home health agency medicaid cost report fundamentals september 9, 2008
TRANSCRIPT
Home Health Agency
Medicaid Cost Report Fundamentals
September 9, 2008
Agenda
• Intermittent Services– Overview of services– Basis of payment– Revenue codes– Medicare Limits– Medicaid Limits– Services under Exception to Policy
• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)– Overview of services– Basis of payment
Agenda
• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) cont…– Procedure codes– Time Study
• Break Time (5-10 minutes)• Medicaid Cost Report
– Purpose– Filing requirements– Worksheet overview– EPSDT/Exception to Policy time study
• Retrospective Cost Settlement
Agenda
• Interim Rate Process– Established agencies
– Changes in provider billing rates
– New agencies
• Break Time (5-10 minutes)
• Interim Medical Monitoring and Treatment (IMMT)– Overview
– Basis of payment
– Procedure codes
– Establishing rates
Agenda
• Billing Issues
• Questions
Overview
• Home health services provide medically necessary home care supports to Iowa Medicaid members.
• There are two categories of home health services:1) Intermittent (regular) services
2) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services Private duty nursing and personal care Also called “Care For Kids”
Intermittent Services
Overview of Services
• “Intermittent service” means services for a patient who has a medically predictable recurring need that does not exceed two to three visits per week for two to three hours at a time.
• The number of hours of intermittent services shall be reasonable and appropriate to meet an established medical need of the patient that cannot be met by a family member, significant other, friend, or neighbor.
• Intermittent services are covered only when provided in the patient’s residence.
Overview of Services
• Intermittent services include the following:– Skilled nursing
– Home health aide
– Physical therapy
– Occupational therapy
– Speech therapy
– Medical social services
– Medical supplies
• These home care services are available for Medicaid eligible persons regardless of age.
Overview of Services
• Unlike the Medicare program, patients need not first require “skilled” care before they are entitled to home health aide services.
• For example, if a patient requires only home health aide services, the patient is entitled to these services under the Medicaid program without respect to the need for skilled services.
Basis of Payment
• Interim payment shall be made on an encounter (per visit) basis.
• An “encounter” is defined as separately identifiable hours which home health agency staff provides continuous service to a patient.
• Payment of home health agency intermittent services is based on the service provided rather than the classification of the home health agency employee providing the service.
Basis of Payment
• Interim encounter (per visit) payment based on revenue code is subject to reasonable cost on a retrospective basis.
• Retrospective cost-settlement is made at the lower of:– Average cost per visit
– Medicare limit per visit
– Medicaid limit per visit
• Tentative cost settlement is performed based on the submitted Medicare and Medicaid cost report
• Final cost settlement is performed based on the finalized Medicare cost report.
Revenue Codes
Code Service550 Skilled Nursing
420 Physical Therapy
430 Occupational Therapy
440 Speech Therapy
570 Home Health Aide
560 Medical Social Services
270 Medical Supplies
Medicare Limits
• The base Medicare limits were established during federal fiscal year 2000.
• Base limits may be subjected to an increase equal to the Medicare home health market basket increase on a yearly basis.
• Limits are based on the providers fiscal year and Metropolitan Statistical Area (MSA).
Medicaid Limits
• The current Medicaid limits were based on 97% of the reimbursable costs during state fiscal year (SFY) 2001.
• Since the base limits were established, they have received the following increases based on legislative approval:
Effective Date % Increase
July 1, 2005 3%
July 1, 2006 3%
July 1, 2008 1%
Services Under Exception to Policy
• When billing services provided under an exception to policy, follow the instructions in the decision letter.
• A current plan of care and a copy of the exception to policy decision letter must accompany each claim.
• The claim must include:– Correct primary diagnosis
– Revenue or procedure code
– Number of hours each service provided
– Reimbursement rate identified in the decision letter for each service provided.
Services Under Exception to Policy
• When the need for services exceeds the intermittent guidelines, a request for an exception to policy may be submitted in writing, by fax (515-281-4597) or by mailing to:
Appeals Section
Department of Human Services
1305 E. Walnut, 5th Floor
Des Moines, IA 50319-0114
• Also may be submitted via internet at www.dhs.state.ia.us
Exception to Policy Revenue Codes
Code Service552 Skilled Nursing, Hourly Charge, HHA
572 Home Health Aide, Hourly Charge, HHA
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
Overview of Services
• Private-duty nursing and personal care services for children with special needs are covered for Medicaid members aged 21 or younger.
