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Ohio Laws and Rules
Rescinded eff 12-11-06
(A) Purpose
This rule sets forth the requirements a county board of MR/DD must meet to establish and maintain waiting lists and long-term service planning registries for home and community-based services. This rule prohibits the establishment of waiting lists or service substitution lists for certain categories of medicaid services.
(B) Definitions
(1) “County board” means a county board of mental retardation and developmental disabilities established under Chapter 5126. of the Revised Code.
(2) “Home and community-based services” means medicaid-funded home and community based services provided pursuant to section 5111.871 of the Revised Code.
(3) “ICF/MR level of care” means a determination made in accordance with rule 5101:3-3-07 of the Administrative Code.
(4) “ODJFS” means the Ohio department of job and family services as established under section 121.02 of the Revised Code.
(5) “ODMR/DD” means the Ohio department of mental retardation and developmental disabilities established under section 121.02 of the Revised Code”ODJFS” means the Ohio department of job and family services as established under section 121.02 of the Revised Code.
(C) Requirements
(1) County boards that have local medicaid administrative authority shall establish and maintain waiting lists and long-term service planning registries for home and community-based services in accordance with rule 5123:2-1-08 of the Administrative Code.
(2) The following individuals shall not be subject to waiting lists or service substitution lists:
(a) Medicaid eligible individuals who are assessed and determined to need medicaid state plan services, including habilitation center services and medicaid case management services, in accordance with their individual service plan. These services shall be provided to the individual within ninety days of the date the need was documented on the individual service plan.
(b) Individuals enrolled in a home and community-based services waiver for persons with an ICF/MR level of care and who are assessed and determined to have a need for the services covered by the waiver, in accordance with their individual service plan. These services shall be provided to the individual within ninety days of the date the need was documented on the individual service plan.
(c) Individuals enrolled in residential facility, home care transition or individual options waivers who are being transferred to a different home and community-based services waiver for persons with an ICF/MR level of care.
(d) Children who are subject to a determination under section 121.38 of the Revised Code and who require home and community-based services through a medicaid waiver administered by the ODMR/DD. For all other services, such children shall be treated by the county board as having emergency status.
(D) ODJFS shall monitor compliance with this rule by the county boards and their contract agencies.
Appendix A
Rule 5101:3-40-01
Individual Options Rates
Service Code Service Billing Maximum Billing Unit
MR770 Adaptive/Assistive Equipment $10,000 Item
MR771 Environmental Modifications $7,500 Item
MR503 Home Delivered Meals $7.00 Meal
MR405 Home maker/Personal Care $337 Day
MR540 Homemaker/Personal Care $4.97 15 min
MR541 Homemaker/Personal Care $19.88 Hour
MR542 Homemaker/Personal Care night supervision $14.00 Hour
MR551 Homemaker/Personal Care_Reserve $19.88 Hour
MR552 Homemaker/Personal Care_Reserve $4.97 15 min
MR514 Interpreter Services $12.00 15 min
MR524 Interpreter Services $48.00 Hour
MR508 Nutritional Services $12.00 15 min
MR528 Nutritional Services $48.00 Hour
MR800 Program Specialist $7.00 15 min
MR801 Program Specialist $28.00 Hour
MR510 Social Work $15.00 15 min
MR520 Social Work $60.00 Hour
MR516 Supported Employment $6.00 15 min
MR526 Supported Employment $24.00 Hour
MR576 Respite Care $200 Day
MR660 Transportation $0.38 mile
The service codes listed are used by ODMRDD. All Individual Options and Residential Facility Waiver providers must bill ODMRDD directly using the service codes authorized by ODMRDD pursuant to rules filed in accordance with agency designation 5123 of the Administrative Code.
