meal services - standard meal | Per meal | $8.80 |
S5170 | Home delivered meal services - therapeutic or kosher meal | Per meal | $10.61 |
S5135 | Community integration services | Per fifteen-minute unit | $3.93 |
T2038 | Community transition services | Per job | $2,000 per waiver enrollment |
S5121 | Home maintenance and chore services | Per job | Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year |
(C) The amount of reimbursement for a service will be the lesser of the provider's billed charge or the medicaid maximum rate.(D) Required modifiers. (1) The "HQ" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement as a group rate will be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.(2) The "TU" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 and the entire claim is being billed as overtime.(3) The "UA" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 and only a portion of the claim is being billed as overtime.(4) The "UD" modifier will be used when a provider submits a claim for billing code S5136 for a half day of structured family caregiving.(5) The "U1" modifier will be used when a provider submits a claim for billing code T1002 and the individual enrolled on the Ohio home care waiver is receiving infusion therapy.(6) The "U2" modifier will be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to an individual enrolled on the Ohio home care waiver for the same date of service.(7) The "U3" modifier will be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to an individual enrolled on the Ohio home care waiver for the same date of service.(8) The "U4" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.(9) The "U6" modifier will be used when a provider submits a claim for billing code S5170 for a therapeutic or kosher home delivered meal.(E) Claims will be submitted to, and reimbursement will be provided by, ODM in accordance with Chapter 5160-1 of the Administrative Code.Ohio Admin. Code 5160-46-06
Effective: 10/1/2024
Five Year Review (FYR) Dates: 7/16/2024 and 10/01/2029
Promulgated Under: 119.03
Statutory Authority: 5162.03, 5166.02
Rule Amplifies: 5166.02, 5166.041
Prior Effective Dates: 01/01/2004, 07/01/2006, 07/01/2008, 01/01/2010, 04/01/2011, 10/01/2011, 07/01/2015, 01/01/2017, 01/01/2019, 07/01/2019, 03/23/2020, 11/01/2021, 01/01/2024