• These services must be prior authorized and are only available if the child’s medical needs exceed skilled nursing and/or home health aide maximums covered through the intermittent home health services.
• Home health agency care for maternity patients and children is a service also included in the EPSDT program.– Members receiving this service would require home care services
due to high-risk factors.
Overview of Services
• These services are intended to:– Promote alternatives to prolonged hospitalizations or
institutionalizations by providing for medially necessary and effective home care.
– Provide ongoing nursing support to a technology-dependent child or a child with multiple medical needs related to an acute or chronic medical condition in the home environment.
Overview of Services
• The objectives of the services are:– To provide direct patient care, supervision of family caregivers,
and teaching of the necessary skills of care for a medically compromised child at home
– To promote quality care and a safe home environment for the patient
– To provide for comprehensive and coordinated care in a cost-effective manner
– To reduce the number of hours funded and provided by the program to the minimum level necessary to meet the medical needs of the child safely while ensuring that quality care is maintained in the child’s home environment.
Overview of Services
• Payment for private-duty nursing or personal care services for patients aged 21 and under will be approved if determined to be medically necessary.
• Medical necessity means:– The service is reasonably calculated to prevent, diagnose, correct,
cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and
– No other equally effective course of treatment is available and suitable for the patient requesting a service.
Overview of Services
• Home health services are directed to support the extra burdens on the parents due to the child’s medical needs.
• They are not available to meet a family’s normal needs for child care and supervision, such as while a parent works.
Overview of Services
• “Personal care services” are services provided by a home health aide which are delegated and supervised by a registered nurse under the direction of the child’s physician.
• Services may be provided to a child in the child’s place of residence or outside the child’s residence when normal life activities take the patient outside the place of residence.
• Some of the care must be provided in the child’s home.
Overview of Services
• “Private-duty nursing services” are services provided to a child by a registered nurse or a licensed practical nurse under the direction of the child’s physician.
• Services may be provided to a child in the child’s place of residence or outside the child’s residence when normal life activities take the patient outside the place of residence.
• Some of the care must be provided in the child’s home.
Basis of Payment
• Interim Payment to a home health agency for private-duty nursing or personal care services is on an hourly fee-for-service basis.
• Only the level of care approved on the prior authorization can be billed.
• Enhanced payment under the interim fee schedule will be made available for services to children who are technology-dependent (ventilator dependent or with a medical condition so unstable as to otherwise require intensive care in a hospital).
Basis of Payment
• Interim payment based on procedure code is subject to reasonable cost on a retrospective basis.
• Retrospective cost-settlement is made at the lower of:– Average cost per visit
– Medicaid limit per visit
• Tentative cost settlement is performed based on the submitted Medicare and Medicaid cost report
• Final cost settlement is performed based on the finalized Medicare cost report.
Procedure Codes
Code Modifier Description
S9122 Home health aide or certified nurse assistant providing care in the home; per hour
S9123 Nursing care in the home by registered nurse; per hour
S9123 TG Hi-Tech nursing care in the home by registered nurse; per hour
S9124 Nursing care in the home by licensed practical nurse; per hour
S9124 TG Hi-Tech nursing care in the home by licensed practical nurse; per hour
90471 Drugs–Administration of Immunization
Time Study
• The purpose of the time study is to convert the average cost per visit to an hourly unit.
• Encounter rate is limited to the lower of:– Actual cost per hour
– Medicaid limit per hour
• Time study must be completed by home health agency in order to calculate retrospective cost settlement.
Break Time (5-10 minutes)
Medicaid Cost Report
Purpose
• The Medicaid cost report provides for the determination of allowable and reasonable costs which are reimbursable under Title XIX, of the Social Security Act.
• Allows for determination of a retrospective cost settlement of payments received from Medicaid to reasonable Medicaid costs.
Reasonable Cost
• Reasonable cost principles are set forth in the following:– Federal Register – 42 CFR Part 413
– Medicare Provider Reimbursement Manual (CMS Pub. §15-I)
– Office of Management and Budget (OMB) Circular A-87, Attachment B
• Reasonable costs include all necessary and proper costs incurred in furnishing services subject to specific items of revenue and cost.
• Cost must be related to the care of Medicaid members.
Filing Requirements
• Home health agencies are required to submit their Medicare and Medicaid cost report 150 days after the end of the fiscal period.
• Home health agencies that provide EPSDT services are required to complete the EPSDT time study.
Worksheets
• Worksheet C provides for the computation of the average home health agency cost per visit to derive total allowable cost attributable to Medicaid patient care visits.
