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Rules and rates were adjusted recently, and the waiver day rate is back for services that support Day and Vocational Habilitation.  You may have read a recent post I did regarding the new rules that did away with the waiver daily rate.  DODD Rule Changes: Days Got to Units, and Hours Disappear.  Near the end of July, DODD reversed their decision to completely eliminate the daily rate.  I think this is an important decision as the state looks to transform the service delivery system and service delivery outcomes.  In my linked post above, I highlighted that the daily rate reduced the overall revenue a provider could earn, assuming the agency ran a program that lasted between 5-6 hours.  That reduction in revenue for an agency, while developing new programming and hiring new kinds of professionals, all in a system that made compliance more complicated,  was not helping move agencies toward embracing the new concepts.  So this is very good news for those agencies who want to see the system transform to a more community inclusive, outcome based system.  But there are a couple of items to make note of.

Community Inclusion

All the work the state did to incorporate a community add-on appears to be silenced as agencies celebrate the return of the daily rate.  The community add-on is a unit based add-on, so billing the daily rate removes that option.  Providers will need to do some number crunching to determine what makes the most sense for them.  Many programs I talk with run a 5.5 hour program, so not billing the waiver day rate reduces reimbursement by three units per person impacted.  You will want to make sure that your program and fiscal models tie out to make up the difference.

Medical and Behavioral Add On

Another limitation of the daily rate, it appears, is that a person with a medical or behavioral add on requires the agency to access unit billing, only, for the services provided.  Agencies will want to check, but it is more likely that the loss of the daily rate efficiency can be made up by the respected add on rates, though the medical add on is only twelve cents.  If you assume that the person receiving a medical add on might also be in a higher acuity, for instance a Group C”, that twelve cents, billed over 5.5 units will generate an additional $.66 cents, while the lack of a daily rate method will reduce an agencies revenue (CODB 6) by $14.94.  Of course if you have been following along at home this whole time, you already expected to be without those dollars, so you haven’t really lost anything more.  The good news of the waiver daily rate just did not address this particular shortfall of the new rate structure.

The Waiver Day Rate Can’t Interfere with CMS Reporting

Let’s remember why this is getting complicated and why certain limitations are being exposed.  Ohio is in the process of showing CMS that we are community focused and that more individuals with developmental disabilities are engaging with their communities and working jobs in the community.  Claims data is an easy way for Ohio to show progress and meet the expectations of our CMS POC (plan of correction).  In addition to the items outlined above, this also means that the VOC HAB Combo code is not coming back as an option.  Our programs will need to provide very distinct times when vocational services are offered and likewise for habilitation services.  If an individual is offered programming for a couple of hours in one area, and a few hours in the other, an agency will need to complete unit billing for each separate service.  The daily rate threshold (5-7 hours) would not have been met for either service, and so unit billing is necessary.

More to come as we head toward October.


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