HISTORY: Eff 2-15-02 (Emer.); 5-9-02
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.85, 5111.02
Rule amplifies: RC 5111.01, 5111.02, 5111.85, 5111.871, 5123.046, 5126.042
R.C. 119.032 review dates: 05/09/2007
Rescinded eff 7-1-05
Rescinded eff 7-6-05
(A) The Ohio department of mental retardation and developmental disabilities (ODMRDD), through an interagency agreement with the Ohio department of job and family services (ODJFS), acts as the administrative agency for components of the medicaid home and community-based services programs in accordance with 5111.91 of the Revised Code. In accordance with 5111.871 of the Revised Code, the ODMRDD, as the designated administrator, shall promulgate rule(s) to require that recipients of home and community-based services are provided choice of medicaid home and community-based providers consistent with federal free choice of provider requirements set forth in 42 C.F.R. 431.51 (as amended June 14, 2002). Any rule(s) authorized by this rule and promulgated by the ODMRDD are valid only to the extent they are consistent with 42 C.F.R. 431.51 (as amended June 14, 2002). If the rules promulgated by ODMRDD are capable of more than one interpretation, they shall be applied in a manner most consistent with the letter and intent of 42 C.F.R. 431.51 (as amended June 14, 2002).
(B) Rules promulgated by ODMRDD shall establish policies related to the provision of free choice of medicaid home and community-based service providers for each service specified in a recipient’s individual service plan and shall include the following:
(1) The general roles and responsibilities of the county board of mental retardation and developmental disabilities as specified in rule 5123: 2-9-11 of the Administrative Code.
(2) The roles and responsibilities of the county board of MRDD for the assurance of due process and fair hearing rights regarding recipients’ free choice of medicaid home and community-based service providers.
(3) The roles and responsibilities of ODMRDD for monitoring and assuring compliance with recipients’ free choice of medicaid home and community-based service provider requirements.
(C) ODJFS shall conduct periodic monitoring and compliance reviews related to free choice of medicaid home and community-based service providers.
Effective: 07/01/2005
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: RC 5111.85, 5111.871
Rule Amplifies: RC 5111.85, 5111.871
(A) The purpose of the rule is to establish the payment standards governing reimbursement for day habilitation services as a component of the medicaid program and as administered by the Ohio department of mental retardation and developmental disabilities (ODMRDD) in accordance with sections 5111.85 and 5111.873 of the Revised Code. Payment standards set forth in this rule shall be applicable for twenty-four months after the effective date of rule 5123:2-9-12 of the Administrative Code.
(B) The ODMRDD is responsible for the daily administration of certain components of the medicaid program to include home and community based services (HCBS) 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.
(C) Payments made to certified providers by the ODMRDD are subject to the provision, conditions, and payment standards set forth in this rule and in accordance with rule 5123:2-9-12 of the Administrative Code. Individuals enrolled in an HCBS program administered by ODMRDD on or after July 1, 2005 shall be subject to payment standards set forth in this rule and in rule 5123:2-9-12 of the Administrative Code.
(D) Reimbursement for day habilitation services shall not exceed the rates in appendix A to this rule.
(E) Certified waiver providers shall submit claims for the provision of day habilitation services in accordance with the process specified in rule 5123:2-9-12 of the Administrative Code.
(F) Certified waiver providers shall receive payment for the provision of day habilitation as indicated in paragraph (C) of this rule when the following conditions exist:
(1) The agency provider has certification for each service they provide in accordance with applicable requirements; and
(2) The agency provider has a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code; and
(3) The waiver service is provided to an individual who is enrolled in a waiver program at the time of service; and
(4) The waiver service is provided in accordance with the enrollee’s individual service plan; and
(5) The waiver service is provided within the limitations specified by the waiver program in which the individual is enrolled.
(G) Payments made under the authority of this rule for the provision of HCBS constitute payment in full and shall not be construed as a partial payment.
(H) Monitoring.
(1) ODJFS will monitor reimbursement made under authority of this rule as necessary to ensure that the funding applicable to day habilitation service is used for the authorized purposes in compliance with laws, regulations, and the provisions governing the medicaid program.
Appendix A
See Appendix A at http://www.registerofohio.state.oh.us/pdfs/5101/3/41/5101$3-41-10_PH_FF_A_APP1_20070621_0937.pdf
Effective: 07/01/2007
R.C. 119.032 review dates: 07/10/2010
Promulgated Under: 119.03
Statutory Authority: 5111.85, 5111.873
Rule Amplifies: 5111.85, 5111.873
Prior Effective Dates: 7/1/05
(A) The purpose of this rule is to establish the payment standards governing reimbursement for home and community-based services (HCBS) provided by certified waiver providers to individuals enrolled in an HCBS program as a component of the medicaid program and as administered by the Ohio department of mental retardation and developmental disabilities (ODMRDD) in accordance with sections 5111.85 and 5111.873 of the Revised Code.