• Total allowable cost is the lower of the following:– Average cost per visit
– Medicare limit per visit
– Medicaid limit per visit
APPORTIONMENT OF PATIENT SERVICE COSTS WKST C
HOME HEALTH AGENCY
PROVIDER: PROVIDER NO.:
CITY: FYE:
MEDICARE COST LIMITATIONSFROM AVERAGE MEDICAID MEDICARE
WKST B, TOTAL COST PROGRAM PROGRAMCOL. 6, COST TOTAL PER COST COST
PATIENT SERVICES LINE: AMOUNTS VISITS VISIT LIMITS LIMITS
1. Skilled Nursing 6 $ $ $ $ 2. Physical Therapy 7 $ $ $ $ 3. Occupational Therapy 8 $ $ $ $ 4. Speech Therapy 9 $ $ $ $ 5. Medical Social Services 10 $ $ $ $ 6. Home Health Aide Services 11 $ $ $ $ 7. TOTAL (sum lines 1-6) ********* $ ********* ********* **********
COST PER VISIT COMPUTATIONAVERAGE
COST T-XIX COSTPER PROGRAM OF
PATIENT SERVICES VISIT VISITS SERVICES
8. Skilled Nursing $ $ 9. Physical Therapy $ $ 10. Occupational Therapy $ $ 11. Speech Therapy $ $ 12. Medical Social Services $ $ 13. Home Health Aide Services $ $ 14. TOTAL (sum lines 8-13) ********* $
MEDICAID LIMITMEDICAID PROGRAM T-XIX COST
COST PROGRAM OFPATIENT SERVICES LIMITS VISITS SERVICES
15. Skilled Nursing $ $ 16. Physical Therapy $ $ 17. Occupational Therapy $ $ 18. Speech Therapy $ $ 19. Medical Social Services $ $ 20. Home Health Aide Services $ $ 21. TOTAL (sum line 15-20) ********* $
MEDICARE LIMITATION COST COMPUTATIONMEDICARE T-XIX COST
COST PROGRAM OFPATIENT SERVICES LIMITS VISITS SERVICES
22. Skilled Nursing $ $ 23. Physical Therapy $ $ 24. Occupational Therapy $ $ 25. Speech Therapy $ $ 26. Medical Social Services $ $ 27. Home Health Aide Services $ $ 28. TOTAL (sum line 15-20) ********* $
T-XIX COSTTOTAL TOTAL COVERED OF
OTHER PATIENT SERVICES COST CHARGES RATIO CHARGES SERVICES
29. Cost of Medical Supplies $ $ % $ $ 30. Cost of Drugs $ $ % $ $
31. COST OF ANCILLARY SERVICES (lesser of lines 14, 21 or 28 plus lines 29 and 30) $
Worksheet C
• W/S C, Lines 1-6:– For all patients, enter from the Medicare cost report for each
patient service:• total cost (Medicare cost report, W/S B, Col. 6)
• total visits (Medicare cost report, W/S S-3, Pt. I, Col. 5)
– Calculate average cost per visit
– Enter the Medicaid program cost limit per visit in effect for the cost report period for each patient service
• If cost report period is not on the state fiscal year of June 30th, there may be two limits in effect during the cost report period.
– Enter the Medicare program cost limit per visit for the cost report period for each patient service
Worksheet C
• W/S C, Lines 8-13:– Enter the current period average cost per visit from W/S C, lines
1-6, for each patient service
– Enter the number of Medicaid program visits for each patient service
– Calculate the total average cost per visit for each patient service
Worksheet C
• W/S C, Lines 15-20:– Enter the current period Medicaid program cost limit per visit
from W/S C, lines 1-6, for each patient service
– Enter the number of Medicaid program visits for each patient service
– Calculate the total Medicaid program limit cost per visit for each patient service
Worksheet C
• W/S C, Lines 22-27:– Enter the current period Medicare program cost limit per visit
from W/S C, lines 1-6, for each patient service
– Enter the number of Medicaid program visits for each patient service
– Calculate the total Medicare program limit cost per visit for each patient service
Worksheet C
• W/S C, Line 29:– Add the lower of lines 14, 21, or 28 to the total of lines 29 and 30
to calculate reasonable and allowable cost of intermittent home health services.
