Chapter 5101:3-31 Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program

(A) The purpose of this rule is to define the terms used in the preadmission screening system providing options and resources today (PASSPORT).

As used in this chapter:

(B) “ADL” means activities of daily living including bathing; grooming; toileting; dressing; eating; and mobility which refers to bed mobility, transfer, and locomotion as defined in rules 5101:3-3-06 and 5101:3-3-08 of the Administrative Code.

(C) “ADS” means adult day service.

(D) “Assessment” means a face-to-face evaluation and interview that is conducted to collect in-depth information about an individual’s current situation and ability to function. It is comprehensive and identifies the individual’s strengths, problems, and care needs in the major functional areas: physical health, medical care utilization, activities of daily living, instrumental activities of daily living, mental and social functioning, financial resources, physical environment, and utilization of services and support.

(E) “Authorized representative” means a person, eighteen years of age or older, acting on behalf of an individual who is applying for or receiving medical assistance. An authorized representative may be a family member, attorney, hospital social worker, or any other person chosen to act on the individual’s behalf. In accordance with rule 5101:1-38-01.2 of the Administrative Code, the individual must provide a written statement naming the authorized representative and the duties that the named authorized representative may perform on the individual’s behalf.

(F) “Care plan” means a written plan between the consumer and caregivers, as applicable, and the case manager that specifies the consumer’s strengths and needs and the interventions that will be used to achieve the desired outcomes.

(G) “CDJFS” means a county department of job and family services.

(H) “Certification” means providers are certified by the Ohio department of aging (ODA) to provide services for PASSPORT as established in rule 173-39-02 of the Administrative Code.

(I) “Consumer” means an individual who has been accepted for enrollment and is receiving PASSPORT services. Consumer includes the consumer’s legal representative and/or authorized representative, as applicable.

(J) “HCBS” or “home and community-based services” means services furnished under the provisions set forth in 42 CFR 441 Subpart G (October 1, 2005) that permit individuals to live in a home setting rather than a nursing facility (NF) or hospital. HCBS waiver services are approved by the centers for medicare and medicaid services (CMS) for specific populations and are not otherwise available under the medicaid state plan.

(K) “CMS” means the centers for medicare and medicaid services (CMS), a federal agency which that is part of the U.S. department of health and human services, and administers the medicaid program and approves home and community-based services waivers.

(L) “IADL” means an instrumental activity of daily living as defined in rule 5101:3-3-08 of the Administrative Code and includes shopping; meal preparation; laundry; community access activities including telephoning, transportation, legal or financial; and environmental activities including house cleaning, heavy chores, yard work or maintenance.

(M) “Individual” means a medicaid recipient or person with pending medicaid eligibility who is making application to a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR); or is applying for home and community-based services (HCBS) waiver enrollment; or is applying for residential state supplement (RSS) funded placement; or is seeking long-term care services.

(N) “Keys amendment facility”, as found in section 1616(e) of the Social Security Act, means an institution, foster home or group living arrangement in which a significant number of recipients of supplemental security income benefits are residing or are likely to reside. Keys amendment facilities include:

(1) Adult foster homes certified under section 173.36 of the Revised Code;

(2) Adult family homes or adult group homes as defined in section 3722.01 of the Revised Code, that is licensed as an adult care facility under section 3722.04 of the Revised Code;

(3) Residential care facility as defined in section 3721.02 of the Revised Code;

(4) Community alternative homes as defined in section 3724.01 of the Revised Code, that are licensed under section 3724.03 of the Revised Code;

(5) Residential facilities of the type defined in division (A)(1)(d)(ii) of section 5119.22 of the Revised Code, that are licensed by the Ohio department of mental health; or,

(6) An apartment or room that is used to provide community mental health housing services, is certified by the Ohio department of mental health under division (M) of section 5119.61 of the Revised Code, and is approved by a board of alcohol, drug addiction, and mental health services in accordance with division (A)(13) of section 340.03 of the Revised Code.

(O) “Level of care” (LOC) means the designation describing a person’s functional levels and nursing needs pursuant to the criteria set forth in rules 5101:3-3-05, 5105:3-3-06, 5101:3-3-07 and 5101:3-3-08 of the Administrative Code.

(P) “Mailing date” means the date that has been metered or postmarked by the United States postal service.

(Q) “NF” means a nursing facility as defined in section 5111.20 of the Revised Code.

(R) “ODA” means the Ohio department of aging.

(S) “ODJFS” means the Ohio department of job and family services.

(T) “PAA” means PASSPORT administrative agency.

(U) “PASSPORT” or “PASSPORT HCBS waiver program” means an HCBS waiver program that serves individuals who are aged sixty and over; have a LOC required for placement in a NF if the waiver program were not available; and meet the passport eligibility criteria and enrollment requirements as described in Chapter 5101:3-31 of the Administrative Code.

