(A) The purpose of this rule is to establish how the rates of reimbursement are set for choices HCBS waiver program services.
(B) Choices HCBS waiver program providers must be long-term care providers certified by the Ohio department of aging (ODA) with an effective medicaid provider agreement in place before service delivery is initiated.
(C) Consumers enrolled in the choices HCBS waiver and may negotiate reimbursement rates with ODA-certified long-term care providers for certain choices HCBS waiver program covered services .
(1) Consumers enrolled in the choices HCBS waiver may negotiate rates for the following services specified in rule 5101:3-32-05 of the Administrative Code:
(a) Home care attendant service (HCAS);
(b) Alternative meals;
(c) Home medical equipment and supplies;
(d) Pest control; and
(e) Minor home modification, maintenance, and repair services.
(2) The consumer shall have in effect, before HCAS services are delivered, a signed agreement with each ODA-certified consumer-directed individual provider delivering HCAS services to the consumer. The agreement shall:
(a) Include the rate of reimbursement negotiated with the provider;
(b) Specify the time period the rates shall be in effect;
(c) Base rates on the units of service as set forth in Chapter 173-39 of the Administrative Code;
(d) Be signed by the choices HCBS waiver program participant and the HCAS provider.
(3) The rates negotiated by the choices HCBS waiver consumer with providers of services in paragraph (C) of this rule shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code. The negotiated rate shall be reviewed by the consumer's case manager and reflected on the consumer's service plan prior to service delivery.
(4) Should the consumer choose not to negotiate a rate of reimbursement for any of the services in paragraph (C) of this rule, the service shall be reimbursed at a rate proposed by the provider and accepted by the consumer and the consumer's case manager. The accepted rate shall be reflected on the consumer's service plan and shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code.
(D) ODA certified long-term care providers shall be reimbursed in accordance with an agreement signed between the provider and the PASSPORT administrative agency (PAA) for the following services:
(1) Adult day health;
(2) Home delivered meals;
(3) Personal emergency response system; and
(4) Home medical equipment and supplies.
The reimbursement rates contained in the agreement shall be set in accordance with rule 5101:3-31-07 of the Administrative Code. The rate shall be reflected on the consumer's service plan and shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code.
(E) Payment for choices HCBS wavier covered services constitutes payment in-full and may not be construed as a partial payment when the payment amount is less than the provider's usual and customary charge. The provider may not bill the consumer for any difference between the medicaid payment and the provider's charge or request the recipient to share in the cost through a co-payment or other similar charge. The provider shall accept medicaid payment as payment in full.
R.C. 119.032 review dates: 07/14/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85 , 173.403
Prior Effective Dates: 8/30/01, 7/1/05, 7/1/11 (Emer.)