DETERMINATION OF MEDICAID REIMBURSEMENTWKST
D
HOME HEALTH AGENCY
PROVIDER: 0 NPI NUMBER: 0000000000
CITY: 0 FYE: 01/00/00
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST
OR CUSTOMARY CHARGES
1. COST OF ANCILLARY SERVICES (Worksheet C, line 29) $ -
2. PLUS: MEDICAL SUPPLIES ALLOWED CHARGES $ -
3. PLUS: IMMUNIZATION ADMINISTRATION ALLOWED CHARGES $ -
4. TOTAL TITLE XIX COST $ -
5. TOTAL CHARGES FOR TITLE XIX SERVICES $ -
6. EXCESS OF TOTAL CUSTOMARY CHARGES OVER TOTAL
REASONABLE COST (only if line 5 exceeds line 4) $ -
7. EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES
(only if line 4 exceeds line 5) $ -
PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT
8. TITLE XIX COST (line 4) $ -
9. EXCESS REASONABLE COST (line 7) $ -
10. PLUS: COST OF EXCEPTION TO POLICY / EPSDT $ -
11. SUBTOTAL $ -
12. LESS: THIRD PARTY PAYMENTS $ -
13. TOTAL REIMBURSABLE COST $ -
14. LESS: TOTAL INTERIM PAYMENTS $ -
15. BALANCE DUE HHA/MEDICAID PROGRAM
(Indicate overpayments in brackets) $ -
Worksheet D, Pt. 1
• W/S D, Pt. I, Line 1:– Transfer amount from, W/S C, line 31
• W/S D, Pt. I, Line 2:– Enter Medical Supplies allowed charges
• W/S D, Pt. 1, Line 3:– Enter Immunization Administration allowed charges
• W/S D, Pt. I, Line 4:– Sum of lines 1, 2 and 3
Worksheet D
• W/S D, Pt. I, Line 5:– Total covered charges for intermittent services
– Do not include EPSDT covered charges
• W/S D, Pt. I, Line 6:– If W/S D, Pt. I, line 4 exceeds W/S D, Pt. I, line 3 report the
difference
• W/S D, Pt. I, Line 7:– If W/S D, Pt. I, line 3 exceeds W/S D, Pt. I, line 4 report the
difference
Worksheet D
• W/S D, Pt. II, Line 8:– Transfer amount from W/S, D, Pt. I, Line 3
• W/S D, Pt. II, Line 9:– Transfer amount from W/S, D, Pt. I, Line 6 if cost exceeds charges
– Make sure to enter as a negative amount
• W/S D, Pt. II, Line 10:– Enter amount of allowable EPSDT/Exception to Policy costs from
the calculation at the bottom of W/S D
• W/S, D, Pt. II, Line 11:– Sum of W/S D, Pt. II line 8, less line 9, plus line10
Worksheet D
• W/S D, Pt. II, Line 12:– Enter amount of third party reimbursement applied to Title XIX
(Medicaid) claims for dates of service during the cost report period.
• W/S D, Pt. II, Line 13:– W/S D, Pt. II, Line 10 less Line 11
• W/S D, Pt. II, Line 14:– Enter amount of Title XIX (Medicaid) reimbursement received for
dates of service during the cost report period.
Worksheet D
• W/S D, Pt. II, Line 15:– W/S D, Pt. II, Line 12 less Line 13
– Negative amount indicates that an overpayment occurred during the cost report period and amount is due to the State.
– Positive amount indicates that an underpayment occurred during the cost report period and amount is due to the agency.
Worksheet D
• EPSDT Calculation:– Enter the amount of hours from W/S E, Pt. II for each patient
service
– Enter the cost per hour from W/S E, Pt. II for each patient service
– Multiply the amount of hours by the cost per hour to calculate total cost per patient service for EPSDT
• Exception to Policy Calculation:– Enter the amount of hours from W/S F, Pt. II for each patient
service
– Enter the cost per hour from W/S F, Pt. II for each patient service
– Multiply the amount of hours by the cost per hour to calculate total cost per patient service for exception to policy
HOME HEALTH AGENCY
EPSDT
PROVIDER: 0 NPI NUMBER: 0000000000
CITY: 0 FYE: 01/00/00
Recipient Begin Date End Date Date Type of
Recipient's Name ID # of Service of Service Paid Service Hours Charges
Worksheet E
• EPSDT Cases– For patients that have received EPSDT under prior authorization,
the following information must be reported for each claim submitted with dates of service during the cost report period:
• Recipient’s name• Recipient ID number• Begin and end date of service• Claim payment date• Type of service rendered, such as RN, Hi-Tech RN, LPN, Hi-Tech LPN, and
Aide• Number of hours of care provided, regardless of the number of visits for each
service• Total charges for the hours of care provided for each type of service
PROVIDER: PROVIDER NO.:
CITY: FYE:
TYPE OF TOTAL HOURS TOTAL CHARGESAVERAGE CHARGE TOTAL COST AVERAGE COST
SERVICE PER SERVICE PER SERVICE PER SERVICE PER SERVICE PER SERVICE
RN $ $ $ $
Hi-Tech RN $ $ $ $
LPN $ $ $ $
Hi-Tech LPN $ $ $ $
Aide $ $ $ $
TOTAL $ $
Do not enter more than 97% of the amount per visit from the most recent cost reporting period ending on or before June 30, 2000.
