For many employment and day programs in Ohio, the proposed DODD rule changes (October 2016), will have a financial impact on their business. Changes to rule 5123:2-9-19 prevent agencies from billing a daily rate for services when providing five to seven hours of supports during the day. Those daily rates were set using the quarter hour unit rate and applying it against 6.25 hours. Daily rates were required for use by an agency that provided between five and seven hours of service for that day, and many providers established programs that were five hours long. That meant for many programs, their expenses were based on a 5 hour day, and their revenues were based on a 6.25 hour day.
Doing The Math
Because of different acuity levels, quarter hour reimbursement rates depend on the person an agency is supporting. As an example we will use $1.80 as the average reimbursement rate for .25 hours of service across the many different individuals an agency serves through Day and Employment programs. If we look at a modest program of 30 individuals, paying for services and supports each day, we can quickly see the loss of revenue these new rules create.
1.80 (average quarter hour rate) * 5 (the difference in 15 minute units between 6.25 hours (daily rate) and the actual 5 hours of programming) * 30 (individuals) =
1.80*5*30 = $270 each day
Now we take that daily reduction out over an average of 200 days for a given year. The result is a $54,000 decrease in revenue.
Modifiers To The Rescue
The state, I believe, is attempting to repurpose those dollars by incorporating new services, as well as billing modifiers that will increase certain services based on health care needs (behavioral and physical) as well as to incentivize agencies to support smaller groups of individuals in community integrated settings.
Key DODD Rule Changes: Fiscal and Program Impact
- No more Daily Rates. Billing gets more complex as providers must itemize their services for a person between day and employment services.
- No more segregated settings for employment. Only locations where the individual interacts with persons without disabilities to the same extent as employees who are not receiving services (Not enclave, Not Mobile Work Crews).
- Vocational Habilitation is not required to be provided in the community, but the services are expected to occur over a defined period of time, with specific outcomes defined within the ISP, with the ultimate goal being community based employment.
- We need to find out quickly where to find “department administered program instruction”, or community modifiers don’t apply.
- Ratios no longer apply, in a rigid mathematical sense, but health and safety is your responsibility.
- OOD Certification is necessary to assure bridging systems can occur, and is intended.
- Have a consistent Person Centered Planning methodology for staff to implement and follow. Everything starts at the beginning.
With less than 6 months to go before new rules are expected to take effect, agencies need to do the heavy lifting associated with generating new fiscal and program models and determine how or if they move forward with implementation.