(B) The ODMRDD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, 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.
(1) Individuals enrolled in an HCBS program administered by ODMRDD prior to the effective date of this rule shall be subject to the payment standards set forth in rule 5123:1-2-08 of the Administrative Code for individual options waiver, or rule 5123:1-2-11 of the Administrative Code for residential facilities and individual options waiver, or rule 5101:3-42-11 of the Administrative Code for level one waiver, or rule 5101:3-40-01 of the Administrative Code for individual options waiver and for all payments under those rules. They shall also be subject to terms of paragraphs (A) to (C) of rule 5101:3-1-60 of the Administrative Code. These individuals shall remain subject to these payment standards until they are transitioned in accordance with the period of time as specified in rule 5123:2-9-06 of the Administrative Code. Individuals shall transition to the statewide payment rates no later than June 30, 2008 as federally approved.
(2) Individuals enrolled in an HCBS program administered by ODMRDD on or after the effective date of this rule shall be subject to the payment standards set forth in this rule and in rule 5123:2-9-06 of the Administrative Code.
(3) Once the period of transition as identified in paragraph (B)(1) of this rule has transpired then the payment standards set forth in this rule and in rule 5123:2-9-06 of the Administrative Code shall be the only applicable payment standards.
(4) The standards and procedures for prior authorization shall apply as defined in rule 5101:3-41-12 of the Administrative Code.
(C) For purposes of payment, services provided to individuals that meet the definition of supported employment as defined in the federally approved waiver document shall be paid as supported employment and shall not be construed as day habilitation. Reimbursement for supported employment shall not be applicable to this rule after December 31, 2007.
(D) Adult foster care
(1) Reimbursement for adult foster care shall not exceed the rates established in appendix A to this rule and be in accordance with rule 5123:2-13-06 of the Administrative Code.
(2) The provider shall bill ODMR/DD its usual and customary charge or the rate in appendix A to this rule.
(3) Individuals receiving adult foster care as a waiver service shall be subject to the service limitations as defined in rule 5123: 2-13-06 of the Administrative Code.
(E) Homemaker/personal care-daily billing unit
(1) Reimbursement for homemaker/personal care-daily billing unit shall not exceed the rates established in appendix A to this rule and be in accordance with rule 5123:2-13-07 of the Administrative Code.
(2) The provider shall bill ODMR/DD in accordance with the payment standards as outlined in rule 5123:2-13-07 of the Administrative Code. Reimbursement rates shall not exceed the maximum rates established in appendix A to this rule unless authorized by ODJFS.
(3) Individuals receiving homemaker/personal care-daily billing unit as a waiver service shall be subject to the service limitations as defined in rule 5123:2-13-07 of the Administrative Code.
(4) ODJFS and ODMRDD shall assure the validity of the cost projection tools used to determine the billing rates for the homemaker personal care daily billing unit waiver service.
(5) ODJFS and ODMRDD shall assure the accuracy of the homemaker personal care-daily billing unit methodology as outlined in the federally approved fiscal controls and quality assurance documents as detailed in the individual options waiver document.
(F) Payments made to certified waiver providers by the ODMRDD are subject to the provision, conditions, and payment standards set forth in this rule and in accordance with rule 5123:2-9-06 of the Administrative Code. Payment of services made under the authority of this rule shall not exceed the maximum payment rates set forth in appendix A to this rule.
(G) Certified waiver providers shall submit claims for the provision of HCBS in accordance with the process specified in rule 5123:2-9-06 of the Administrative Code.
(H) Certified waiver providers of HCBS shall receive payment for the provision of HCBS as indicated in paragraph (E) of this rule when the following conditions exist:
(1) The waiver service is provided by an individual or agency provider that has certification for each service they provide in accordance with applicable requirements; and
(2) The waiver service is provided by an individual or agency provider that has a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code; and
(3) The waiver service is provided to an individual who is enrolled in a waiver program at the time of service; and
(4) The waiver service is provided in accordance with the enrollee’s individual service plan; and
(5) The waiver service is provided within the limitations specified by the waiver program in which the individual is enrolled; and
(6) The waiver service provided to the individual is documented in accordance with rule 5123:2-9-05 of the Administrative Code; and
(7) The waiver service is provided to an enrollee who is not an inpatient of a hospital, residing in a nursing facility, or an intermediate care facility for individuals with mental retardation and other developmental disabilities (ICF/MR).
