Waiver Reimbursement and Related IssuesLastest UpdatesPlease note: Items updated on February 15, 2008 (last version January 18, 2008) are in blue font
Daily Rates | On-Site/On Call | Transportation | Foster Care | Transition
Prior Authorization | Room & Board | Living Alone | Other Issues
TARGETED IMPROVEMENTS TO THE WAIVER REIMBURSEMENT SYSTEM:
ODMRDD Committees providing input on targeted improvements
* Daily Billing Unit
* Adult Day Services and Transportation
* ODDP
* Data Collection/Base Rates
CMS approval documentation for the Daily Billing Unit has been received.
DAILY BILLING UNIT:
Elimination of 15 minute ratio-based rates and the implementation of daily billing unit for H/PC Individual Options Waiver Homemaker/Personal Care (H/PC).
- Revised Individual Options waiver amendment submitted to CMS on August 17, 2007. Amendment included daily rate for H/PC in non-foster care settings with two or more individuals living together. Revised amendment to change "daily rate" to "daily billing unit". CMS has approved the Dailly Billing Unit.
- CMS granted a second six month extension of the deadline for the transition away from negotiated rates, to 06/30/2008. However, ODMRDD remains steadfastly committed to the March 31, 2008 deadline that is in the emergency filed rule. Here are the transition deadline for individuals in shared services settings that are in the emergency filed rule:
- All negotiated rates are gone by March 31, 2008 (this includes individuals sharing H/PC, setting and providers who have not yet transitioned to the 15 minute ratio system)·
- All individuals sharing H/PC, the setting and their provider transitioned by by December 20, 2008.
- ODMRDD is requiring all individuals not sharing services to transition by March 31,2008.
- ODMRDD is requiring all individuals in Adult Foster Care settings and whose H/PC is funded by a negotiated rate to transition by March 31, 2008.
- '06 rule revised to reflect 6 month extension of transition period
- The daily billing unit rule was emergency filed and effective on December 21, 2007. Notwithstands parts of '06 rule. ODMRDD original filed the same rule and it is expected to make it through the rule making process.
- Impact on transition, "pause' communicated by ODMRDD to the field.
- ODMRDD convened two of three stakeholders groups with limited participants.
- ISP and Prior Authorization
- Web Portal Testing is complete and web portal is in production.
- Utilization Review and PAWS stakeholders group has not been convened yet
- Web portal is available. ODMRDD is encouraging county boards to enter site-specific information into the web portal (Daily Rate Application, or "DRA") as soon as possible. As of the morning of February 12, 2008, 830 sites had been entered in the DRA by county boards. As of February 13th, 131 PAWS had been submitted to ODMRDD by county boards.
- Further modifications to the 20/20 were made available on February 8, 2008. Click Here for a copy of the most current version of the 20/20 formula.
- Individuals not funded through Medicaid will be included in 20/20.
- All individuals on the IO waiver will be entered into the DRA.
- Individuals who are not on the IO waiver AND whose services are reimbursed exactly the same as those on the daily billing unit (5123:2-9-06/2-13-07) will be entered in the DRA. Others will not be entered in the DRA.
- ODMRDD training for all stakeholders and OPRA regional trainings providers held through February 15, 2008. ODMRDD to continue with training for Regional Consultants.
- Daily billing unit proposal process flow for providers:
Step One
Estimate each individual's H/PC needs and cost
Units of service by ratio
Routine or On Site/On Call
Determine Medical Assistance Rate Modification applicability
Determine Behavioral Assistance Rate Modification applicability
CODB
Estimate cost for each individual in 20/20
Request prior authorization as indicated
Step Two
Determine average hourly rate for setting
Estimate staff hours necessary to meet all of the individuals' needs
Divide estimated cost for setting by the estimated hours for the setting to get average hourly rate.
Step Three
Deliver and document HPC services
Document staff units of HPC, including all time and individuals regardless of ratios
Document days of service for each individual
Document services according to waiver service documentation and daily billing unit rules
May decide to track ratios, OSOC/routine, add ons by individual and 15 minute units
Step Four
Submit weekly claims for services
Enter staff units of HPC into ODMRDD web portal
Enter days of service for each indiividual into ODMRDD web portal
Submit claim for each individual with proper daily rate for the week
Step Five
Utilization management
Monitor actual hours to authorized hours
Monitor actual reimbursement to authorized dollars
May monitor ratios, OSOC/routine and add ons to planned
Request ISP revisions as indicated.
*Outstanding issues include:
- Four primary areas of concern
- ODMRDD's On Site/On Call Interpretation Implementation
- Timely and Accurate ISP and PAWS Revisions
- Prior Authorization
- Maximum daily billing unit amount of $403.98 and impact on turnaround time for provider claims
- Expedited appeal process for ISP disputes – OPRA continues to express concern over lack of an expedited process for ISP disputes
- Timeliness of ISP and PAWS revisions
- Prior authorization process - ODMRDD has revised the prior authorization process to speed up their response to prior authorization requests.