Instructions For EPSDT/Exception To Policy And Request For Additional InformationFor Medicaid Home Health Agency Cost Reports With Fiscal Periods Ending After June 30, 2000
Worksheet E Part 2 Instructions:
#2 Total the amount of charges for each service type for all Title XIX patients relative to non-intermittent care listed on worksheet E.
#5 Divide column 4 (Total Cost Per Service) by column 1 (Total Hours Per Service) and enter the result in column 5 (Average Cost Per Service).
Request For Additional Information:
services are included.
#2 If all costs related to providing non-intermittent care are located in a cost center such as Private Duty Nursing, please provide an analysis of these
costs and specify which costs are applicable to rendering services to all EPSDT/Exception to Policy patients.
HOME HEALTH AGENCYTOTAL CHARGES AND COST FOR EPSDT / EXCEPTION TO POLICY CASES
Worksheet E Instructions:
TOTAL CHARGES AND COST PER SERVICE FOR EPSDT / EXCEPTION TO POLICY CASES:
#1 For each claim submitted under an EPSDT/Exception to Policy, list recipient's name, ID number, beginning and ending date of service, and
claim payment date.
#2 Indicate the type of service rendered under the exception to policy, such as RN, Hi-Tech RN, LPN, Hi-Tech LPN, and Aide.
#3 Include with each entry the number of hours of care provided, regardless of the number of visits for each type of service.
#3 Divide column 2 (Total Charge Per Service) by column 1 (Total Hours Per Service) and enter the result in column 3 (Average Charge Per Service).
#4 Enter the total cost (direct and certain indirect as indicated) associated with each service type for all Title XIX patients relative to non-intermittent
care. Indirect costs allowed for this purpose include: health insurance expenses; liability insurance; and non-billable supplies.
#6 Enter the Total Title XIX EPSDT/Exception To Policy Cost for all services (Column 4-Total) amount on line 9 of Worksheet D.
#4 Include with each entry the total charges for the hours of care provided for each type of service.
#5 For each recipient classified as EPSDT/Exception to Policy, please attach a copy of the DHS letter reflecting approval of your request for exception.
#1 Total the number of hours for each service type for all Title XIX patients relative to non-intermittent care listed on worksheet E.
determine an average cost per hour for these services, we request you provide us the following additional information:
#1 Please indicate the cost center or department in your Medicare/Medicaid Cost Report where all costs related to providing non-intermittent care
Home health claims for services rendered under EPSDT/Exception to Policy are settled on the basis of an average cost per hour rather than cost per
visit. For recipients age 21 and over, there is a monthly cap per recipient of $2,374. There is no cost cap for recipients under the age of 21. In order to
Worksheet E, Part 2
• For EPSDT cases, report the following information for each type of service rendered:– Col. 1 - Total the number of hours for each service type for all
Title XIX patients relative to non-intermittent care listed on Worksheet E
– Col. 2 - total the amount of charges for each service type for all Title XIX patients relative to non-intermittent care listed on Worksheet E
– Col. 3 - Divide column 2 (Total Charge Per Service) by column 1 (Total Hours Per Service), enter results (Average Charge Per Service)
Worksheet E, Part 2
• For EPSDT cases, report the following information for each type of service rendered:– Col. 4 - Enter the total cost (direct and certain indirect as
indicated) associated with each service type for all Title XIX patients relative to non-intermittent care
• Indirect costs allowed for this purpose include: health insurance expense, liability insurance; and non-billable supplies
– Col. 5 – Divide column 4 (Total Cost Per Service) by column 1 (Total Hours Per Service) and enter the results (Average Cost Per Service)
Worksheet E, Part 2
• Transfer the total Title XIX EPSDT cost for all services (column 4-total) on Worksheet D, line 10
• Additional information requested:– Indicate the cost center or department in your Medicare/Medicaid
cost report where all costs related to providing non-intermittent care services are included.
