ohio home and community-based service waivers ohio home care waiver provider education and technical...
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Ohio Home and Community-Based Service WaiversOhio Home Care Waiver
Provider Education and Technical Assistance
www.pcghealth.com
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Training Overview
Priorities for Ohio Home Care Waiver:• Waiver Population and Services-3-5• Changes to Transition Waiver- Page 6-7• Waiver Rules-Pages 8-10• Waiver Requirements-Pages 11-41• Incident Reporting-Pages 42-46• Billing-Pages 47-54• International Classification of Diseases
(ICD-10)- Pages 55-57
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Waiver Overview
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About Ohio Home and Community-Based Waiver Services
• The Ohio Department of Medicaid (ODM) currently administers and operates two home and community-based waiver programs: Ohio Home Care Waiver and the Transitions II Aging Carve-Out Waiver.
• The ODM-administered waiver programs provide eligible individuals in need of long-term care facility services with a cost-effective home and community-based alternative that recognizes the need for autonomy and independence.
• The waiver programs support the individual’s right to choose to live in the community, encouraging them to live as independently as possible and with self-determination, while providing the services, supports and safeguards needed to ensure their health and welfare.
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Waiver Target Population and Services
Ohio Home Care Waiver Serves Medicaid eligible individuals under the age of 60 with long-term
care needs that, in the absence of certain services, would require their needs to be met in a hospital or nursing facility.
Transitions Carve-Out Waiver Serves Medicaid eligible individuals age 60 and older who were
previously enrolled on the Home Care waiver and continue to need services that would otherwise be met in a hospital or nursing facility.
Waiver services include nursing, personal care aide services, home care attendant services, adult day health center services, home-delivered meals, home modifications, supplemental adaptive and assistive devices, supplemental transportation, out-of-home respite and emergency response systems.
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Changes to Transition Carve-Out Waiver
• The Transitions Carve-Out waiver is ending on June 30, 2015 and its services are moving to the PASSPORT waiver operated by the Ohio Department of Aging (ODA).
• Individuals who are currently receiving transition carve-out services will be transitioning to PASSPORT on February 1, 2015. Individuals enrolled on the Home Care waiver who are turning 60 will also be moving to PASSPORT.
Providers who wish to continue to deliver services to this population must:• Be an ODA-certified PASSPORT provider for current service delivery, or• Apply to become an ODA-certified PASSPORT provider, if not one already
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How to become a PASSPORT provider
• ODA is accepting applications from Home Care and Transitions Carve-Out agencies, non-agency nurse, and non-agency home care attendant providers. Non-agency personal care aides will be contacted individually, as their
waiver individual is ready to transition to the PASSPORT waiver.
• To submit an on-line application for PASSPORT certification, please visit the website: http://www.aging.ohio.gov/resources/providerinformation/
• If you are already an ODA PASSPORT provider, go to local PASSPORT agency to verify the waiver services you deliver are included in certification:
https://aging.ohio.gov/services/passportpassportadministrativeagencies.aspx If the service is not included in your certification, please request a service
addition to your certification.
Please direct any certification questions to ODA at phone 614-779-0248 or email [email protected]
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Waiver Rules
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Ohio Administrative Code
Enrolled waiver providers have agreed to follow the rules and standards of the waiver program(s) based on their provider agreement with the ODM. Waiver providers must read and understand the Ohio Administrative Code rules.
5160-45-01; Definitions 5160-45-03; Individual Choice and Control 5160-45-05; Incident Management, Investigation, Response System 5160-45-06; Structural Reviews and Alleged Overpayments 5160-45-10; Conditions of Participation
For the official rule(s), refer to codes.ohio.gov/oac
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Ohio Administrative Code continued
Ohio Home Care Waiver Program 5160-46-04; Covered Services, Requirements, Specifications 5160-46-04.1; Home Care Attendant Services 5160-46-06; Reimbursement Rates and Billing 5160-46-06.1; Home Care Attendant Rates and Billing
For the official rule(s), refer to codes.ohio.gov/oac
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Waiver Requirements
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Structural Reviews of Providers
Waiver providers are subject to Structural Reviews to evaluate provider compliance with all applicable Ohio Administrative Codes. • Medicare-certified and/or otherwise accredited agencies as
defined in rule 5160-45-01 of the OAC are subject to reviews in accordance with their certification and accreditation, and therefore shall be exempt from a regularly scheduled structural review.
