Ohio Home and Community-Based
Service Waivers
Ohio Home Care Waiver
Provider Education and Technical Assistance
www.pcghealth.com
Training Overview
Priorities for Ohio Home Care Waiver:
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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
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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
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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
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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.
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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
provider_enrollment@age.ohio.gov
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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).
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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
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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/WebcheckCommunityListing
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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:
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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
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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): 5160-46-04
 For the official rule(s), refer to codes.ohio.gov/oac
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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
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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 selfadministration 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?
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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
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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 Information
The clinical record must
contain the individual’s
identifying information:
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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)
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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:
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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
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Clinical records must be kept in a secure location.
Keep all records for 6 years.
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COP continued, Boundaries
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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
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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
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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
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Individual is behaving inappropriately toward the provider
Individual is consistently non-compliant with physician orders, or is noncompliant 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: ohiohcbs@pcgus.com
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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
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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 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
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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
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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
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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:
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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?
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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
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PCG: http://ohiohcbs.pcgus.com/
CMS: www.cms.gov/ICD10
ODM: http://www.medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx
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QUESTIONS
Please email all waiver provider inquiries to:
ohiowaivers@pcgus.com
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Public Consulting Group, Inc.
P.O. Box 151510 Columbus, Ohio 43215
(877) 908-1746, www.ohiohcbs@pcgus.com
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