– If all costs related to providing non-intermittent care are located in a cost center such as Private Duty nursing, provide an analysis of these costs and specify which costs are applicable to all EPSDT patients.
HOME HEALTH AGENCY
EXCEPTION TO POLICY CASES
PROVIDER: 0 NPI NUMBER: 0000000000
CITY: 0 FYE: 01/00/00
Recipient Begin Date End Date Date Type of
Recipient's Name ID # of Service of Service Paid Service Hours Charges
Worksheet F
• Exception to Policy Cases– For patients that have received Exception to Policy services, the
following information must be reported for each claim submitted with dates of service during the cost report period:
• Recipient’s name• Recipient ID number• Begin and end date of service• Claim payment date• Type of service rendered, such as RN, Hi-Tech RN, LPN, Hi-Tech LPN, and
Aide• Number of hours of care provided, regardless of the number of visits for each
service• Total charges for the hours of care provided for each type of service
Worksheet F
• For each recipient classified as Exception to Policy, attach a copy of the letter reflecting approval of your request for exception.
HOME HEALTH AGENCY
TOTAL CHARGES AND COST FOR EXCEPTION TO POLICY CASES
PROVIDER: 0 NPI NUMBER: 0000000000
CITY: 0 FYE: 01/00/00
TOTAL CHARGES AND COST PER SERVICE FOR EXCEPTION TO POLICY CASES:
TYPE OF TOTAL HOURS TOTAL CHARGES AVERAGE CHARGE TOTAL COST AVERAGE COST
SERVICE PER SERVICE PER SERVICE PER SERVICE PER SERVICE PER SERVICE
RN - $ - $ - $ - $ -
Hi-Tech RN - $ - $ - $ - $ -
LPN - $ - $ - $ - $ -
Hi-Tech LPN - $ - $ - $ - $ -
Aide - $ - $ - $ - $ -
TOTAL - $ - $ -
Instructions For Exception To Policy And Request For Additional Information
For Medicaid Home Health Agency Cost Reports With Fiscal Periods Ending After June 30, 2000
Worksheet F Instructions:
#1 For each claim submitted under an Exception to Policy, list recipient's name, ID number, beginning and ending date of service, and
claim payment date.
#2 Indicate the type of service rendered under the exception to policy, such as RN, Hi-Tech RN, LPN, Hi-Tech LPN, and Aide.
#3 Include with each entry the number of hours of care provided, regardless of the number of visits for each type of service.
#4 Include with each entry the total charges for the hours of care provided for each type of service.
#5 For each Exception to Policy recipient, please attach a copy of the DHS letter reflecting approval of your request for exception.
Worksheet F Part 2 Instructions:
#1 Total the number of hours for each service type for all Exception to Policy Title XIX patients relative to non-intermittent care listed on worksheet F.
#2 Total the amount of charges for each service type for all Exception to Policy Title XIX patients relative to non-intermittent care listed on worksheet F.
#3 Divide column 2 (Total Charge Per Service) by column 1 (Total Hours Per Service) and enter the result in column 3 (Average Charge Per Service).
#4 Enter the total cost (direct and certain indirect as indicated) associated with each service type for all Title XIX patients relative to non-intermittent
care. Indirect costs allowed for this purpose include: health insurance expenses; liability insurance; and non-billable supplies.
#5 Divide column 4 (Total Cost Per Service) by column 1 (Total Hours Per Service) and enter the result in column 5 (Average Cost Per Service).
#6 Enter the Total Exception to Policy Title XIX Cost for all services (Column 4-Total) amount on line 9 of Worksheet D.
Not to exceed the Medicaid Limit set by converting the current Medicaid Per Visit to a per hour limit using the submitted time study.
Request For Additional Information:
Home health claims for services rendered under Exception to Policy are settled on the basis of an average cost per hour rather than cost per
visit. For recipients age 21 and over, there is a monthly cap per recipient of $2,374. There is no cost cap for recipients under the age of 21.
In order to determine an average cost per hour for these services, we request you provide us the following additional information:
#1 Please indicate the cost center or department in your Medicare/Medicaid Cost Report where all costs related to providing non-intermittent
care services are included.
#2 If all costs related to providing non-intermittent care are located in a cost center such as Private Duty Nursing, please provide an analysis of these
costs and specify which costs are applicable to rendering services to all Exception to Policy patients.
