Ohio Home and Community-Based Service Waivers - PowerPoint Presentation

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Ohio Home and Community-Based Service Waivers

Ohio Home Care Waiver Provider Education and Technical Assistance

www.pcghealth.comSlide2

Training Overview

2

Priorities for

Ohio Home Care Waiver:

Waiver Population and Services-3-5

Changes to Transition Waiver- Page 6-7

Waiver Rules-Pages 8-10Waiver Requirements-Pages 11-41Incident Reporting-Pages 42-46Billing-Pages 47-54International Classification of Diseases (ICD-10)- Pages 55-57Slide3

Waiver Overview

3Slide4

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

5

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 WaiverServes 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.Slide6

Changes to Transition Carve-Out Waiver

6

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 alreadySlide7

How to become a PASSPORT provider

7

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.aspxIf 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

provider_enrollment@age.ohio.govSlide8

Waiver Rules

8Slide9

Ohio Administrative Code

9

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 Overpayments5160-45-10; Conditions of ParticipationFor the official rule(s), refer to codes.ohio.gov/oacSlide10

Ohio Administrative Code continued

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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 BillingFor the official rule(s), refer to codes.ohio.gov/oacSlide11

Waiver Requirements

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Structural Reviews of Providers

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W

aiver

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/

oacSlide13

Structural Reviews continued

13

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; andThe 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.Slide14

Background Check for Non-Agency Providers

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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.Slide15

Background Check for Non-Agency Providers continued

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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-ListingContact 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/

oacSlide16

Background Check for Agency Providers

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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/oacSlide17

Background Check for Providers continued

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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  43218Slide18

Provider Requirements

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Registered Nurse (RN) Requirements

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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 individualPhysician’s order (plan of care) must be updated at least once every 60 daysEnsure 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): 5160-46-04For the official rule(s), refer to codes.ohio.gov/oacSlide20

Licensed Practical Nurse (LPN) Requirements

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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): 5160-46-04For the official rule(s), refer to codes.ohio.gov/oacSlide21

Personal Care Aide (PCA)

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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/

oacSlide22

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): 5160-46-0422Slide23

What is My Ohio HCP?

23Website 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

24You will click on “create account”

Complete all fields and hit “save”

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Documentation Requirements

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Clinical Records

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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): 5160-46-04For the official rule(s), refer to codes.ohio.gov/oacSlide27

Identifying Information

The clinical record must contain the individual’s identifying information:NameAddressDate of birthAge, 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 restrictions27Slide28

All Services Plan (ASP)

28

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. Slide29

Service Documentation

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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 signatureNote: Documentation must support the submitted claim(s).Slide30

Conditions of Participation

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Conditions of Participation (COP)

31

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 ServicesFor 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. Slide32

COP continued, Confidentiality of Information

32

Clinical records must be kept in a secure location.

Keep all records for 6 years.Slide33

COP continued, Boundaries

33

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 IndividualWaiver 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.Slide34

COP continued, Provider Behaviors

34

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 residenceUse illegal drugs or chemical substancesConsume 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 unfitSlide35

COP continued, Provider Behaviors

35

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 gainLend or give the individual, authorized representative, household or family members money or other personal itemsSlide36

COP continued, Provider Behaviors

36

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 gainUse information about the individual, authorized representative, or the individual’s family for personal gainSlide37

COP continued, Significant Events

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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 individualChanges in environmental conditions affecting the individualIndividual’s caregiver status has changed Individual no longer requires medically necessary servicesSlide38

COP continued, Significant Events

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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): 5160-45-10For the official rule(s), refer to codes.ohio.gov/oacSlide39

COP continued, How to Contact Case Management Agency

39

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) 372-6176Slide40

COP continued, Terminating Services with an Individual

40

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, incarceratedNote: Discharge summary should be written on the last day of service and contain an overview of individual’s care requirements.Slide41

COP continued, Change of Information

41

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 emailNote: Providers should also notify their Case Management Agency.PCG Contact Information:

Phone: 877-908-1746 

Fax: 614-386-1344 

E-mail: 

ohiohcbs@pcgus.comSlide42

Incident Reporting

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Incident Management

43

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/oacNote: 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.comSlide44

Reportable Incidents

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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;

Slide45

Reportable Incidents continued

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(

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.Slide46

Incident Reporting

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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.Slide47

Provider Billing

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Restrictions on Service & Billing

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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 firstIf the primary insurance covers the entire service cost, provider may not bill MedicaidODM has 30 days to make a payment from the date of a clean submissionClaims 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.aspxSlide49

Billing Accuracy/ Remittance Advice

49Providers 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.Slide50

Base and Subsequent Units

50

Providers must bill pursuant to ba

se 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 SOhio Administrative Code(s): 5160-46-06 For the reimbursement rule(s), refer to codes.ohio.gov/oacSlide51

Example: Non-Agency/RN

51

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 2/27/13Total of 1 Shift not to exceed 8 hours (1+7=8) 8 Hours equals 32 unitsSlide52

Example: Agency/Private Duty Nursing

52

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 dateTotal 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 Slide53

Example: Non-Agency/PCA

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Billing Code: T1019(Personal Care Services); B=13, S=160

Authorized time period: 3/1/2013-3/31/2013

Daniel P. 

Cryer

, CSTO  2589631B= 13 Visits or ShiftsS= 160--15 minute increments or 40 additional hours (160/4=40)From 3/1/2013 thru 3/31/2013Total 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.Slide54

Billing for Agencies, Nurses, & PCA’s

54

Refer to the ODM training materials related to billing practices for:

Personal Care Aides

Non-Agency Nurses

AgenciesFor the specific billing materials, visit ohiohcbs.pcgus.comSlide55

ICD-10 Transition

55

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.Slide56

What ICD-10 codes should I use?

56

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)Slide57

ICD-10 Resources

57

PCG:

http://ohiohcbs.pcgus.com/

CMS:

www.cms.gov/ICD10ODM: http://www.medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx Slide58

QUESTIONS

58

Please email all waiver provider inquiries to:

ohiowaivers@pcgus.comSlide59

59

Public Consulting Group, Inc.

P.O. Box 151510

Columbus, Ohio

43215

(877) 908-1746, www.ohiohcbs@pcgus.com