5101:3-41-20 Self-empowered life funding - payment standards as administered by the department of developmental disabilities.

(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 the self-empowered life funding waiver program as a component of the medicaid program and as administered by the Ohio 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 the self-empowered life funding waiver administered by the DODD shall be subject to the payment standards set forth in this rule.

(D) The standards and procedures set for prior authorization as defined in rule 5101:3-41-12 of the Administrative Code shall not apply to individuals enrolled on the self-empowered life funding waiver.

(E) For purposes of payment, HCBS services provided to individuals enrolled on the self-empowered life funding waiver must meet the definition of the waiver service as federally approved.

(F) Budget limitations.

(1) Children receiving services under the self-empowered life funding waiver shall be subject to a budget limitation of twenty-five thousand dollars for the individual's waiver eligibility span.

(2) Adults receiving services under the self-empowered life funding waiver shall be subject to a budget limitation of forty-thousand dollars for the individual's waiver eligibility span.

(G) Individuals enrolled in the self-empowered life funding HCBS program administered by DODD shall be subject to the payment standards set forth in this rule and in the following rules of the Administrative Code as specified:

(1) Community inclusion shall be in accordance with rule 5123:2-9-42 of the Administrative Code.

(2) Residential respite shall be in accordance with rule 5123:2-9-34 of the Administrative Code.

(3) Supported employment- enclave shall be in accordance with rules 5123:2-9-16 and 5123:2-9-19 of the Administrative Code.

(4) Participant-directed goods and services shall be in accordance with rule 5123:2-9-45 of the Administrative Code.

(5) Participant/family stability assistance shall be in accordance with rule 5123:2-9-46 of the Administrative Code.

(6) Support brokerage shall be in accordance with rule 5123:2-9-47 of the Administrative Code.

(7) Clinical/therapeutic intervention shall be in accordance with rule 5123:2-9-41 of the Administrative Code.

(8) Residential and community respite shall be in accordance with rule 5123:2-9-34 of the Administrative Code.

(9) Functional behavioral assessment shall be in accordance with rule 5123:2-9-43 of the Administrative Code.

(10) Adult day support shall be in accordance with rules 5123:2-9-17 and 5123:2-9-19 of the Administrative Code.

(11) Vocational habilitation shall be in accordance with rules 5123:2-9-14 and 5123:2-9-19 of the Administrative Code.

(12) Integrated employment shall be in accordance with rule 5123:2-9-44 of the Administrative Code.

(13) Non medical transportation shall be in accordance with rules 5123:2-9-18 and 5123:2-9-19 of the Administrative Code.

(14) Remote monitoring shall be in accordance with rule 5123:2-9-35 of the Administrative Code.

(15) Remote monitoring equipment shall be in accordance with rule 5123:2-9-35 of the Administrative Code.

(H) For purposes of payment, HCBS services provided to individuals enrolled on the self-empowered life funding waiver must meet the definition of the waiver service as federally approved.

(I) Payment for self-empowered life funding waiver services shall not exceed the rates established in appendix A to this rule.

(J) 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.

(K) 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. 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.

(L) Certified or licensed waiver providers shall submit claims for the self-empowered life funding services through an approved financial management services agency designated by the DODD and ODJFS.

(M) 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 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 residential respite as one of the waiver services shall not be considered a resident of an ICF/MR if an ICF/MR is providing the residential respite service.

(b) An ICF/MR providing residential respite services for any DODD administered waiver program that offers such services shall not bill medicaid through the ICF/MR program. Payments for residential respite services shall be made through the waiver program in which the individual is enrolled.

(N) Payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.

(O) ODJFS authority.

ODJFS retains the final authority to establish payment rates for waiver services approved under the self-empowered life funding waiver and has final approval of any policies and rules that govern any component of the medicaid program.

(P) 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.

(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.

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Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.873 , 5111.91 , 5111.871
Rule Amplifies: 5111.85 , 5111.873