(V) “Region” means the geographic area in which a PAA administers the PASSPORT program.

(W) “SSI” means supplemental security income as set forth in Title XVI of the Social Security Act, 86 Stat. 1475 (1972), 42 U.S.C.A. 1383, as amended.

(X) “Subregion” means a geographic area located within a PAA region for the purpose of establishing PASSPORT unit rates as set forth in rule 5101:3-31-11 of the Administrative Code.

(Y) “Waiver service provider” means an agency or person with a signed medicaid provider agreement with ODJFS to provide HCBS waiver services, and who meets the PASSPORT conditions of participation set forth in rule 5101:3-31-06 of the Administrative Code.

Effective: 07/01/2006

R.C. 119.032 review dates: 04/14/2006 and 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 7/16/84, 12/22/86 (Emer), 3/23/87, 7/1/90, 1/14/96, 9/1/98, 3/1/00, 3/3/01

(A) Before an individual can be eligible for enrollment in pre-admission screening system providing options and resources today (PASSPORT), all of the following criteria must be met:

(1) A county department of job and family services (CDJFS) must have determined the individual to be financially eligible for medicaid in accordance with Chapters 5101:1-37 and 5101:1-39 of the Administrative Code.

(2) The waiver service cost of the twelve-month care plan does not exceed the individual cost limit. The individual cost limit is calculated by Ohio department of aging (ODA) at least biennially. The cost limit is a dollar amount equal to sixty per cent of the total medicaid cost for nursing facility (NF) services. The total medicaid cost for NF services is obtained by multiplying the average annual medicaid NF per diem rate by the number of days in the most recent state fiscal year in which data is available.

(a) If the PASSPORT administrative agency (PAA) determines that the applicant’s needs cannot be met within the cost limit, the individual shall not be enrolled. However, if a consumer who has been enrolled and is receiving PASSPORT services experiences a change in his or her condition that causes the cost of care to exceed the cost limit, the consumer may remain on the wavier at a higher cost not to exceed one hundred per cent of the total medicaid cost for NF services to avoid service disruption to the consumer if the PAA grants approval to do so.

(b) If the consumer’s needs exceed one hundred per cent of the total medicaid cost for NF services, the consumer shall be disenrolled from the waiver.

(3) The needed services are not readily available through another source at the level required to allow the individual to live in the community.

(4) The individual’s health related needs can be safely met in a home setting as determined by the PAA.

(5) Prior to PASSPORT enrollment, the attending physician must approve that the services are appropriate to meet the individual’s needs. The physician’s approval may be either verbal or written. If the approval is verbal, written approval must be obtained within thirty days of the enrollment date. The PAA shall be responsible for obtaining the physician’s approval.

(6) The individual agrees to participate in PASSPORT.

(7) While receiving PASSPORT, the consumer must not be a resident of a “Keys Amendment facility” as defined in rule 5101:3-31-02 of the Administrative Code; and must not reside in a hospital or NF as defined in rule 5101:3-31-02 of the Administrative Code. For purposes of this rule a resident of a “Keys Amendment facility” is an individual who receives services from the facility and is not a family member of the owner or operator of the facility.

(8) The individual is age sixty or older at time of enrollment.

(9) The individual must be determined to meet the criteria for an intermediate or skilled level of care in accordance with rule 5101:3-3-05 or 5101:3-3-06 of the Administrative Code and, in the absence of PASSPORT, would require NF services as defined in 42 C.F.R. 440.40 and 42 C.F.R. 440.150 (dated October 1, 2007).

(10) PASSPORT has not reached the centers for medicare and medicaid services (CMS)-authorized limit of consumers for the current year.

(11) A consumer who has been enrolled in and is receiving PASSPORT services may subsequently be enrolled in and receive hospice services under medicaid or medicare. A person who is enrolled in hospice under medicaid or medicare is not eligible to enroll in PASSPORT if that hospice enrollment occurred prior to PASSPORT enrollment.

(12) The individual must require the provision of at least one waiver service on a monthly basis as documented in the consumer’s approved care plan.

(B) If, at any time, the individual or consumer fails or ceases to meet any of the eligibility criteria identified in this rule, the individual or consumer shall be denied or disenrolled from PASSPORT. In such instances, the individual or consumer shall be notified by the CDJFS and entitled to hearing rights in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 01/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 12/22/86 (Emer.), 3/23/87, 1/14/96, 2/22/01, 1/31/05

(A) The Ohio department of aging (ODA) is responsible for the daily administration of the PASSPORT home and community based services (HCBS) waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS), in accordance with sections 5111.91 and 5111.871 of the Revised Code. ODA will establish processes and procedures to enroll individuals on this waiver.