(a) An individual enrolled in an ODMRDD administered waiver program which offers institutional respite as one of the waiver services shall not be considered a resident of an ICF/MR if an ICF/MR is providing the institutional respite service.
(b) An ICF/MR providing institutional respite services for any ODMRDD administered waiver program that offers such services shall not bill medicaid through the ICF/MR program. Payments for institutional respite services shall be made through the waiver program in which the individual is enrolled.
(I) Payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.
(J) Due process.
(1) Applicants for waiver enrollment or individuals enrolled on any waiver administered by ODMRDD shall be afforded due process in accordance with section 5101.35 of the Revised Code through the state fair hearing process, and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.
(2) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of ODMRDD, and/or the county board of mental retardation and developmental disabilities is required during the hearing proceedings to justify the decision under appeal, in accordance with section 5126.055 of the Revised Code.
(K) Monitoring.
(1) ODJFS will monitor reimbursement made under authority of this rule as necessary to ensure that the funding applicable to HCBS are used for authorized purposes in compliance with laws, regulations, and the provisions governing the medicaid program.
Appendix A
Fee Schedule Maximums for Home and Community-Based Services
See Appendix A at http://www.registerofohio.state.oh.us/pdfs/5101/3/41/5101$3-41-11_PH_FF_A_APP1_20080310_1333.pdf
Effective: 03/20/2008
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.873, 5111.85
Rule Amplifies: 5111.873, 5111.85
Prior Effective Dates: 7/1/2005, 10/1/2007, 12/21/07 (Emer)
(A) Purpose
The purpose of this rule is to establish standards and procedures for prior authorization of waiver services when the individual funding level exceeds the funding range determined by the Ohio developmental disabilities profile (ODDP) for medicaid waiver services administered pursuant to section 5111.871 of the Revised Code. The procedures set forth in this rule shall not apply to services administered as part of the “Level One” waiver authorized by rule 5101:3-42-01 of the Administrative Code.
(B) Definitions
(1) “CBMRDD” means the county board of mental retardation and developmental disabilities.
(2) “Funding range” means the dollar range to which an individual has been assigned for the purpose of funding waiver services. The funding range applicable to an individual is determined by the score derived from an assessment using the ODDP that has been completed by a county board employee qualified to administer the tool. If prior authorization is issued pursuant to this rule, the dollar range in which the individual funding level resides shall be considered the funding range for the duration of the individual’s waiver eligibility span or for the period specified in the written notification provided pursuant to paragraphs (G) or (J) of this rule.
(3) “Individual” means a person with mental retardation or other development disability who is eligible to receive Home and Community Based Services (HCBS) as an alternative to placement in an intermediate care facility for the mentally retarded under the applicable HCBS waiver. A guardian or authorized representative as defined in rule 5101:1-2-01 of the Administrative Code may take any action on behalf of the individual, may make choices for an individual or may receive notice on behalf of an individual to the extent permitted by applicable law.
(4) “Individual funding level” means the total funds, calculated on a twelve month basis, that are necessary for payment for waiver services that have been determined through the individual service plan (ISP) development process to be sufficient in amount, duration and scope to meet the health and welfare needs of an individual.
(5) “ISP” means the individual service plan, a written description of the services, supports, and activities to be provided to an individual.
(6) “Ohio developmental disabilities profile (ODDP)” means the standardized instrument utilized by the Ohio department of mental retardation and developmental disabilities (ODMRDD) to assess the relative needs and circumstances of an individual compared to others. The consumer-specific responses are scored and the individual is assigned to a funding range, which enables similarly-situated individuals to access comparable services under the waiver on a statewide basis.
(7) “ODJFS” means the Ohio department of job and family services.
(8) “ODMRDD” means the Ohio department of mental retardation and developmental disabilities.
(9) “Payment authorization for waiver services (PAWS)” means the process followed and the form used to communicate the amount and payment for each waiver service that has been established through the approved ISP process and that is contained in the ISP of an eligible enrollee.
(10) “Waiver eligibility span” means the twelve month period that begins on the effective date of the individual’s initial waiver enrollment or date of re-determination.
