5101:3-31-07 PASSPORT HCBS waiver program rate setting.

(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. Rates determined under this rule shall not exceed the maximum reimbursement rate for PASSPORT HCBS services in appendix A to rule 5101:3-1-06.1 of the Administrative Code.

(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 rate 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) Transportation and non-medical transportation services rendered simultaneously by the same provider to more than one PASSPORT consumer residing in the same household and traveling in the same vehicle to the same destination shall be reimbursed at a rate that is seventy-five per cent of the provider's per job bid rate set in accordance with paragraph (C) of this rule, and shall be used if the provider is delivering any combination of transportation and/or non-medical transportation services.

(E) A per item rate shall be determined for home medical equipment and supplies as set forth in rule 173-39-02.7 of the Administrative Code.

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

(2) 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.

(F) For the following services, the Ohio department of aging (ODA) shall establish unit rates and the PAA shall enter into a contract with each provider using a specific rate set by ODA. The rate set by ODA shall not exceed the medicaid maximum set forth in appendix A to rule 5101:3-1-06.1 of the Administrative Code.

(1) Enhanced and the intensive level of adult day services as specified in rule 179-39-02.1 of the Administrative Code;

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

(3) Personal care services provided by ODA-certified long-term care consumer-directed personal care provider as specified in rule 173-39-02.11 of the Administrative Code; and

(4) Enhanced community living services as specified in rule 173-39-02.20 of the Administrative Code.

(G) Personal care services rendered during the same visit by the same ODA-certified long-term care consumer-directed personal care provider to more than one but less than four PASSPORT consumers in the same household, as identified in the consumers' service plans, shall be reimbursed one hundred per cent of the provider's per unit rate set in accordance with paragraph (F) of this rule for one PASSPORT consumer. The provider shall be reimbursed seventy-five per cent of the provider's per unit rate for each subsequent PASSPORT consumer in the household receiving services during the visit.

(H) The PAA will use unit rates for certain PASSPORT services.

(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; and

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

(2) The PAA shall contract for services with providers who are certified by ODA as set forth in rule 173-39-02 of the Administrative Code to provide the services specified in paragraph (H)(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 appendix A to rule 5101:3-1-06.1 of the Administrative Code; and

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

(4) ODA shall establish a regional rate for each service in paragraph (H)(1) of this rule. 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 (H)(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 (H)(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 (H)(4) of this rule.

(I) Adult day service transportation services rendered simultaneously by the same provider to more than one consumer residing in the same household and traveling in the same vehicle to the same destination shall be reimbursed at a rate that is seventy-five per cent of the provider's unit rate set in accordance with paragraph (H) of this rule.

(J) Personal care services, except personal care services provided under paragraph (F) of this rule, that are rendered during the same visit by the same provider to more than one but less than four PASSPORT consumers in the same household, as identified in the consumers' service plans, shall be reimbursed one hundred per cent of the provider's per unit rate set in accordance with paragraph (H) of this rule for one PASSPORT consumer. The provider shall be reimbursed seventy-five per cent of their per unit rate for each subsequent PASSPORT consumer in the household receiving services during the visit.

(K) 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.

(L) 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: 09/29/2011
R.C. 119.032 review dates: 03/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85 , 173.40
Prior Effective Dates: 9/1/98, 3/1/00, 7/1/06, 7/1/08, 7/1/11 (Emer.), 3/17/11