(B) Individuals who wish to enroll in PASSPORT must have a financial eligibility determination made by the county department of job and family services (CDJFS) and an assessment of PASSPORT waiver eligibility made by the PASSPORT administering agency (PAA). The individual may contact either the CDJFS or the PAA to start the enrollment process and the two agencies shall coordinate processing the request for enrollment into the PASSPORT HCBS waiver program:

(1) Individuals initially contacting the CDJFS will complete the “Request for Cash, Food Stamps, and Medical Assistance” (JFS 07200, rev. 5/05) and the “Request for Medicaid Home and Community Based Services” (JFS 02399, rev. 6/04) in accordance with rule 5101:1-38-01.2 of the Administrative Code. The CDJFS will notify the PAA of the individual’s application for waiver services. The PAA will initiate contact with the individual to complete the enrollment process.

(2) Individuals initially contacting the PAA will receive an in person assessment to determine eligibility for the PASSPORT HCBS waiver program. The PAA may assist the individual in applying for medicaid if not already initiated by completing the JFS 07200 and JFS 02399.

(C) Using the procedures outlined in rule 173-42-01 of the Administrative Code, the PAA shall offer enrollment to the individual if the individual has been determined eligible and a waiver slot is available. If a waiting list is employed, waiver slots shall be made available in accordance with rule 173-42-01 of the Administrative Code.

(D) The PAA shall make the determination of PASSPORT eligibility using the criteria set forth in rule 5101:3-31-03 of the Administrative Code. The PAA shall notify the CDJFS of the results of the PASSPORT eligibility determination.

(E) Any applicant for PASSPORT HCBS waiver program services is entitled to notice and hearing rights as set forth in section 5101.35 of the Revised Code and division-level designation 5101:6 of the Administrative Code.

Replaces: 5101:3-31-04

Effective: 01/01/2006

R.C. 119.032 review dates: 01/01/2011

Promulgated Under: 119.03

Statutory Authority: 173.40, 5111.02

Rule Amplifies: 173.40, 5111.01, 5111.02

Prior Effective Dates: 7/16/84, 12/22/86(Emer.), 3/23/87, 7/1/90, 1/14/96, 2/22/01

(A) The purpose of this rule is to establish services covered by the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) wavier program.

(B) The PASSPORT HCBS waiver program benefit package is limited to the following services:

(1) Adult day services as set forth in rule 173-39-02.1 of the Administrative Code;

(2) Chore services as set forth in rule 173-39-02.5 of the Administrative Code;

(3) Emergency response system services as set forth in rule 173-39-02.6 of the Administrative Code;

(4) Home medical equipment and supplies services as set forth in rule 173-39-02.7 of the Administrative Code;

(5) Homemaker services as set forth in rule 173-39-02.8 of the Administrative Code;

(6) Minor home modification, maintenance and repair services as set forth in rule 173-39-02.9 of the Administrative Code;

(7) Nutrition consultation services as set forth in rule 173-39-02.10 of the Administrative Code;

(8) Personal care services as set forth in rule 173-39-02.11 of the Administrative Code;

(9) Social work counseling services as set forth in rule 173-39-02.12 of the Administrative Code;

(10) Transportation services as set forth in rule 173-39-02.13 of the Administrative Code;

(11) Home delivered meal services as set forth in rule 173-39-02.14 of the Administrative Code;

(12) Independent living assistance services as set forth in rule 173-39-02.15 of the Administrative Code.

(13) Community transition services as set forth in rule 173-39-02.17 of the Administrative Code.

(14) Non-medical transportation services as set forth in rule 173-39-02.18 of the Administrative Code.

(C) Services will be delivered consistent with the consumer care plan as documented in the PASSPORT information management system (PIMS).

Replaces: 5101:3-31-08

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 7/16/84, 12/22/86 (Emer.), 3/23/87, 7/1/90, 1/14/96, 9/1/98, 7/1/06

(A) The purpose of this rule is to establish the conditions under which providers are able to participate in the preadmission screening system providing options and resources today (PASSPORT) home and community based services HCBS waiver program.

(B) In order to obtain a medicaid provider agreement to be a PASSPORT provider, the provider must be certified by the Ohio department of aging (ODA) or its designee in accordance with the provisions of Chapter 173-39 of the Administrative Code.

(1) The provider may be certified as either:

(a) An ODA certified long-term care agency provider in accordance with the provisions of rule 173-39-02 of the Administrative Code, or

(b) An ODA certified long-term care non-agency provider in accordance with the provisions of rule 173-39-02 of the Administrative Code.

(C) Individuals enrolled in the PASSPORT HCBS waiver shall be given a free choice of qualified providers in accordance with Chapter 5101:3-41 of the Administrative Code.