(C) ODMRDD will review requests from individuals for prior authorization of waiver services when the individual funding level resulting from the ISP exceeds the funding range determined by the ODDP.
(D) Individuals shall submit requests for prior authorization in writing to ODMRDD. The CBMRDD shall assist in the preparation and submission of requests when the individual requests assistance. Upon receipt of a request for prior authorization, ODMRDD shall immediately notify the CBMRDD of the request.
(E) Upon notification of a request for prior authorization from an individual or ODMRDD, the CBMRDD shall, within five business days, obtain and submit all of the following documentation to ODMRDD.
(1) The name, address, waiver type and waiver enrollment number of the individual for whom the request is being made;
(2) The name, address, phone number and e-mail address of the contact person(s) from the CBMRDD involved in the development of the ISP and assisting with the individual’s request for prior authorization;
(3) The individual funding level being requested and documentation of the specific amount, frequency, ratio, rates and rate modification(s) for all services used in the calculation of the funding level;
(4) A brief summary of the request, including the specific criterion in paragraph (F) of this rule that the individual expects will be met;
(5) A copy of the assessment information used in the development of the ISP and any additional documentation in support of the request;
(6) A photocopy or electronic copy of the current or proposed ISP, including documentation of a behavior plan and/or documentation of the services requested, that produced a funding level that exceeds the funding range assigned by the ODDP;
(7) Results, including scoring, of the ODDP and the resulting assigned funding range;
(8) The expected date(s) of implementation of the waiver services if prior authorized and the period for which authorization is requested;
(9) A copy of all additional documents including those presented by the individual, and any and all relevant documentation related to a request for fair hearing made under section 5101.35 of the Revised Code in accordance with Chapter 5101:6 of the Administrative Code.
(10) In addition to the previous list, the CBMRDD shall also obtain and submit any other documentation requested by ODJFS or ODMRDD.
(F) ODMRDD shall prior authorize waiver services when the CBMRDD cannot recommend an ISP that ensures the health and welfare of the individual within the assigned funding range, and all of the criteria specified in paragraph (I) of this rule, and at least one of the following criteria are met:
(1) Episodes of injury to self or others that have occurred within the last three months when there is a continuing risk of injury to self or others.
(2) Presence of consistent behaviors in which the individual displays all of the following:
(a) Lacks impulse control; and
(b) Exhibits purposeful, dysfunctional goal-directed behavior to obtain or avoid something; and
(c) Requires constant monitoring and continual redirection and/or behavioral intervention.
(3) Presence of a progressive medical condition or a mental illness that is generally associated with:
(a) Behaviors posing a risk to self or others; and
(b) Requiring a controlled environment to maintain health and safety.
(4) Presence of a medical condition which, without staff intervention, would threaten the individual’s medical stability.
(5) Inability of an unpaid caregiver to provide previous levels of support and/or to provide the level of support currently required.
(6) Alterations in staffing ratios resulting from circumstances beyond the control of the individual. Examples may include the loss of a roommate or a change in the individual’s vocational schedule.
(7) An emergency situation that creates for an individual a risk of substantial self-harm or substantial harm to others if action is not taken within thirty days. An emergency may involve:
(a) Abuse, neglect or exploitation of the individual;
(b) Health and safety conditions that pose a serious risk to the individual or others, including immediate harm or death;
(c) Changes in the emotional or physical condition of the individual that necessitate substantial accommodations that cannot be reasonably provided by the individual’s caretaker.
(G) When ODMRDD authorizes a request made pursuant to this rule, ODMRDD shall issue written notification of its decision to the individual and the contact person from the CBMRDD. Notification will include the individual’s right to request a hearing under the process set forth in section 5101.35 of the Revised Code in accordance with Chapter 5101:6 of the Administrative Code.
(H) On the fifth business day after receipt of all documents specified in paragraph (E) of this rule, ODMRDD shall submit in writing to ODJFS all requests for prior authorization that have not been authorized according to paragraph (G) of this rule. Requests submitted to ODJFS for prior authorization shall include:
(1) All documents specified in paragraph (E) of this rule;
(2) A copy of the individual’s written request for prior authorization;
(3) A copy of all documentation and correspondence produced by ODMRDD during the prior authorization review process;
(4) A written recommendation from ODMRDD regarding the individual’s request, including any findings and an explanation in support of the recommendation.