If requested to do so by ODM or its designee (PCG), agencies shall submit a copy of their updated certification and/or accreditation, and shall make available to ODM or its designee within 10 business days, all review reports and accepted plans of correction from the certification and/or accreditation bodies.
Ohio Administrative Code: 5160-45-06 For the official rule, refer to codes.ohio.gov/oac
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Structural Reviews continued
All other ODM-administered waiver procedures shall be subject to structural reviews by ODM or its designee during each of the first three years after a provider begins furnishing billable services. Thereafter, reviews shall be conducted annually unless, at the discretion of ODM, biennial reviews may be conducted, when all of the following apply:
There were no findings against the provider during the provider’s most recent structural review;
The provider was not substantiated to be the violator in an incident described in rule 5160-45-05;
The provider was not the subject of more than one provider occurrence during the previous 12 months; and
The provider does not live with an individual receiving ODM-administered waiver services.
Note: All ODM-administered waiver providers may be subject to an announced or unannounced structural review at any time as determined by ODM or its designee.
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Background Check for Non-Agency Providers
Each enrolled non-agency waiver provider, before the anniversary date of their Medicaid provider agreement, shall be informed of the requirement to:
• provide a set of fingerprint impressions, and • complete a criminal records check. This is a requirement for continued approval as a provider.
Provider background check(s) must be conducted by the Ohio Bureau of Criminal Identification and Investigation (BCI&I), following the receipt of fingerprint impressions and required document(s).
• If BCI&I does not receive the report within the required timeframe, ODM will move forward with revoking the provider’s agreement with the department.
• Failure to submit the annual background check will lead to termination of provider number.
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Background Check for Non-Agency Providers continued
• To obtain a background check, you must go to a location that performs electronic Web Check.
• A listing of Web Check agencies can be found on the Ohio Attorney General’s website at the following link, Web Check Community Listing:
ohioattorneygeneral.gov/Services/Business/WebCheck/WebcheckCommunity-Listing
• Contact BCI&I by telephone at (877) 224-0043 for additional information.
Ohio Administrative Code: 5160-45-08 For the official rule, refer to: codes.ohio.gov/oac
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Background Check for Agency Providers
Agency providers may not employ or continue to employ an individual if:• employee is included on the databases listed in OAC• employee fails to submit a records check conducted by BCI&I, including
failure to access and complete fingerprint impression sheet
As a condition of continued employment, agencies shall conduct a criminal records check of employees at least once every five years.
Administrative Code: 5160-45-07 For the official rule, refer to: codes.ohio.gov/oac
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Background Check for Providers continued
New and existing providers are also required to submit a Federal Bureau of Investigation (FBI) background check in addition to the Ohio background check if any of the following applies:
• You do not currently live in the State of Ohio.• You have not lived in Ohio for the last five consecutive years.• You have been arrested and/or convicted of a crime in another state.• ODM instructed you to obtain an FBI background check.
Background checks from either BCI& I and FBI must be sent directly to this ODM address:
The Ohio Department of Medicaid
Attention: BCI Coordinator
P.O. Box 183017
Columbus, Ohio 43218
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Provider Requirements
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Registered Nurse (RN) Requirements
Registered Nurses must do the following:• Maintain a valid Ohio nursing license• Follow the Nurse Practice Act• Obtain physician orders and be listed on the All Services Plan (ASP) prior to
delivering services to any individual Physician’s order (plan of care) must be updated at least once every 60
days• Ensure all verbal orders are documented including date, time, and
physician. If orders are not obtained before the end of 60 days, nurses do not have the authorization to deliver services.
Ohio Administrative Code(s): 5160-46-04 For the official rule(s), refer to codes.ohio.gov/oac
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Licensed Practical Nurse (LPN) Requirements
• Face-to-face visits at least every 60 days with the directing RN to evaluate the provision of waiver nursing services, LPN performance, and to assure services are being delivered in accordance with approved All Services Plan
• Face-to-face visits at least every 120 days with directing RN, LPN, and Individual/Guardian to evaluate all of the above in addition to the individual’s satisfaction with care delivery
• Maintain documentation of plan of care review and physician orders by directing RN
• All parties must sign and date the face-to-face documentation
Ohio Administrative Code(s): 5160-46-04 For the official rule(s), refer to codes.ohio.gov/oac
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Personal Care Aide (PCA)
• Obtain a certificate within the last 24 months from a competency program. The approved program must include: personal care aide services, basic home safety, and universal precautions for prevention of disease transmission
• Obtain and maintain first aid certification from a class that is not solely internet-based and includes hands-on training by a certified instructor.