Replaces: 5101:3-31-08

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 7/16/84, 12/22/86 (Emer), 3/23/87, 7/1/90, 1/14/96, 9/1/98

(A) The purpose of this rule is to describe the methods used to determine provider rates for the preadmission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) waiver program.

(B) Subject to the limits set forth in rule 5101:3-1-06 of the Administrative Code, rate setting methodologies shall be established for the following categories:

(1) Per job bid rate;

(2) Per item rate; and

(3) Unit rate.

(C) A per job bid shall be used to determine the rate for the following services:

(1) Minor home modification services as set forth in rule 173-39-02.9 of the Administrative Code;

(2) Chore services as set forth in rule 173-39-02.5 of the Administrative Code;

(3) Transportation services as set forth in rule 173-39-02.13 of the Administrative Code;

(4) Non-medical transportation services as set forth in rule 173-39-02.18 of the Administrative Code; and

(5) Community transition services as set forth in rule 173-39-02.17 of the Administrative Code.

(D) A per item rate shall be determined for the following services:

(1) Home medical equipment and supplies as set forth in rule 173-39-02.7 of the Administrative Code.

(a) The cost of the item shall not exceed the medicaid state plan rate.

(b) The cost of an item that does not have an established medicaid rate shall be reimbursed at a per item bid rate submitted and agreed to in writing by the PASSPORT administrative agency (PAA) prior to delivery of the item.

(E) Unit rates shall be established by the PAA.

(1) Unit rates shall be used by the PAA for the following services:

(a) Adult day services transportation as set forth in rule 173-39-02.1 of the Administrative Code;

(b) Home delivered meal services as set forth in rule 173-39-02.14 of the Administrative Code;

(c) Homemaker services as set forth in rule 173-39-02.8 of the Administrative Code;

(d) Social work counseling services as set forth in rule 173-39-02.12 of the Administrative Code;

(e) Nutritional consultation services as set forth in rule 173-39-02.10 of the Administrative Code;

(f) Personal care services as set forth in rule 173-39-02.11 of the Administrative Code;

(g) Independent living assistance services as set forth in rule 173-39-02.15 of the Administrative Code; and

(h) Emergency response system services as set forth in rule 173-39-02.6 of the Administrative Code.

(2) The PAA shall contract for services with providers who are certified by the Ohio department of aging (ODA) as set forth in rule 173-39-02 of the Administrative Code to provide the services specified in paragraph (E)(1) of this rule in the region/subregions for which the rate will be established.

(3) The PAA shall:

(a) Specify the time period for which the rates shall be in effect;

(b) Specify the timelines for contracting;

(c) Define the region/subregions for which the rates will be established;

(d) Base rates on the units of service as set forth in rule 173-39-02.1 to 173-39-02.18 of the Administrative Code; and

(e) Require that the contract reflects the rate the provider is willing to accept as set forth in paragraph (E)(5) of this rule.

(4) ODA shall establish a regional rate for each service. The regional rate shall be determined as follows:

(a) The regional rate for each service shall be the weighted average rate paid in the region using cost and unit data either from the most recently completed state fiscal year or the most recent twelve calendar months for which complete data is available, whichever is later; and

(b) For contracting purposes, the PAA shall adjust the regional rate up to the nearest number that is divisible by four, out to two decimal places.

(5) Contract rates shall be established as follows:

(a) No provider shall have a contract rate that exceeds the rate for that service as established in appendix A to rule 5101:3-1-06.1 of the Administrative Code.

(b) Providers with rates less than or equal to the regional rate as set forth in paragraph (E)(4) of this rule shall accept a contract rate equal to the regional rate or elect a contract rate lower than the regional rate.

(c) Providers with rates greater than the regional rate as set forth in paragraph (E)(4) of this rule may keep the greater than regional rate or may elect to accept a lower contract rate.

(d) Providers who are certified after the regional rate is established shall have a contract rate less than or equal to the regional rate set forth in paragraph (E)(4) of this rule.

(e) If there is not sufficient data available to establish a regional rate as set forth in paragraph (E)(4) of this rule for a service, the regional rate for that service shall be equal to the statewide average rate for that service.

(F) The unit rates for the enhanced level and the intensive level of adult day services, as specified in rule 173-39-02.1 of the Administrative Code, are set forth in appendix A of to rule 5101:3-1-06.1 of the Administrative Code.

(G) PASSPORT service payment constitutes payment in full and shall not be construed as a partial payment when the payment amount is less than the provider’s charge. The provider shall not bill the consumer for any difference between the medicaid payment and the provider’s charge or request the consumer to share in the cost through a co-payment or other similar charge. The provider shall consider medicaid payment as payment in full.

(H) The department or its designee shall evaluate unit rates within two years of the effective date of this rule and every two years thereafter.

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 9/1/98, 3/1/00, 7/1/06

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