The Ohio Department of Developmental Disabilities (DODD) has been engaged with stakeholders to consider potential ways to maintain needed Adult Day Support (ADS) and Vocational Habilitation (VH) services for people with disabilities as the system moves toward a gradual return to services delivered in adult day centers. While the future is unclear, it seems almost certain the state of Ohio will need to reimagine how day, employment, and vocational services are provided.

The expanded ADS and VH service delivery options made available through DODD’s request to the Centers for Medicare and Medicaid Services (CMS) to allow for service definitions to be modified throughout the declared state of emergency (Appendix K) create the opportunity for non-center-based ADS and VH services to be reimbursed during this time of transition -- not only back to center-based services but also forward to possible new ADS and VH service options that are delivered in much smaller, more integrated community-based settings. While the state is not able to create new services at this time, the stakeholders support the expanded service delivery options that are currently available and have agreed to use them as a model that represents a Start Toward Emerging Possibilities (STEP).

It is important that the return to services delivered in adult day centers be carefully planned with a focus on meeting the needs of each person  with disabilities while continuing to keep them healthy and safe. For many people, receiving services outside of their home poses significant risks. As an alternative to services in day service centers, the STEP model uses the three modes of service delivery described in Appendix K and only allows for services to be delivered in small groups of no more than four people at the same time:

1. In person in a person's home
2. In person in integrated settings (not a person's home or day service site)
3. Teleservice: using technology to directly interact with the person

The STEP model focuses on direct service delivery time but allows for limited amounts of service delivery on behalf of a person to ensure the person has all needed equipment and supplies to participate in services outside of the day service center.

This service option would certainly not be needed or even appropriate for every person but could prove to be a useful option for many throughout this state of emergency and as the disabilities services system transitions into whatever the new normal might look like. It is envisioned that it is especially suited to people who live alone or who live with family. It provides the opportunity for brief periods of respite for primary caregivers while allowing the person to continue to make progress toward outcomes identified in the Individual Service Plan (ISP) while remaining safely at home. The person-centered planning team would determine how to best meet the needs of the person.

STEP service delivery may include activities, such as

• discussing healthy practices and ways to stay safe.
• instruction and practical application of using personal protective equipment (PPE), such as masks and gloves, and appropriate handwashing techniques.
• explaining the meaning of social distancing and practicing its use as situations permit.
• preparing people for community participation and possible return to day service centers.
• instruction about use of technology including various applications and platforms to teach, enhance or maintain skills.
• recreational activities or exercise to keep people active while primarily at home.
• job/vocational skills training in developing areas or to maintain skills while out of work.
• instruction about using technology, such as video conferencing, to connecting with friends and family.
• identifying and exploring online education opportunities in areas of interest or Individual Service Plan (ISP) outcomes.
• any other activities in accordance with ADS and VH service definitions and as outlined in a person’s ISP.

Reimbursement

The current rate model for ADS and VH services relies on the Acuity Assessment Instrument (AAI) staffing ratio that is required to meet the needs of the person in a large congregate setting. As the STEP model is designed specifically to support people either with one-on-one services or in groups of no more than four people, reimbursement will be at the current rates for Acuity Group C, which is the rate for the ratio of one staff to three people. Rates are adjusted based on Cost of Doing Business categories. As there is a limit to the number of people in a group, froup Size will be a required field on all claims.  The Group Size will not affect the reimbursement rate.

For ease of tracking and claim submission, specific billing codes have been created within MBS to represent STEP services, which will be billed in 15-minute units. A second set of billing codes has been created to represent claims that qualify for the Community Integration Add-On. The billing codes can be found at the chart at the bottom of this page.

Additionally, the use of the STEP billing codes eliminates the need for the county board to request an Administrative Budget Override for each person who utilizes the STEP model. DODD’s billing system will recognize that these billing codes are to be paid at the rates established for Acuity Group C.

It is anticipated that many centers will only open partially at first, and some people will not be ready to receive services in a congregate setting right away. The provider will resume standard billing (codes and rates) for services delivered in the day service center and will continue to utilize the STEP model billing (codes and rates) for services that fit within the model. 

If a person meets the established criteria, the provider may bill for the Medical Add-On and/or Behavioral Add-On as appropriate. The provider may also bill for the Community Integration Add-On if the services meet the requirements established for this rate modification. Specifically, the services are delivered in integrated settings (not in a person's home or in a day service center) in a group of four or fewer people by staff who have completed the required training in community integration.

As a rule, routine Homemaker/Personal Care (HPC), Shared Living and ADS are not permitted to be billed concurrently. Any potential for overlaps between HPC or Shared Living services and this modified adult day service option will need to be carefully considered on a case-by-case basis and only authorized when supported by a documented need.

Providers who are interested in delivering services following the STEP model should contact the local county board to discuss which people might have a need for and benefit from ADS and/or VH services delivered in this fashion. Once authorized, the STEP model may be utilized for services delivered on or after May 11, 2020.

DODD’s Medicaid Billing System will be able to accommodate claims with the STEP billing codes immediately. The Medicaid Services System (MSS), the Cost Projection Tool (CPT), and the Payment Authorization for Waiver Services (PAWS) system, however, will not be able to be utilized to authorize these services for approximately four to six weeks.  Therefore, these services will need to be authorized outside of those systems during this time period. 

Additional information will be shared when those systems have been updated.

The chart below includes the STEP billing codes and PAWS Roll-up codes.