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CPT and Medicaid Overview

The Medicaid Services System (MSS) including the Cost Projection Tool (CPT)

The Medicaid Services System (MSS) is a comprehensive system that integrates cost projection, prior authorization, daily rate calculation and payment authorization of IO and Level One waiver services. MSS was developed to be a “user friendly” system that would achieve efficiencies and ensure compliance in the waiver cost projection and authorization process. MSS houses the following DODD applications related to cost projection and authorization of IO and Level One Waiver Services:

Service Rates and Codes (SRC)

SRC in an application internal to DODD that contains the rates and services codes for every IO and Level One Waiver service. The Cost Projection Tool interfaces with SRC to obtain rates and service codes for the purpose of cost calculations.

Cost Projection Tool (CPT)

The Cost Projection Tool is a single, common application for cost projection to be used by all County Boards of DD and providers. It will replace all other cost projection tools in use today and provide a core DODD system to integrate other Department applications. CPT will improve data flow, integrity and streamline the payment authorization process.

Beginning January 1, 2011, County Boards of DD are required to use CPT to project costs for individuals with an IO or Level One waiver at initial enrollment and redetermination. All individuals must be transitioned to CPT by December 31, 2011. Paragraph I of OAC 5123:2-9-06 describes CPT implementation requirements in detail.

Prior Authorization (PA)

The Prior Authorization application is a new tool that has been developed to interface with CPT, although it will not be available until after the first release of CPT. The PA application will create an electronic PA request and budget using the costs generated in CPT. The request will be transmitted to the department through the PA application. Users will be able to view the status of prior authorization requests that they have submitted.

Daily Rate Application (DRA)

DRA is an application that apportions Homemaker/Personal Care (HPC) service costs of IO waiver enrollees living in shared settings to calculate the appropriate level of reimbursement associated with HPC Daily Billing Units (DBUs). The DRA has been rebuilt and enhanced to obtain site costs directly from an interface with CPT. As individuals who share services are transitioned to CPT, they will also transition to the “new” DRA and their “legacy” DRA site will be closed.

Services Payment Authorization (SPA)

SPA will ultimately become the area within MSS that replaces the current PAWS application. SPA directly interfaces with CPT and is the location where Counties recommend authorization for the costs of services projected in CPT. Projected costs must be authorized in SPA before they flow into the DRA. Provider payments through our MBS System cannot be processed without authorization through SPA. The vision of SPA will not be fully realized until PAWS is phased out, which is scheduled for December 31, 2011.

Payment Authorization for Waiver Services (PAWS)

PAWS is the system by which County Boards of Developmental Disabilities recommend authorization of reimbursement for services rendered to individuals enrolled on a waiver. Any claim submitted by a provider must be matched to an approved PAWS record in order for the claim to be paid. PAWS will exist as it does today upon the first release of CPT. However, by the end of 2011, a component of CPT called Services Payment Authorization (SPA) will allow County Boards of DD to authorize a completed cost projection and will send that authorization through PAWS to MBS for individuals who are in the DRA. At that point, counties will no longer submit PAWS plans for individuals who are in the DRA. Instead, authorization of services will be handled through the SPA. Eventually, SPA will handle authorization for all IO and Level One individuals.

The Medicaid Services System Flow Chart

Graphically displays the Medicaid Services System and all of its interfaces

• MSS Flow Chart

Previous CPT Communications:

• Business Transformation Memo 12/09
• CPT Roles and Security Memo 01/10
• CPT Update 03/10
• CPT Update 05/10

Other CPT Resources:

• CPT Training Schedule – Coming Soon
• CPT Help Desk Information – Coming Soon
  

Medicaid Presentation to the Arc June 11

What is Medicaid? [ + ]

Medicaid is a federal program allowing eligible Ohioans with low incomes to receive needed health services. Services available for payment by Medicaid are unique to each state and are approved under what is called a State Plan. Ohio’s State Plan covers services such as hospital stays, check-ups for children and for pregnant women, nursing services, medication coverage, and other services for people who are Medicaid eligible. Medicaid does not pay money to you; instead, it pays a provider that delivers healthcare services to you. Each month, you should receive a Medicaid card to show you are covered. To find out more about becoming a Medicaid recipient, please contact your local County Board of DODD or your local county Department of Job and Family Services.

A list of benefits from Ohio’s Medicaid program can also be found by visiting Job and Family Services Helping Ohioans.

For additional information regarding the overview of Medicaid services, visit Medicaid Program Overview.

Medicaid Eligibility [ + ]

Below are some links to the Ohio Department of Job and Family Services (ODJFS) website, detailing Medicaid eligibility and the services that are available in Ohio’s Medicaid program.

• Medicaid Eligibility

Overview of Waivers  

Currently, the Ohio Department of Developmental Disabilities administers two waivers: the Individual Options (IO) waiver and the Level I waiver (LI). To decide which waiver best fits your needs, and to review a comprehensive list of service options forms, eligibility requirements and other helpful tips and information, select from the following:

Level One Waiver [ + ]

• General Forms
• Enrollment Forms
• Provider Certification Forms

Prescreen Tool and Protocol:
The pre-screen tool will be used as a first step to determine how an individual can be appropriately supported once enrolled for Level I Waiver services.  The prescreening tool identifies if there are health and safety issues that must be addressed before enrollment into the Level I Waiver.  If the issues are not addressed in the Individual Service Plan, the individual cannot be enrolled on the Level I Waiver.

• Prescreening Tool - Frequently Asked Questions
• "W" is for Waiver
• Level I Waiver Handbook
• Level I Letter to County Boards

Individual Options Waiver [ + ]

• Application Forms
• IO Waiver Handbook

Please review the links below to find all waiver services offered in Ohio. Please note that some services are designed for individuals with developmental disabilities, while others are designed to serve older Ohioans and Ohioans with severe medical issues.

• List of all available Ohio waivers from Ohio Legal Rights Service
• Waiver brochure from Ohio Department of Job and Family Services

Additional Information regarding Medicaid Services [ + ]

• General Information about Ohio’s Medicaid Services:  http://jfs.ohio.gov/OHP/index.stm

• List of Benefits that can be received through the Ohio’s Medicaid State Plan (this is combined language for the link we have on that page twice): http://jfs.ohio.gov/ohp/consumers/benefits.stm

• Information about Money Follows the Person, known in Ohio as Helping Ohioans Move, Expanding Choice (or HOME Choice): http://jfs.ohio.gov/OHP/consumers/HOMEChoice.stm

• Information for Medicaid Managed Care:
[ + ]
• Medicaid Managed Care Weekly
• Letter to Interested Parties
  A Notification of Regional Rollout and Commencement of Mandatory Managed Care Plan Enrollment for Select Aged, Blind and Disabled (ABD) Medicaid Consumers
• Consumer's Guide to Choosing a Medicaid Managed Care Plan (MCP)
• Managed Care Regional Map
• Medicaid Managed Care Weekly
• Letter to Interested Parties
  A Notification of Regional Rollout and Commencement of Mandatory Managed Care Plan Enrollment for Select Aged, Blind and Disabled (ABD) Medicaid Consumers
• Consumer's Guide to Choosing a Medicaid Managed Care Plan (MCP)
• Managed Care Regional Map

• Services Available Under CORE

• Services Available Under CORE Plus

A free Adobe Acrobat Reader is required to view and print the .PDF forms on this page.

Questions or comments about content on this webpage?
Contact: Kelley Higginbotham / kelley.higginbotham@dodd.ohio.gov