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 the individual options or level one HCBS programs administered by DODD shall be subject to the payment standards set forth in rules 5101:3-41-18 and 5101:3-41-19 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) Homemaker personal care rate modification for former residents of developmental centers.
(1) DODD shall pay an add-on rate modification for routine homemaker personal care services to providers serving individuals that are former residents of developmental centers in accordance with section 263.20.70 Amended Substitute House Bill No. 153 of the 129th General Assembly. The add-on will apply if the following conditions are met:
(a) The individual was a resident of a developmental center prior to enrollment in the individual options waiver; and
(b) The homemaker personal care service is identified in the individual service plan and the individual began receiving the service on or after July 1, 2011; and
(c) The director of DODD determines that the homemaker personal care add-on is warranted by the individual's special circumstances, including the individual's diagnosis, service needs, or length of stay at the developmental center, and that serving the individual through the individual options waiver is fiscally prudent for the medicaid program.
(2) The homemaker personal care rate add-on modification referenced in paragraph (G) of this rule shall be limited to fifty-two cents for each fifteen minute unit of routine homemaker personal care service provided to the individual.
(3) The homemaker personal care rate add-on modification amount shall be limited to former developmental center residents during the first year of their waiver enrollment and shall apply for enrollments beginning on or after July 1, 2011 and ending June 30, 2013.
(4) DODD shall provide ODJFS with supporting documentation of the homemaker personal care rate add-on for former developmental center residents upon request.
(H) 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.
(I) 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.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.85, 5111.873, 5111.91, 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, 7/15/11