• Complete twelve hours of in-service continuing education annually that must occur on or before the anniversary date of their enrollment as a provider.
Ohio Administrative Code(s): 5160-46-04 For the official rule(s), refer to codes.ohio.gov/oac
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Medication Administration PCA Requirements
PCA’s cannot administer medications. They may only assist individuals with self-administration of medications. Examples: PCA may hand pill bottle to individual, but never the actual medications; PCA may provide pill box, but never place pills in box.
Ohio Administrative Code(s): 5160-46-04
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What is My Ohio HCP?
• Website that organizes all of a provider’s important Ohio home care program information onto a private, individualized page. It includes important records, forms, tools, surveys, news and updates, contact information and more.
• To create your individualized account go to: http://www.ohiohcp.org/
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Creating an Account
• You will click on “create account” • Complete all fields and hit “save”
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Documentation Requirements
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Clinical Records
All waiver nursing and personal care aide service providers:• Must maintain two copies of individual’s clinical record.• Must leave a legible copy of complete clinical record including the daily
visit note in the individual’s home.• Must keep the original in their place of business.
Ohio Administrative Code(s): 5160-46-04 For the official rule(s), refer to codes.ohio.gov/oac
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Identifying InformationThe clinical record must contain the individual’s identifying information:• Name• Address• Date of birth• Age, Gender, Race, Marital
Status• Significant Phone Number• Physician name and number• Medical history• Copy of any advance
directives (DNR or medical power of attorney, if present)
• Drug allergies/dietary restrictions
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All Services Plan (ASP)
• Provider must obtain the ASP prior to rendering services (must have your name, service, and approved start date).
• Provider must deliver services as written in the ASP (not allowed to perform more and unidentified services)
• Providers must keep a copy of the ASP in the individual’s home• ASP is the authorizing document for services
Any authorized changes must be updated in the ASP and distributed to all service providers by the case manager. Do not accept verbal changes from your waiver individual.
Provider must submit a written request to the case management agency when ASP update is overdue.
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Service Documentation
Service documentation is required for each visit and must contain all of the following: Tasks performed/or not performed Arrival and departure times Dated provider signature Dated individual or authorized representative signature
Note: Documentation must support the submitted claim(s).
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Conditions of Participation
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Conditions of Participation (COP)
• Ohio Administrative Code 5160-45-10, often referred to as the Conditions of Participation (COP), outlines 5 main areas between the waiver provider and individual enrolled on a waiver:
Confidentiality Boundaries Behaviors Significant Events Terminating Services
For the official rule, refer to codes.ohio.gov/oac
Note: Providers are evaluated to assure their compliance with the Conditions of Participation on an on-going basis.
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COP continued, Confidentiality of Information
• Clinical records must be kept in a secure location.• Keep all records for 6 years.
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COP continued, Boundaries
• Health Insurance Portability & Accountability Act (HIPAA) Individuals have a right to privacy which includes restricting with whom
their personal information is shared. Individual’s privacy rights are protected under HIPPA.
• Waiver providers must always deliver services both professionally and respectfully
• Conflict of Interest or Taking Advantage of Individual Waiver provider may not engage in behavior that might be considered a
conflict of interest or allows one to take advantage of the relationship that develops due to service delivery.
