On October 6, U.S. Supreme Court Chief Justice John Roberts denied an application that would have stayed implementation of the U.S. Department of Labor's Home Care Final Rule. The rule applies minimum wage and overtime protections to domestic service workers.
Additionally, on December 9, the Ohio General Assembly clarified in law that an Independent Provider who provides services to an individual on Medicaid is not a public employee.
Below is information about how DODD will make overtime payments to eligible independent providers who bill for more than 40 hours or160 fifteen-minute units in a work week for dates of service beginning January 1, 2016.
1. How is "work week" defined?
A work week begins Sunday at 12:00 a.m. and ends Saturday at 11:59 p.m.
2. What hours or units of service are to be included when determining whether an independent provider exceeded 40 hours or 160 fifteen-minute units of service in a work week?
Time spent delivering services as an independent provider under waiver programs administered by the Ohio Department of Medicaid, the Ohio Department of Aging, and DODD, as well as time spent delivering Private Duty Nursing as an independent provider should be included.
Independent providers are responsible for identifying the time at which 40 hours or 160 fifteen-minute units of service were exceeded and submitting overtime claims for the appropriate services.
- A provider works Monday – Friday 3:00 p.m.–9:00 p.m. (30 hours) delivering Homemaker/Personal Care services to a person enrolled in the Individual Options Waiver.
- The provider works the following Saturday from 7:00 a.m. – 7:00 p.m. (12 hours) delivering Personal Care Aide services to a person enrolled in the Ohio Home Care Waiver.
- The provider submits claims for 30 hours of regular Homemaker/Personal Care for the person enrolled in the Individual Options Waiver (APC), 10 hours of regular Personal Care Aid for the person enrolled in the Ohio Home Care Waiver (T1019), and 2 hours of overtime for the person enrolled in the Ohio Home Care Waiver (T1019 with the TU modifier.)
3. What should independent providers do if working more than 40 hours (160 fifteen-minute units) in a work week?
- Maintain a schedule of hours worked each week, in addition to regular waiver documentation that is currently maintained. Include the types of services provided and the names of individuals served.
- Submit claims, as usual, for the first 40 hours or 160 fifteen-minute units worked.
- For all units of service provided after the first 40 hours, use the appropriate overtime procedure code. Procedure codes for waivers administered by DODD are listed below.
4. Do independent providers have to submit claims differently to be paid overtime?
Yes, for the Individual Options, Level One, and SELF Waivers, independent providers will need to use new procedure codes for overtime claims. When providing services under the Transitions DD Waiver, independent providers will need to use a new modifier in conjunction with their regular procedure codes.
- For Homemaker/Personal Care:
APV when providing services under the Individual Options Waiver
FPV when providing routine services under the Level One Waiver
EPV when providing emergency services under the Level One Waiver
- For On-site/On-call:
AOV when providing services under the Individual Options Waiver
FOV when providing routine services under the Level One Waiver
EOV when providing emergency services under the Level One Waiver
- For Community Inclusion under the SELF Waiver –
- For Personal Care Aide or Waiver Nursing under the Transitions DD Waiver –
TU modifier must be added to the T1019, T1002, or T1003 procedure codes
5. How will independent providers know what overtime code to use?
Independent providers must use the code that relates to whatever service was being delivered at the time they exceed 40 hours (160 fifteen-minute units) in a work week.
- A provider works with an individual enrolled in the Individual Options Waiver. He delivers 40 hours of Homemaker/Personal Care, then works an 8-hour on-site/on-call shift in a work week. The provider will use the regular Homemaker/Personal Care code (APC) for the first 40 hours, then use the AOV code for the On-site/On-call hours.
- A provider delivers 42 hours of Personal Care Aide services in a work week to an individual enrolled in the Transitions DD Waiver. The provider will use the regular T1019 procedure code for the first 40 hours. For the remaining 8 units of service, the provider will add the "TU" modifier to the claim.
6. How are overtime rates calculated?
Waiver rates are made up of several components including a wage component, employee-related expenses (payroll taxes, Workers' Compensation, health care, retirement, and paid time off), productivity (time that is worked but not billed; includes ISP meetings, staff meetings, travel time, etc.), and administration/training. Overtime rates will be calculated based on the wage component of the rate.
7. What amount of reimbursement will independent providers receive for overtime claims?
As with all waiver services, providers are reimbursed at either their usual and customary rate for the service, which is entered in the rate field at the time claims are submitted by the provider, or the Medicaid maximum reimbursement rate established for the service in the Ohio Administrative Code (OAC), whichever is lower.
The following are the Medicaid maximum reimbursement rates for overtime claims.
