LAW
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Ohio Laws and Rules
(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)