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COP continued, Provider Behaviors
All waiver service providers shall not:• Submit a claim for services rendered while the individual is hospitalized,
institutionalized, or incarcerated• Consume the individual’s food and/or drink• Bring family, friends, pets, or anyone else to the individual’s place of
residence• Take the individual to the provider’s place of residence• Use illegal drugs or chemical substances• Consume alcohol/ be under alcohol influence while delivering services • Report for duty or remain on duty when provider is using any controlled
substance• Deliver services to the individual when the provider is medically,
physically, or emotionally unfit
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COP continued, Provider Behaviors
• Discuss religion, politics, or personal issues with the individual• Accept, obtain or attempt to obtain money or anything of value from the
individual• Borrow money, credit cards or other items from the individual, authorized
representative, household or family members of individual• Be designated on a financial account or credit card held by the individual,
authorized representative, household or family members of individual• Use of property of the individual, authorized representative, household or
family members for personal gain• Lend or give the individual, authorized representative, household or family
members money or other personal items
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COP continued, Provider Behaviors
• Engage in behavior that causes or may cause physical, verbal, mental, or emotional distress or abuse to the individual
• Leave the home for a purpose unrelated to the provision of services without notifying the appropriate parties
• Use the individual’s motor vehicle, unless solely for the benefit of individual• Engage in activities that may distract from service• Engage in behavior that takes advantage of or manipulates the individual,
the individual’s authorized representative or family, or the waiver program rules resulting in an advantage for personal gain
• Use information about the individual, authorized representative, or the individual’s family for personal gain
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COP continued, Significant Events
All waiver service providers must notify ODM or its designee (PCG) within twenty-four hours when the provider is aware of issues/significant events that may affect the individual and/or provider’s ability to render services as directed in the individual’s all services plan. Some issues include, but are not limited to:• Individual consistently declines services• Individual moves to another residential address• Changes in the physical, mental, and/or emotional status of individual• Changes in environmental conditions affecting the individual• Individual’s caregiver status has changed • Individual no longer requires medically necessary services
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COP continued, Significant Events
• Individual is behaving inappropriately toward the provider• Individual is consistently non-compliant with physician orders, or is non-
compliant with physician orders that may jeopardize the individuals health and welfare
• Individual’s requests consistently conflict with their all services plan• Individual is experiencing other health and welfare issues
Ohio Administrative Code(s): 5160-45-10 For the official rule(s), refer to codes.ohio.gov/oac
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COP continued, How to Contact Case Management Agency
• During normal business hours, providers must call or email the case manager using their contact information located on the ASP
• After hours, on the weekend or holidays, call the applicable number(s) below for further direction: Care Star: (800) 616-3718 Care Source Marietta: (855) 288-0003 Care Source Cleveland: (855) 263-9003 Council on Aging: (855) 372-6176
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COP continued, Terminating Services with an Individual
• Submit written notification to the individual and ODM or its designee (PCG) at least 30 calendar days before the anticipated last date of service if the provider is terminating services to the individual. Provider must submit verbal and written notification to the individual and PCG at
least ten days before the anticipated last date of service.
• Exceptions to the 30-day notice: Hospitalized for 3 days Individual admitted to extended care facility, incarcerated
Note: Discharge summary should be written on the last day of service and contain an overview of individual’s care requirements.
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COP continued, Change of Information
In the event of a change in contact information, the provider shall notify ODM via the Medicaid information technology system (MITS) and PCG, no later than seven calendar days after such changes have occurred. These changes might include the provider’s: address telephone and fax numbers email
Note: Providers should also notify their Case Management Agency.
PCG Contact Information:Phone: 877-908-1746 Fax: 614-386-1344 E-mail: [email protected]
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Incident Reporting
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Incident Management
• ODM has designated PCG to perform investigatory functions set forth in Ohio Administrative Code: 5160-45
• PCG must initiate incident reports following identification during any PCG oversight processes
• PCG must determine if an incident occurred, and if so, ensure that preventative measures are in place to prevent future occurrences For the official rule, refer to codes.ohio.gov/oac
Note: All waiver providers are required to complete an Incident Management training by ODM. Attendance is reported to ODM. This may be viewed on PCG’s website at: ohiohcbs.pcgus.com
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Reportable Incidents
Reportable incidents shall include, but not be limited to:
(1) Physical, emotional, mental and/or sexual abuse of an individual;
(2) Neglect of an individual;
(3) Abandonment of an individual;
(4) Exploitation of an individual;
(5) Death of an individual;
(6) Accident or injury of an individual;
(7) An unexpected crisis in the individual’s family or environment, with health and welfare implications for the individual;
(8) Loss of an individual’s informal caregiver or family member, with health and welfare implications for the individual;
(9) Inappropriate delivery of services to an individual, with health and welfare implications for the individual;
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Reportable Incidents continued
(10) Services provided to an individual that are beyond the provider's scope of practice;
(11) Services delivered to an individual without physician's orders;
(12) Errors in the administration of medication to the individual;
(13) Alleged illegal activity by the individual or in the individual’s environment;
(14) Inappropriate use or abuse of substances by the individual;
(15) Theft of the individual’s money;
(16) Theft of the individual’s personal property; and
(17) Theft of the individual’s medication.
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Incident Reporting
Reporting, notification and response requirements:• If a waiver provider learns of a reportable incident, they must report
the incident to the Case Management Agency within twenty-four hours.
• Subsequently, PCG reviews within one business day of submission to verify: Was immediate action taken to ensure the health and welfare of the
Individual? In the event of a death, was the county coroner notified if the disability
of the Individual was a result of an accident, injury, or trauma?