#3 Please complete a Time Study using intermittent services along with the documentation used to support hours and visits used.
Worksheet F, Part 2
• For Exception to Policy cases, report the following information for each type of service rendered:– Col. 1 - Total the number of hours for each service type for all
Title XIX patients relative to non-intermittent care listed on Worksheet E
– Col. 2 - total the amount of charges for each service type for all Title XIX patients relative to non-intermittent care listed on Worksheet E
– Col. 3 - Divide column 2 (Total Charge Per Service) by column 1 (Total Hours Per Service), enter results (Average Charge Per Service)
Worksheet F, Part 2
• For Exception to Policy cases, report the following information for each type of service rendered:– Col. 4 - Enter the total cost (direct and certain indirect as
indicated) associated with each service type for all Title XIX patients relative to non-intermittent care
• Indirect costs allowed for this purpose include: health insurance expense, liability insurance; and non-billable supplies
– Col. 5 – Divide column 4 (Total Cost Per Service) by column 1 (Total Hours Per Service) and enter the results (Average Cost Per Service)
Worksheet F, Part 2
• Transfer the total Title XIX Exception to Policy cost for all services (column 4-total) on Worksheet D, line 10
• Additional information requested:– Indicate the cost center or department in your Medicare/Medicaid
cost report where all costs related to providing non-intermittent care services are included.
Provider Name:Provider Number:
Skilled Nursing Services:Time Study Basis (weeks/months/year)Time Study Period to
1. Total Number of Hours per Time Study2. Total Number of Visits per Time Study3. Average Length of Stay (Hours/Visit)
Home Aide Services:Time Study Basis (weeks/months/year)Time Study Period to
1. Total Number of Hours per Time Study2. Total Number of Visits per Time Study3. Average Length of Stay (Hours/Visit)
NO TE: Please attach time study or other supporting documentation used to determine your basis
EPSDT/Exception to Policy Time Study
• If an agency had provided EPSDT/Exception to Policy services during the cost report period, the Iowa Medicaid Enterprise will send out a time study worksheet that must be completed by the providers in order to complete the cost settlement calculation.
• Time study is only required during the tentative settlement process.
EPSDT/Exception to Policy Time Study
• For skilled nursing and home aide services, the following must be completed on the time study worksheet:– Time study basis – was the information gathered on a weekly,
monthly, or yearly basis. • If weekly or monthly please indicate how many weeks or months
– Time study period
– Total number of hours per time study
– Total number of visits per time study
– Calculate the average length of stay (hours divided by visits)
• Attach supporting documentation used in completing the time study
Retrospective Cost Settlement
Purpose
• A retrospective cost settlement is typically designed to permit a reconciliation between estimated and actual cost.
• Estimated cost is defined as interim payments made during the cost report period.
• Actual cost is defined as the reasonable and allowable cost reported on the cost report.
Purpose
• A retrospective review of the interim payments made to a home health agency during the cost report period.
• These payments are compared to the actual home health agency costs (based on the Medicaid cost report) for providing services to Medicaid members.
Process
• After review of the Medicaid cost report, the Iowa Medicaid Enterprise the amount of overpayment (amount due state) or underpayment (amount due agency) for services provided to Medicaid members
• Total payments include the following:– Medicaid interim payments
– Third party payments
Process
• Amount Due Agency - “Underpayment”– Pays the home health agency the difference between Medicaid
reasonable cost and total payments if actual Medicaid costs are determined to exceed the total payments made during the cost report period.
• Amount Due Program - “Overpayment”– The Iowa Medicaid Enterprise recoups from the home health
agency the difference between Medicaid reasonable cost and total payments if actual Medicaid costs are determined to be less than total payments.
Interim Rate Process
Established Agencies
• Based on review of the submitted Medicaid cost report, the interim cost to charge ratio will be updated to reflect the most current data.
• The effective date of the new interim rate will be the first day of the next month upon completion of the tentative settlement.– Example – Tentative settlement is completed on 09/15/08, the
effective date of the new interim rate would be 10/01/08
Changes in Provider Billing Rates
• The Iowa Medicaid Enterprise receives a letter from the agency related to changes in the billing rates for home health services.
• The Iowa Medicaid Enterprise will recalculate a new interim cost-to-charge ratio based on the new billing rates.
• A letter will be sent to the provider giving them the option to change the interim rates based on the new billing rates.– If the provider provider does not elect to change their interim rate,
they will remain at the rate that was set during the tentative settlement.