(I) When reviewing requests pursuant to this rule, ODJFS shall determine that waiver services are medically necessary when these services:
(1) Are appropriate to the individual’s health and welfare needs, living arrangement, circumstances and expected outcomes; and
(2) Are of an appropriate type, amount, duration, scope and intensity ; and
(3) Are the most efficient and effective services that, when combined with other non-waiver services, ensure the health and welfare of the individual receiving the services; and
(4) Protect the individual from substantial harm expected to occur if the requested services are not authorized.
(J) ODJFS shall issue written notification of its decision to prior authorize or deny the request, within ten business days of receipt of all documentation specified in paragraph (H) of this rule from ODMRDD. Notice shall be sent to the individual, the contact person from the CBMRDD and ODMRDD and will include the individual’s right to request a hearing under the process set forth in section 5101.35 of the Revised Code in accordance with Chapter 5101:6 of the Administrative Code.
(K) Any failure of ODMRDD or ODJFS to comply with the timeframes established in this rule does not constitute prior authorization for any request.
(L) ODMRDD shall submit to ODJFS, no less than quarterly, a summary of all requests received from individuals in a format agreed upon by both ODMRDD and ODJFS.
(M) ODJFS shall periodically analyze the frequency and distribution of all requests for prior authorization to identify statistically significant patterns or trends.
(N) ODJFS and ODMRDD shall maintain all written records related to review of prior authorization for a period of six years following receipt of the request or until an initiated audit is resolved, whichever is longer.
(O) ODJFS shall periodically review prior authorization requests submitted to ODMRDD and any associated documentation, including PAWS.
(P) ODMRDD shall systematically evaluate compliance with prior authorization requirements by verifying that each individual’s funding level is maintained within the assigned funding range. Results of this evaluation shall be provided in writing to ODJFS no less than quarterly.
(Q) The CBMRDD shall implement all components of written prior authorization decision(s) issued by ODMRDD or ODJFS according to the timeframe(s) established within that notice.
(R) Notwithstanding the procedures set forth in this rule, ODJFS may in its sole discretion, and in accordance with federal guidelines, authorize services and amend ISPs for individuals if ODJFS determines that such services are medically necessary and the procedures set forth in this rule would not accommodate a request for such medically necessary services.
(S) Nothing in this rule shall be construed to permit ODJFS to amend provider payment rates as specified in rule 5123:2-9-06 of the Administrative Code and authorized by rule 5101:3-41-11 of the Administrative Code.
Effective: 07/01/2005
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02, 5111.85
Rule Amplifies: 5111.02, 5111.85
(A) Purpose.
This rule establishes the process for ODJFS determination of the rate when a home and community-based services (HCBS) waiver provider and county board of mental retardation and developmental disabilities (CBMRDD) cannot reach agreement in negotiating a payment rate for HCBS waiver services pursuant to Chapters 5123:1-2 and 5123:2-8 of the Administrative Code. The ODJFS shall make the rate determination in accordance with rule 5123:2-9-06 of the Administrative Code for individual enrollees that have not transitioned to the new waiver reimbursement system pursuant to paragraph (J) of rule 5123:2-9-06 of the Administrative Code, as authorized by rule 5101:3-41-11 of the Administrative Code.
(B) A request for ODJFS determination of waiver services payment rate may be submitted by a HCBS provider or a county board when a HCBS waiver provider chosen by a waiver enrollee cannot reach agreement with the CBMRDD regarding a rate to provide waiver service(s).
(1) The provider shall submit to ODJFS documentation requested by ODJFS, including but not limited to:
(a) A notarized request for a determination of the payment rate for a specified waiver service(s); and
(b) The provider proposed rate for each waiver service code and the requested effective date; and
(c) A statement justifying each proposed rate individually and any supporting documentation.
(2) The CBMRDD shall submit to ODJFS documentation requested by ODJFS, including but not limited to:
(a) The CBMRDD proposed rate for each waiver service code and the requested effective date; and
(b) A statement justifying each proposed rate and any supporting documentation.
(C) ODJFS may request any additional documentation to make the determination of the rate in accordance with this rule.