Note: ODM may conduct a separate, independent review or investigation of any reportable incident.
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Provider Billing
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Restrictions on Service & Billing
• Only bill for the services provided• Only bill for services delivered face-to-face• Providers may not subcontract out their services• Providers may not bill for services provided while the individual is in the
hospital or extended care facility• Insurances other than Medicaid must be billed first• If the primary insurance covers the entire service cost, provider may not bill
Medicaid• ODM has 30 days to make a payment from the date of a clean submission• Claims must be submitted via the Medicaid Information Technology System
(MITS) portal or Electronic Data Interchange (EDI) MITS Web Portal https://portal.ohmits.com/public/Providers/tabid/43/Default.aspx
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Billing Accuracy/ Remittance Advice
• Providers must check all claims prior to submission for payment• If using a billing vendor, providers must ensure the claim has the
correct code, date of service, and served individual• Providers must ensure that the clinical documentation matches the
appropriate individual, length of visit, date billed, and PAID amount. Review remittance advices after each payment by comparing to
clinical documentation including the All Services Plan. If an overpayment is found or a claim was billed incorrectly,
provider has 60 days to resubmit a correction to the claim.
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Base and Subsequent Units
Providers must bill pursuant to base and subsequent units:• 1 Subsequent Unit = 15 minutes, after the base unit (first hour) of each visit• 1 hour = 4 subsequent units• Example: 1 visit of 3 hours
1 Base (1 B)
8 Subsequent Units
(2 hours x 4 subsequent units) or 8 S
Ohio Administrative Code(s): 5160-46-06 For the reimbursement rule(s), refer to codes.ohio.gov/oac
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Example: Non-Agency/RN
Billing Code: T1002(Waiver Nursing); B=1; S=28 Authorized time period--2/11/2013--2/27/2013 Mickey Mouse, RN 1234567
• B= 1 Visit or Shift• S= 28 Additional 15 minute increments or 7 hours (28/4=7)• From 2/11/13 thru 2/27/13• Total of 1 Shift not to exceed 8 hours (1+7=8) • 8 Hours equals 32 units
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Example: Agency/Private Duty Nursing
Billing Code: PDN/Agency T1000; B=28, S=784 Authorized time period: 3/1/2013 until the end of ASP date Kerry Bates, 7654321
• B= 28 Visits or Shifts• S= 784-- 15 minute increments or 196 Additional Hours (784/4=196)• From 3/1/2013 until the end of the ASP date• Total of 28 Visits or Shifts not to exceed 224 hours (28+196=224)• Break down would be 224/28= 8, so 28~ 8 hour shifts per month until the end of
the ASP.• 8 hours equals 32 units per visit
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Example: Non-Agency/PCA
Billing Code: T1019(Personal Care Services); B=13, S=160 Authorized time period: 3/1/2013-3/31/2013 Daniel P. Cryer, CSTO 2589631
• B= 13 Visits or Shifts• S= 160--15 minute increments or 40 additional hours (160/4=40)• From 3/1/2013 thru 3/31/2013• Total of 13 Visits or Shifts not to exceed 53 hours (13+40=53)• Break down would be 53/13= 4, so 13~ 4 hour shifts for the month of March
2013.• 4 hours equals 16 units per visit.
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Billing for Agencies, Nurses, & PCA’s
Refer to the ODM training materials related to billing practices for:• Personal Care Aides• Non-Agency Nurses• Agencies
For the specific billing materials, visit ohiohcbs.pcgus.com
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ICD-10 Transition
What service providers are affected?• All providers that are currently required to include ICD-9 codes on
claims will be required to use ICD-10 codes beginning with the date of service or date of discharge of October 1, 2015.
• Ancillary service providers are included, such as transportation and waiver providers.
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What ICD-10 codes should I use?
• Research the codes that will apply to your business• If another provider supplies your ICD-10 codes, you must ensure those
providers are ICD-10 compliant• Consider identifying the most commonly utilized ICD-9 codes and determine
the correlating ICD-10 codes• If you utilize a clearinghouse/ billing service, you must ensure the vendor
will be ready to accommodate the ICD-10 transition. (Send test claims)
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ICD-10 Resources
• PCG: http://ohiohcbs.pcgus.com/• CMS: www.cms.gov/ICD10• ODM: http://www.medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx
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Public Consulting Group, Inc.P.O. Box 151510 Columbus, Ohio 43215
(877) 908-1746, [email protected]