– The purpose is to estimate interim payment as close to actual cost as possible.
New Agency Interim Rates
• The Iowa Medicaid Enterprise Provider Cost Audit and Rate Setting unit is notified a new agency has been enrolled in the Medicaid program.
• Provider Cost Audit and Rate Setting will send the new agency a welcome letter, which explains the following:– Cost report filing requirements– Initial interim rate will be established at a cost-to-charge ratio of
80%
• If the agency determines that the initial interim rate should be different they should contact the Provider Cost Audit and Rate Setting unit
Break Time (5-10 minutes)
Interim Medical Monitoring and Treatment (IMMT) and Respite Services
Overview
• Waiver services that can be provided by a home health agency in a consumer’s home.
• Interim medical monitoring and treatment (IMMT) is monitoring and treatment of a medical nature requiring specially trained caregivers beyond what is normally available in a day care setting for persons age 20 and under.
• IMMT services shall provide experiences for each consumer’s social, emotional, intellectual, and physical development.
Overview
• IMMT services include comprehensive development care and any special services for a consumer with special needs; and will include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis.
Overview
• Respite care services are provided to the consumer that gives temporary relief to the usual caregiver and provides all the necessary care that the usual caregiver would provide during the time period.
• The purpose of respite care is to enable the consumer to remain in their current living situation
• Two types of respite care:– Specialized respite
– Basic individual respite
Overview
• Specialized respite is provided on a staff to consumer ratio of 1:1 or higher for individuals with specialized needs requiring monitoring or supervision provided by a licensed registered nurse or licensed practical nurse.
• Basic individual respite is provided on a staff to consumer ration of 1:1 or higher for individuals without specialized medical needs that would require care by a licensed registered nurse or licensed practical nurse
Basis of Payment
• Upon provider request, rates are calculated for specialized respite, basic respite, and IMMT services based on the cost per visit used to complete the most recent cost settlement calculation.
• The most recent time study is also used– If the time study is older than 12 months, a new time study must
be completed for rate setting
• Cost per visit used is the lower of:– Average cost per visit– Medicare limit per visit– Medicaid limit per visit
Procedure Codes
Code DescriptionW2500 Specialized Respite When Provided By Licensed Nurse
W2501 Basic Individual Respite When Provided By A HHA
W2513 IMMT When Provided By A HHA
W2514 IMMT When Provided By A Nurse
W2518 IMMT When Provided By A HHA
W2519 IMMT When Provided By A Nurse
Establishing Rates
• The Iowa Medicaid Enterprise will review the most recent settled cost report and determine the cost per visit and time study to use to calculate rates.
• If the time study is older than 12 months, the Iowa Medicaid Enterprise will request a new time study be completed.
• Providers will be notified of the rates that have been established for IMMT and respite services.
Billing Issues
Issue #1 - Units
• Issue– There have been some scanning errors on paper claims for Home
Health agencies resulting in adjustments made during the cost settlement process for units.
• Action– Agencies should check the weekly remits to make sure the units
paid agree to the paper claim submitted.
Issue #2 – EPSDT Services
• Issue– For EPSDT services, agencies will only bill the revenue code on
the claim form.
• Action– Agencies must bill the procedure code, in addition to the revenue
code for EPSDT services.
Issue #3 – Submitted Charges
• Issue– Agencies have been reporting total charges based on increments of
time and subsequently reporting 1 unit as the visit.
• Action– Agencies should report the per visit charge related to the 1 unit of
service.• Example – Agencies reports charges in 15 minute increments on the
claim with a unit of 1. For a 90 minute visit, the charges reported is equal to (6 * the 15 minute charge).
• However, agencies should have a per visit charge, which does not account for specific increments of time. The per visit charge amount is what should be reported on the claim for 1 unit of service.
Issue #4 – Exception To Policy
• Issue– Agencies have been billing home health intermittent
services as Exception to Policy units.
• Action– Agencies should only bill revenue code 552 and/or 572
when one of the following criteria met:• Receive and Exception to Policy letter from Iowa DHS
granting services be provided on a hourly basis.• Prior authorization for EPSDT has been approved, revenue
code 552 and/or 572 should be billed with the appropriate HCPCS code.
Provider Cost Audit and Rate Setting Unit
Iowa Medicaid Enterprise
P.O. Box 36450
Des Moines, IA 50315
515-725-1108 (Local)
866-863-8610 (Toll-Free)
E-Mail: [email protected]
QUESTIONS?