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Overtime: Independent Providers

DODD makes overtime payments to eligible independent providers who bill for more than 40 hours or 160 15-minute units in a workweek.

A workweek begins Sunday at 12 AM and ends Saturday at 11:59 PM.

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 are included when determining whether an independent provider exceeded 40 hours or 160 fifteen-minute units of service in a work week

Independent providers are responsible for identifying the time at which 40 hours or 160 15-minute units of service were exceeded and submitting overtime claims for the appropriate services.

For example

  • During weekdays, an independent provider delivers 30 hours of Homemaker/Personal Care or HPC services to a person enrolled in the Individual Options Waiver. 
  • On Saturdays, the same provider works for 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.

When working more than 40 hours or 160 15-minute units within a workweek, independent providers should

  • Maintain a schedule of hours worked each week, in addition to regular waiver documentation maintained; include the types of services provided and the names of each person served.
  • Submit claims, as usual, for the first 40 hours or 160 15-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.

Overtime rates prior to January 1, 2020, are available here.

Submitting Claims with Overtime

Independent providers will submit claims differently to be paid overtime for the Individual Options, Level One, and SELF Waivers. Independent providers will need to use the following procedure codes for overtime claims.  

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 – SPV

For Personal Care Aide or Waiver Nursing, the TU modifier must be added to the T1019, T1002, or T1003 procedure codes.

Independent providers must use the code that relates to the service delivered at the time they exceed 40 hours or 160 fifteen-minute units in a workweek.

If a provider forgets to use the overtime code or modifier and submits a claim with 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 time frames specified in sections 5123-9-06 and 5160-1-19 of the Ohio Administrative Code.

All independent providers serving people in group settings under the Individual Options and Level One Waivers will be required to indicate the appropriate group size.

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.

Calculating Overtime Rates

Waiver rates are made up of several components including

  • a wage component,
  • employee-related expenses, such as such as payroll taxes, Workers' Compensation, health care, retirement, and paid time off,
  • productivity, meaning time that is worked but not billed, which includes ISP meetings, staff meetings, travel time, etc.,
  • and administration and training. 

Overtime rates are calculated based on the wage component of the rate.

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, whichever is lower.

Applying Add-ons

All add-ons are applied to the rate after calculating the overtime rate.

For example, Cost of doing business category 1

  • HPC overtime reimbursement rate = $27.39/hour ($6.84 for each 15-minute unit)
  • Behavior add-on = $2.52/hour ($.63 for each 15-minute unit)
  • Total reimbursement = $27.39 + $2.52 = $29.91/hour ($6.84 + $.63 = $7.47 for each 15-minute unit)

Authorizing and Monitoring Overtime Claims

Each service and support administrator working for a county board of developmental disabilities works with the person accessing services and their team to identify a typical schedule during which supportive services are needed.

Based upon this information, a certain number of units or hours of service are authorized in the person's Individual Service Plan or ISP. The number of units or hours cannot be exceeded without an adjustment in the ISP. 

For example
  • A person receives 60 hours of Homemaker/Personal Care services each week. Typically, one provider works 40 hours each week and another works 20 hours. A provider is unable to work in a particular week leaving the remaining provider to deliver 40 hours of regular Homemaker/Personal Care and in the same week another 20 hours of overtime Homemaker/Personal Care. 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.

DODD will run reports periodically to track overtime payments made to individual providers, as well as to monitor the financial impact of overtime claims. 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.

Services will not be reduced as a result of overtime payments.  At this time, overtime payments will not count against a person's range or waiver caps.

DODD recognizes that overtime will sometimes be necessary, such as in emergencies 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 remote support.