LAW
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Ohio Laws and Rules
(A) Purpose.
The purpose of this rule is to establish the payment standards governing reimbursement for home and community-based services (HCBS) provided by certified or licensed waiver providers to individuals enrolled in a HCBS program as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5111.85 and 5111.873 of the Revised Code.
(B) The DODD 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.
(C) Individuals enrolled in a HCBS program administered by DODD shall be subject to the payment standards set forth in this rule and in rule 5123:2-9-06 of the Administrative Code.
(D) The standards and procedures set for prior authorization as defined in rule 5101:3-41-12 of the Administrative Code shall apply for individuals enrolled on the individual options waiver.
(E) For purposes of payment, HCBS services provided to individuals enrolled on the level one or individual options waivers must meet the definition of the waiver service as defined in the federally approved waiver document.
(F) Projection of costs for HCBS services.
(1) Beginning on and after December 31, 2010, the county boards of developmental disabilities shall project waiver service costs in accordance with the individual service plan for individuals initially enrolled on the individual options or level one waivers or at an enrollee’s annual re-determination date for waiver services by using the authorized cost projection tool as referenced in rule 5123: 2-9-06 of the Administrative Code.
(2) HCBS service cost projections made in accordance with paragraph (F)(1) of this rule shall be completed no later than December 31, 2011.
(3) DODD providers of HCBS waiver services shall have access to the cost projection tool upon request to the department. Providers may prepare draft versions of the cost projection tool and forward to the county board for consideration.
(G) Adult foster care.
(1) Payment 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 DODD its usual and customary charge or a rate that does not exceed the maximum rate established 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.
(4) Documentation requirements for the adult foster care waiver service shall be in accordance with rule 5123: 2-13-06 of the Administrative Code.
(H) Homemaker/personal care-daily billing unit.
(1) Payment 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 5123:2-9-31 of the Administrative Code.
(2) The provider shall bill DODD and document services provided in accordance with the payment standards as outlined in rule 5123:2-9-31 of the Administrative Code.
(3) County boards of developmental disabilities shall project and enter the total planned homemaker personal care costs and the total planned provider hours into the daily rate application system for homemaker personal care services projected with a cost projection tool validated by DODD and approved by ODJFS until the enrollee(s) HCBS services costs are projected with the authorized cost projection tool as referenced in paragraph (F) of this rule.
(4) Certified providers of the homemaker personal care-daily billing unit service shall enter their actual direct service hours into the daily rate application system prior to requesting payment for the service from DODD for homemaker personal care services projected with a cost projection tool validated by DODD and approved by ODJFS until the enrollee(s) HCBS services costs are projected with the authorized cost projection tool as referenced in paragraph (F) of this rule.
(5) Individuals receiving homemaker/personal care-daily billing unit as a waiver service shall be subject to the service limitations as defined in rule 5123:2-9-31 of the Administrative Code.
(6) ODJFS shall periodically review the DODD cost projection tool to determine that the waiver service costs projected by the cost projection tool are projected in accordance with the administrative rules.
(I) Adult family living.
(1) Payment for adult family living shall not exceed the maximum medicaid rates established in appendix A to this rule and be in accordance with rule 5123:2-9-32 of the Administrative Code.
(2) Providers of adult family living shall bill in accordance with payment standards as defined in rule 5123:2-9-32 of the Administrative Code.
(3) Documentation requirements for adult family living shall be in accordance with rule 5123:2-9-32 of the Administrative Code.
(4) DODD shall collect data during the first year to determine if the funding range groupings and rates are cost effective.
(J) Residential and community respite.
(1) Payment for residential and community respite shall not exceed the maximum medicaid rates established in appendix A to this rule and be in accordance with rule 5123:2-9-34 of the Administrative Code.
(2) Providers of residential and community respite shall bill in accordance with the payment standards as defined in rule 5123:2-9-34 of the Administrative Code.
(3) Documentation requirements for residential and community respite shall be in accordance with rule 5123:2-9-34 of the Administrative Code.
(K) Remote monitoring and equipment.
(1) Payment for remote monitoring and equipment shall not exceed the maximum medicaid rates established in appendix A to this rule and be in accordance with rule 5123:2-9-35 of the Administrative Code.
(2) Providers of remote monitoring and equipment shall bill in accordance with the payment standards as defined in rule 5123:2-9-35 of the Administrative Code.
(3) Documentation of service requirements for remote monitoring and equipment shall be in accordance with rule 5123:2-9-35 of the Administrative Code.
(4) DODD shall collect data during the first year to determine if individuals receiving remote monitoring reduces or replaces the amount of homemaker personal care an individual needs.
(5) DODD shall collect data during the first year to determine if the rate for remote monitoring equipment is cost effective.
(L) Payments made to certified or licensed waiver providers by the DODD 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.
(M) Certified or licensed 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.
(N) Certified or licensed waiver providers of HCBS shall receive payment for the provision of HCBS as indicated in this rule when the following conditions exist:
(1) The waiver service is provided by an independent or agency provider that has certification or licensure for each service they provide in accordance with applicable requirements; and
(2) The waiver service is provided by an independent 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 unless other documentation requirements are specified in this rule; 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 a DODD 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 DODD 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.
(O) Payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.
(P) ODJFS authority.
ODJFS retains the final authority to establish payment rates for waiver services approved under the level one and individual options waivers and has final approval of any policies and rules that govern any component of the medicaid program.
(Q) Due process.
(1) Applicants for waiver enrollment or individuals enrolled on any waiver administered by DODD 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 DODD, and/or the county board of developmental disabilities is required during the hearing proceedings to justify the decision under appeal, in accordance with section 5126.055 of the Revised Code.
(R) Monitoring.
(1) ODJFS will monitor payment 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.
(2) ODJFS and DODD may recover any overpayment identified by requesting voluntary repayment, or through provider payment offsets, or formal adjudicatory or non-adjudicatory recovery proceedings.
Effective: 07/15/2011
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.85, 5111.873, 5111.91 and 5111.871
Rule Amplifies: 5111.85, 5111.873
Prior Effective Dates: 7/1/05, 10/1/07, 12/21/07 (Emer.), 3/20/08, 7/1/10