- Impact of unplanned weekly absences on roommates – cost of roommate's services unlikely to be impacted, unless individual is absent for 7 – 12 days or more. Depends on whether 7 absences occur in one 7 day billing cycle.
- Lack of XML upload to ODMRDD web portal for providers – to be completed a month or so after implementation of daily billing unit. XML upload available but not tested yet.
- Claims correction process, will have more than one opportunity to submit a claim and will have ability to correct claims
- Opt-out option for providers – (F)(3) of the draft daily billing unit rule enables the Director of ODMRDD to allow a provider to continue on the 15 minute unit ratio system in the event of a unique and/or extenuating circumstance.
- Validation of cost projection tools – being completed by ODMRDD and ODJFS. See 20/20 Updates below for status of validation.
- Transition to daily rate for individuals living with settings that are already transitioned to 15 minute unit system – to be completed by December 20, 2008
- UCR issues with dynamic daily rate – (H)(2) of the draft daily billing unit rule requires the 15 minute unit rate be used for UCR purposes
- Utilization reports to be discussed with stakeholder group
- Web portal developed by ODMRDD IT and tested by ODJFS, providers, billing agents and county boards. All providers were able to test web portal with old data. The web portal is now available. To access web portal, submit security affidavit for access to "DRAUser". As of December 11, 2007 68 security affidavits had been processed by ODMRDD for DRA access. As of February 12th, 830 sites had been entered in the DRA.
- Cost calculation tool, 20/20 version control remains an issue.
- Elimination of ratios for transportation services
ON SITE/ON CALL:
How to document and bill for staff time at night.
ODDevelopmental Disabilities announced on February 8, 2007 that it is working on clarification of on site/on call issue.
- Staff cannot be awake and asleep at the same time, and if one person is receiving routine H/PC then OSOC would not apply to that person. Departments are working on apportionment methodology. Stakeholders group convened and discussed possible OSOC solutions.
- ODMRDD announced a solution for the daily billing unit apportionment and for the 15 minute ratio system. The provider will be paid the same in both environments, if the service has not been billed and paid for.
- In the 15 minute unit ratio system, providers will only bill for routine H/PC according to the interpretation of routine H/PC provided by ODMRDD in their memo. To review ODMRDD's memo, please go to www.opra.org under MRDD Issues and then Waiver Reimbursement.
- In the daily billing unit environment, the routine rate will be apportioned among all individuals assessed as needing routine and not being appropriate for OSOC and those that have been assessed as appropriate for OSOC. In other words, providers will not be compensated for providing OSOC services, rather will only be paid the routine H/PC rate at the ratio of individuals assessed as needing routine and not being appropriate for OSOC.
- An example of the OSOC apportionment methodology is in the department's memorandum that can be found at www.opra.org in the MRDD Issues - Waiver Reimbursement section. There are examples in (D)(3) of the draft daily billing unit rule 5123:2-13-07.
- Request remains at ODMRDD from OPRA Board of Trustees to revise OSOC rates commensurate with cost associated with increase in minimum wage.
TRANSPORTATION
Adapted and non-adapted transportation in the waiver environment.
- ODDevelopmental Disabilities agreed to revisit rate methodology for non-day hab/supported employment transportation during the late fall 2006/early winter 2007. To date, this review has occurred only for adult day services and has not occurred for other transportation.
- ODDevelopmental Disabilities director Martin has expressed concern about the availability of adapted transportation.
- Ratios persist in non-day habilitation transportation services
- ODMRDD clarified that either nonmedical transportation or transportation and H/PC may be used to transport individuals receiving adult day services. Providers cautioned to fully consider adult day services budget and funding range issues before finalizing plans that include adult day services-related transportation.
FOSTER CARE:
Separate service requirements and reimbursement mechanism for foster care services.
- Foster care rule effective date of October 1st.
- Site specific service definition …
- Prohibition on doing H/PC in your own home, only foster care.
- Daily rate.
- Notwithstands parts of '06 rule.
- Relatives and legal guardians excluded from foster care, not H/PC.
- Other services not included in foster care definition, would need to fit under the individual's range or be prior authorized.
- ODJFS received notification on July 20, 2007 that the Individual Options waiver amendment was approved by CMS.
- Issues of concern to OPRA
- Agency provider rates were reduced 4 - 14% from the rule previously filed by the department.
- Would in effect prohibit individual providers from billing any adult foster care whenever they had another provider doing respite. For example, if an individual adult foster care provider went to the movies for 3 hours and another provider provided H/PC during that time, the individual adult foster care provider would be prohibited from billing for any adult foster care services provided that entire day or the H/PC provider would be prohibited from billing for their services.
- ODJFS and ODMRDD decided on a group size adjuster of 85% for two people, 75% for three people and 65% for four people. OPRA has expressed to ODMRDD, its significant concern about this adjustment amount.
- The rates ignore the medical and behavioral rate modifications.