(D) The rates established pursuant to this rule shall not exceed the provider’s usual and customary rate pursuant to rule 5101:3-1-02 of the Administrative Code. Payment rates determined under this rule shall not exceed the rates in appendix A to this rule.
(E) ODJFS shall make a rate determination within thirty business days of receipt of all requested documentation as defined in paragraph (B) of this rule and notify the provider and CBMRDD of the decision in writing.
(F) The determination of a payment rate shall not be subject to hearings under Chapter 119. of the Revised Code or hearings conducted under authority of section 5111.06 of the Revised Code.
(G) Requests by any provider or county board pursuant to this rule, for payment rates for services to any individual waiver enrollee, per type of service shall be requested only once for enrollees that have not transitioned to the new waiver reimbursement system pursuant to rule 5123:2-9-06 of the Administrative Code or a written request for reconsideration of the rate is submitted to ODJFS by ODMRDD.
(H) ODJFS may upon review of any available information deny any rate determination requests or establish rate(s) at a level consistent with historical rates for the requesting provider or increase or decrease some or all of the requesting provider’s rates for some or all of the provider’s consumers.
APPENDIX A
Program Service Code Service Unit Title Service Amount
IO MR540 15 minute Homemaker/Personal Care $4.97
IO MR552 15 minute Homemaker/Personal Care -reserve $4.97
L1 MR913 15 minute Homemaker/Personal Care -1:1 Service Agency $3.78
L1 MR927 15 minute Homemaker/Personal Care – 1:1 Service- Agency- Emer $3.78
L1 MR914 15 minute Homemaker/Personal Care -1:1 Service Indiv $3.25
L1 MR928 15 minute Homemaker/Personal Care -1:1 Service Indiv -Emer $3.25
L1 MR929 15 minute Homemaker/Personal Care – Group Service Agency – Emer $2.84
L1 MR930 15 minute Homemaker/Personal Care – Group Service – Indiv – Emer $2.84
L1 MR915 15 minute Homemaker/Personal Care – Group Service Agency $2.44
L1 MR916 15 minute Homemaker/Personal Care – Group Service – Indiv $2.44
IO MR541 Hour Homemaker/Personal Care $19.88
IO MR551 Hour Homemaker/Personal Care -reserve $19.88
IO MR542 Hour Homemaker/Personal Care -night spv. $14.00
IO MR405 Day Homemaker/Personal Care $337.00
Replaces: 5101:3-41-13
Effective: 09/29/2006
R.C. 119.032 review dates: 09/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02, 5111.85, 5111.871
Rule Amplifies: 5111.871
Prior Effective Dates: 8/26/05 (Emer), 11/24/05, 6/30/06 (Emer)
(A) The purpose of this rule is to establish payment standards governing reimbursement for adult day support, vocational habilitation, supported employment-enclave, supported employment – community, supported employment adapted equipment and non-medical transportation to access one or more of these services as components of the medicaid program and as administered by the Ohio department of mental retardation and developmental disabilities (ODMRDD) in accordance with sections 5111.85 and 5111.873 of the Revised Code.
(B) The ODMRDD is responsible for the daily administration of certain components of the medicaid program to include home and community based services (HCBS) 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.
(C) Definitions
(1) Day habilitation means an HCBS waiver service as defined in rule 5123:2-9-10 of the Administrative Code.
(2) Supported employment means an HCBS waiver service as defined in rule 5123:2-9-13 of the Administrative Code.
(3) Adult day services means adult day support and vocational habilitation as defined in rule 5123:2-9-17 of the Administrative Code, supported employment- enclave, supported employment-community, and supported employment adapted equipment as defined in rule 5123:2-9-16 of the Administrative Code and non-medical transportation to access one or more of these services as defined in rule 5123:2-9-18 of the Administrative Code.
(D) The following service limitations apply:
(1) Individuals that receive day habilitation as a waiver service may not receive this service at the same time as adult day support, vocational habilitation, or supported employment – enclave; and
(2) Individuals that receive supported employment as defined in paragraph (C) (2) of this rule may not receive the service at the same time as supported employment – community or supported employment – enclave.
