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Guidance: Reimbursement for Center-Based Services

The Ohio Department of Developmental Disabilities (DODD) continues to consider ways to maintain needed Adult Day Support (ADS) and Vocational Habilitation (VH) services for Ohioans with developmental disabilities as the state moves toward a gradual return to services delivered in adult day centers. It is essential that the return to services provided in adult day centers be carefully planned with a focus on meeting the needs of each person while continuing to keep them healthy and safe. 

An order issued on March 24, 2020, by Governor Mike DeWine, limited the ability of Adult Day Programs to operate normally. The order defines that the number of people together must be 10 or less, including staff and people served, which places a limit on staffing ratios that is more restrictive than what exists outside of the order. As a result, DODD will adjust the payment for services to reflect the required smaller group sizes. This will enable people receiving services to gradually return at the smaller group sizes safely. 

This modification to payment rates will be evaluated every 30 days. DODD will issue communication when the modification to payment rates will be terminated and the date on which providers will resume standard billing (codes and rates).  

Reimbursement

The current rate model for ADS and VH services relies on the AAI staffing ratio that is required to meet needs in a congregate setting. The governor’s order is designed to support individuals in a group of no more than 10 people, including staff. Reimbursement will be at the current rates for Acuity Group C, which represents services in smaller ratios. Rates are adjusted based on Cost of Doing Business categories. As there is a limit to the number of individuals in a group, while group size is not required to be reflected in a person’s Individual Service Plan, group size will be a required field on all claims but will not impact the reimbursement rate.

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, and staff has received the required training.

DODD’s Medicaid Billing System will be able to accommodate claims with the adjusted billing codes immediately for services rendered on or after June 1, 2020. The Medicaid Services System (MSS), the Cost Projection Tool (CPT), and the Payment Authorization for Waiver Services (PAWS) system, however, will not authorize these services for approximately four weeks. Therefore, these services will need to be authorized outside of those systems during this time. Additional information will be shared when those systems have been updated.

The chart on the following page includes the specific billing codes that have been created to adjust for this rate and the corresponding PAWS Roll-up Codes.

Waiver

Service Title

DODD Billing Code

PAWS Roll-up Code

IO

Adult Day Support - Daily Unit

ADX

A25

IO

Vocational Habilitation - Daily Unit

AVX

A25

 

 

 

 

LV1

Adult Day Support - Daily Unit

FDX

F25

LV1

Vocational Habilitation - Daily Unit

FVX

F25

 

 

 

 

SELF

Adult Day Support - Daily Unit

SDX

S25

SELF

Vocational Habilitation - Daily Unit

SVX

S25

 

 

 

 

IO

Adult Day Support - 15-minute unit

ADY

A25

IO

Vocational Habilitation - 15-minute unit

AVY

A25

 

 

 

 

LV1

Adult Day Support - 15-minute unit

FDY

F25

LV1

Vocational Habilitation - 15-minute unit

FVY

F25

 

 

 

 

SELF

Adult Day Support - 15-minute unit

SDY

S25

SELF

Vocational Habilitation - 15-minute unit

SVY

S25

 

 

 

 

IO

Adult Day Support - CI Add-on

ADZ

A25

IO

Vocational Habilitation - CI Add-on

AVZ

A25

 

 

 

 

LV1

Adult Day Support - CI Add-on

FDZ

F25

LV1

Vocational Habilitation - CI Add-on

FVZ

F25

 

 

 

 

SELF

Adult Day Support - CI Add-on

SDZ

S25

SELF

Vocational Habilitation - CI Add-on

SVZ

S25