- If an individual receiving H/PC in a manner that meets the definition of adult foster care and will be negatively impacted by the new rule, please send a summary of your situation to: Tracy Williams with ODMRDD at Tracy.Williams@dmr.state.oh.us. ODMRDD is tracking the impact of this rule.
TRANSITION:
The transition from the current reimbursement system to the new waiver reimbursement system.
- ODMRDD communicated to the field regarding transition:
- Requesting that individuals not sharing services be transitioned by December 31, 2007. As of January 31, 2008 this included 250 individuals.
- The daily billing unit rule was emergency filed and effective December 21, 2007.
- Transition to the 15 minute unit/ratio system in congregate settings will not occur as the daily billing unit rule is effective. These individuals will be transitioned directly to the daily billing unit
- As of January 31, 2008 the number of individuals in congregate settings yet to be transitioned from the negotiated rate system was 2,609.
- As of January 31, 2008 the total number of individuals yet to be transitioned from the negotiated rate system was 2,859.
- "Pause" of transition recommended by ODMRDD while negotiating with CMS on "targeted improvements" to the waiver reimbursement system to be lifted, as daily billing unit rule is now effective.
- ODMRDD plans to transition individuals who have not been transitioned to the 15 minute/ratio system and those who live with these individuals to the daily billing unit system by March 31, 2008. In settings where all of the individuals living together have already transitioned to the 15 minute/ratio system, these individuals will be transitioned to the daily billing unit system by December 20, 2008.
- Deadline for complete transition extended by CMS to June 30, 2008, however, ODMRDD rule requires transition by March 31, 2008. ODMRDD remains committed to finishing the transition from negotiated rates by March 31st. The transition deadlines were revised in the emergency filed rule.
- Estimated impact is $2 million savings to $21 million cost; utilization rate is a big factor. Governor, House and Senate include $6.5M per year for projected cost overruns associated with the transition in ODMRDD budget.
- Many people monitoring Ohio's progress with transition including CMS, ODJFS, Governor's office and OBM.
PRIOR AUTHORIZATION:
The process used when services are projected to cost over the individual's funding range.
- The state is not meeting the timelines in the prior authorization rule for processing prior authorizations.
- Revised rule "to be refilled;" currently on hold.
- County boards submit requests instead of individual.
- Funding level is authorized rather than funding range.
- ODMRDD has revised the prior authorization process to speed up their response to prior authorization requests.
- An interactive training tool for prior authorization developed by ODMRDD was released by ODMRDD.
ROOM AND BOARD:
Defining and paying for non-waiver services.
- On February 6, 2008 the ODMRDD filed the
final new Room and Board rule for Licensed Non-ICF/MR settings. It is
set to be effective July 1, 2008.
Click Here for Room & Board Licensure Rule (PDF)
- On January 4, 2008, ODMRDD "Refiled" the room and board rule for nonICF/MR licensed settings. For additional information, contact Mark Davis at mdavis@opra.org.
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Chart of accounts approach
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Assignment of responsibility for payment and other tasks associated with room and board
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Recommending increase from $50 to $75 retained by individual monthly
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Assessment of resources available to each individual to be done by county board
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Annual review of room and board cost and payment by licensed siteo
- Outstanding issues:
- Elimination or mitigation of licensure citations due to lack of funding not included in proposed rule
LIVING ALONE:
Changes to the ODJFS Authorization Rule for the Individual Options Waiver.
- Rule was effective January 1, 2007.
- Waiver services are consistent with efficiency, economy and quality of care.
- When reasonable, waiver services are not provided entirely at a 1:1 ratio.
- When combined with other non-waiver services, waiver services must ensure the health and welfare.
- One hour of face-to-face requirement.
OTHER ISSUES RELATED TO WAIVER REIMBURSEMENT:
Waiver Reimbusement Update - 12/21/2007
-- Daily Billing Unit Rule - Emergency Rule
-- Appendix A
-- Waiver Reimbursement Rule – Emergency (revised for Daily Billing Unit)
20/20 updates
96 units
- Limited to 96 units per day.
- Two providers providing services at the same time to an individual getting 24/7 services.
- ODJFS reports nothing in federal regulations to prohibit changing to more than 96 units being acceptable.
- Awaiting confirmation from CMS in writing.
- Remains a requirement in the reimbursement rule for now.
Direct support wages impact
- OPRA has expressed significant concern to ODDevelopmental Disabilities regarding the negative impact of the new rates on direct support wages
- Director Martin supports adequate wages for direct support professionals
Range 2 and 3 insufficiency and Environmental modifications
- Creative consultation
- ODDP inaccuracies
- Prior authorizations
Billing and payment issues
- OPRA is tracking issues associated with billing and payment for waiver services. Please let mdavis@opra.org know of any significant delays or issues you are experiencing with billing or payment for waiver services
- The strategy of ODMRDD, county boards and providers had been to generally transition the "easiest" settings first.
The "Members Only" section at www.opra.org contains many tools that may be used by members in their implementation of the new waiver reimbursement system. For access to these tools, OPRA members will need their user name and password. Registration for members is available at the Members Only Log In/Register page.
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