Homemaker/Personal Care (APV, FPV, EPV)
Regular Rate effective 1/1/16||
Overtime rate effective 1/1/16|
On-Site/On-Call (AOV, FOV, EOV)
Regular Rate effective 1/1/18||
Overtime Rate effective 1/1/18|
Community Inclusion – Personal Assistance (SPV)
Maximum negotiated hourly rate|
Personal Care Aide (with TU modifier)
15-Minute unit Rate|
Waiver Nursing – LPN (with TU modifier)
15-Minute unit Rate|
Waiver Nursing – RN (with TU modifier)
15-Minute unit Rate|
8. How do independent providers submit claims for overtime when serving someone who is eligible for a rate modification, such as the medical add-on, behavior add-on, or community-integration add-on?
All add-ons are applied to the rate after calculating the overtime rate.
Example (Cost of doing business category 1)
- HPC overtime reimbursement rate = $22.16/hour ($5.54 for each 15-minute unit)
- Behavior add-on = $2.52/hour ($.63 for each 15-minute unit)
- Total reimbursement = $22.16 + $2.52 = $24.68/hour ($5.54 + $.63 = $6.17 for each 15-minute unit)
9. How do independent providers who serve multiple people during a single visit submit overtime claims?
Independent providers who serve individuals enrolled in the Individual Options Waiver will no longer be able to submit daily billing units calculated through the daily rate application (DRA). All independent providers serving people in group settings under the Individual Options and Level One Waivers will be required to bill 15-minute units of service and indicate the appropriate group size.
Independent providers who serve individuals enrolled in the Transitions DD Waiver must continue to use the "HQ" modifier when delivering services to groups of 2 – 3 people.
When delivering more than 160 fifteen-minute units of service, independent providers must submit the appropriate overtime code or modifier, along with either the group size or group modifier, in order to be reimbursed at the overtime rate.
10.What if an independent provider forgets to submit the overtime code/modifier and only submits the regular code?
The provider will be reimbursed at the regular, non-overtime rate. However, the provider may adjust the claim in order to receive the appropriate overtime payment. All adjustments to claims must be submitted in accordance with the timeframes specified in sections 5123:2-9-06 and 5160-1-19 of the Ohio Administrative Code.
11.What if an independent provider accidentally submits an overtime code/modifier when the provider did not deliver more than 40 hours or 160 fifteen-minute units of service in a work week?
The provider must adjust the claim to back-out the overtime claim and resubmit the regular, non-overtime procedure code.
12. Are overtime payments authorized by the county board?
The Service and Support Administrator (SSA) works with the team to identify a typical schedule during which services are required for an individual. Based upon this information, a certain number of units/hours of service are authorized in the Individual Service Plan (ISP). The number of units/hours cannot be exceeded without an adjustment in the ISP.
- A person receives 60 hours of Homemaker/Personal Care each week. Typically, one provider works 40 hours/week and another works 20 hours/week. One provider is unable to work in a particular week due to a family emergency. As a result, the remaining provider delivers 40 hours of regular Homemaker/Personal Care (APC) and 20 hours of overtime Homemaker/Personal Care (APV) that week. The total number of hours does not exceed the authorization in the ISP, although the costs will be higher.
- A person is authorized to receive 40 hours of Personal Care Aide each week. A provider submits claims for the routine Personal Care Aide services and also submits an additional 4 units with the TU modifier. The additional 4 units will be rejected, as they exceed the number of units authorized for the week. The provider may also face sanctions for submitting claims for services not authorized in the ISP.
13.How will overtime claims be monitored?
DODD will run reports periodically to track overtime payments made to individual providers, as well as to monitor the financial impact of overtime claims. Providers who failed to submit claims for overtime when working more than 40 hours or providing more than 160 fifteen-minute units of service in a work week will be reminded of their ability to adjust the claim. Those who submit claims for overtime when more than 40 hours or 160 fifteen-minute units of service were not delivered may be subject to audits and/or investigation.
14.Will services have to be reduced when overtime claims are paid so that an individual stays within the funding range of the Ohio Developmental Disabilities Profile (ODDP) or the Level One or SELF Waiver caps?
No, services will not be reduced as a result of overtime payments. At this time, overtime payments WILL NOT count against individuals' ODDP ranges or waiver caps.
DODD recognizes that overtime will sometimes be necessary, such as in emergency situations or when no other provider is willing to serve a person. In the future, however, overtime hours worked by a provider on behalf of a single individual will count against that individual's ODDP range or waiver cap. As a result, individuals/families should begin talking with their Service and Support Administrators to explore ways to begin reducing the number of routine overtime hours to avoid a future reduction in services. Strategies to reduce routine overtime may include recruiting additional providers or exploring the use of technology, such as emergency response systems or remote monitoring.
If you have questions, please contact the DODD Support Center at 800-617-6733.