(E) Payment standards
(1) Subject to the service limitations in paragraph (D) of this rule, individuals who:
(a) Are receiving day habilitation may continue to receive day habilitation and shall be subject to the payment standards as defined in rule 5123:2-9-12 and rule 5101:3-41-10 of the Administrative Code for the individual options and level one waiver; and/or
(b) Are receiving supported employment may continue to receive supported employment and shall be subject to the payment standards as defined in rule 5123:1-2-08 and rule 5101:3-40-01 of the Administrative Code for the individual options waiver and rule 5101:3-41-11 of the Administrative Code for the level one waiver; and/or
(c) Are receiving or are requesting to receive one or more of the adult day services as defined in paragraph (C) of this rule shall be subject to the payment standards set forth in this rule and rule 5123:2-9-19 of the Administrative Code.
(2) Day habilitation and supported employment as defined in paragraph (C) of this rule shall not be available as waiver services after December 31, 2007.
(F) Individuals that receive one or more adult day support, vocational habilitation, supported employment-enclave, supported employment-community waiver services as defined in rules 5123:2-9-16 and 5123:2-9-17 of the Administrative Code shall be eligible to receive non-medical transportation as a waiver service as defined in rule 5123:2-9-18 of the Administrative Code. Transportation services may be provided in addition to the non-medical transportation services.
(G) Reimbursement for adult day support, vocational habilitation, supported employment-enclave, supported employment-community, supported employment – adapted equipment, and non-medical transportation shall not exceed the rates in appendix A to this rule nor exceed the annual budget limitation in appendix B to this rule. The provider shall bill ODMRDD its usual and customary charge or the rate in appendix A to this rule. Without regard to the rate of reimbursement that may be identified in appendix A to this rule, no provider of adult day services shall receive reimbursement at a rate in excess of the rate in the federally approved waiver amendment.
(H) Certified waiver providers shall submit claims for the provision of adult day services in accordance with the process specified in rule 5123:2-9-19 of the Administrative Code.
(I) Certified waiver providers shall receive payment for the provision of adult day services as indicated in paragraph (E) of this rule when the following conditions exist:
(1) The agency provider has certification for each service they provide in accordance with applicable requirements; and
(2) The provider has a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code; and
(3) The waiver service is provided to an individual who is enrolled in a waiver program at the time of service; and
(4) The waiver service is provided in accordance with the enrollee’s individual service plan; and
(5) The waiver service provided to the individual is documented in accordance with rules 5123:2-9-05 and 5123: 2-9-19 of the Administrative Code; and
(6) The waiver service is provided to the individual by direct service staff who meet the certification standards in accordance with rule 5123:2-9-19 of the Administrative Code; and
(J) Payments made under the authority of this rule for the provision of HCBS constitute payment in full and shall not be construed as a partial payment.
(K) Cost report
(1) County boards of mental retardation and developmental disabilities shall submit cost reports to the ODMRDD for the purpose of allocating adult day services costs in accordance with the federally approved waiver. The format of the cost report shall be designed by ODMRDD and accepted by ODJFS.
(L) Due process
(1) Applicants for waiver enrollment or individuals enrolled on a waiver administered by ODMRDD shall be afforded due process in accordance with section 5101.35 of the Revised Code through the state fair hearing process and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.
(2) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of ODMRDD and/or the county board of mental retardation and developmental disabilities is required during the hearing proceedings to justify the decision under appeal in accordance with section 5126.055 of the Revised Code.
(M) Monitoring
ODJFS shall monitor reimbursement made under authority of this rule as necessary to ensure that the funding applicable to HCBS is used for authorized purposes in compliance with laws, regulations and provisions governing the medicaid program.
5101:3-41-15 Appendix A
Billing Codes
See Appendix A at http://www.registerofohio.state.oh.us/jsps/PublicDisplayRules/processPublicDisplayRules.jsp?entered_rule_no=5101%3A3-41-15&doWhat=GETBYRULENUM&Submit=Search
Appendix B
Budget Limitations
See Appendix B at http://www.registerofohio.state.oh.us/jsps/PublicDisplayRules/processPublicDisplayRules.jsp?entered_rule_no=5101%3A3-41-15&doWhat=GETBYRULENUM&Submit=Search
Effective: 10/01/2007
R.C. 119.032 review dates: 01/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.873, 5111.85
Rule Amplifies: 5111.873, 5111.85
Prior Effective Dates: 1/01/07, 07/01/07