5101:3-41-19 Level one waiver-payment standards.

(A) Purpose.

The purpose of this rule is to establish the payment standards for the level one waiver 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 5166.02 ( 5111.85 ) and 5166.23 , ( 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 medicaid (ODM) in accordance with sections 5162.35 , ( 5111.91 ) and 5166.21 ,( 5111.871 ) of the Revised Code.

(C) Individuals enrolled in the level one 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) Informal respite shall be in accordance with rule 5123:2-9-21 of the Administrative Code.

(2) Community respite shall be in accordance with rule 5123:2-9-22 of the Administrative Code.

(3) Environmental accessibility adaptations shall be in accordance with rule 5123:2-9-23 of the Administrative Code.

(4) Transportation shall be in accordance with rule 5123:2-9-24 of the Administrative Code.

(5) Specialized medical equipment and supplies shall be in accordance with rule 5123:2-9-25 of the Administrative Code.

(6) Personal emergency response systems shall be in accordance with rule 5123:2-9-26 of the Administrative Code.

(7) Emergency assistance under the level one waiver shall be in accordance with rule 5123:2-9-27 of the Administrative Code.

(8) Homemaker personal care shall be in accordance with rule 5123:2-9-30 of the Administrative Code.

(9) Adult day services shall be in accordance with rule 5101:3-41-15 of the Administrative Code.

(10) Home-delivered meals shall be in accordance with rule 5123:2-9-29 of the Administrative Code.

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

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

(D) For purposes of payment, HCBS services provided to individuals enrolled on the level one waiver must meet the definition of the waiver service as defined in the federally approved waiver document.

(E) Payment for level one waiver services shall not exceed the rates established in appendix A to this rule.

(F) 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.

(G) 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.

(H) 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.

(I) 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.

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

(K) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the level one waiver and has final approval of any policies and rules that govern any component of the medicaid program.

(L) Monitoring.

(1) ODM 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) ODM and DODD may recover any overpayment identified by requesting voluntary repayment, or through provider payment offsets, or formal adjudicatory or non-adjudicatory recovery proceedings.

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Effective: 09/01/2013
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.873
Rule Amplifies: 5111.85 , 5111.873 , 5111.91 , 5111.871
Prior Effective Dates: 3/19/2012