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Ohio Laws and Rules
(A) Purpose
The purpose of this rule is to specify the conditions under which agency providers and county boards of mental retardation and developmental disabilities (county boards) certified by the Ohio department of mental retardation and developmental disabilities (ODMRDD) to provide adult day support, as defined in rule 5123:2-9-17 of the Administrative Code, may contract with and reimburse providers certified by the Ohio department of aging(ODA) for adult day support services provided to individuals enrolled on home and community-based services (HCBS) waivers administered by ODMRDD.
(B) Definitions
(1) “Adult day support services provided through contract with ODA-certified providers” means adult day support services, as defined in paragraph (B)(1) of rule 5123:2-9-17 of the Administrative Code, that are delivered in accordance with the requirements of rule 173-39- 02.1 of the Administrative Code.
(2) “ODA” means the Ohio department of aging as established by section 121.02 of the Revised Code.
(3) “ODA-certified provider” means an agency that is certified by ODA as a long-term care provider that meets the conditions of participation contained in rule 173-39-02 of the Administrative Code.
(C) Payment rates
Agency providers and county boards that contract with ODA-certified providers in accordance with this rule shall be reimbursed at the lesser of the charges that they include on the claims they submit for payment or the statewide payment rate for the waiver service that is delivered, as defined in the appendix to this rule.
(D) Standards and requirements for contracting with ODA-certified providers of adult day support services
(1) The agency provider or county board shall retain documentation on file that verifies that the ODA-certified provider of adult day support services:
(a) Maintains current long-term care agency provider certification by ODA to provide enhanced and/or intensive adult day services in adult day service centers, as defined in rule 173-39- 02.1 of the Administrative Code.
(b) Requires all employees and subcontractors who provide adult day support services to comply with rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety.
(c) Participates in annual on-site provider structural compliance reviews conducted by ODA in accordance with rule 173-39-04 of the Administrative Code.
(d) Meets the requirements of rule 173-39-04 of the Administrative Code within forty-five business days from each date a structural compliance review report is mailed from the ODA designee.
(E) Acuity assessments, staff intensity group assignments, and budget limitations
(1) Service and support administrators (SSAs) employed by county boards shall implement all requirements contained in paragraph (E) of rule 5123:2-9-19 of the Administrative Code for purposes of calculating the budget limitation for each individual receiving adult day support services provided through contract with an ODA-certified provider. Budget limitations are contained in appendix B to rule 5123:2-9-19 of the Administrative Code.
(2) In addition, the SSA will assign to the individual a separate budget limitation for the provision of non-medical transportation services to access adult day support services provided through contract with ODA-certified providers. These budget limitations are also contained in appendix B to rule 5123:2-9-19 of the Administrative Code.
(F) Individual service plan (ISP) planning and administrative review processes
(1) SSAs employed by county boards shall implement all requirements contained in paragraphs (G)(1), (G)(3), (G)(4), (G)(5), (G)(6), and (G)(7) of rule 5123:2-9-19 of the Administrative Code for purposes of developing an ISP for each individual receiving adult day support services provided through contract with an ODA-certified provider.
(2) Applicants for and recipients of adult day support services provided through contract with an ODA-certified provider are eligible to request an administrative review under paragraph
(K) of rule 5123:2-9-19 of the Administrative Code for the purpose of altering the budget limitation resulting from administration of the ODMRDD acuity assessment instrument.
(G) Billing units and payment conditions
(1) A unit of adult day support services provided through contract with an ODA-certified provider does not include transportation time.
(2) Adult day support services provided through contract with an ODA-certified provider shall be billed in fifteen-minute units or a daily billing unit depending on the amount of time an individual is directly receiving these services.
(3) Units of service shall be determined according to the following calculations:
(a) A daily billing unit shall be used when between five and seven hours of adult day support services are provided through contract by the same ODA-certified provider in one calendar day to one individual.
(b) A fifteen-minute billing unit shall be used when less than five or more than seven hours of adult day support services are provided through contract by the same ODA-certified provider in one calendar day to one individual. The number of units is equivalent to the total number of minutes of service provided in one calendar day divided by fifteen minutes. One additional unit of service may be added to this quotient if the remainder equals eight or more minutes of service.
(4) Notwithstanding the requirements of paragraph (F) of rule 173-39- 02.1 of the Administrative Code, ODA-certified providers of contracted adult day support services are not required to arrange or provide non-medical transportation services for individuals, but may provide non-medical transportation services directly or through a subcontract, if selected by the individual.
(5) ODA-certified providers of contracted adult day support services are subject to the applicable provider and vehicle standards for non-medical transportation services contained in rule 5123:2-9-18 of the Administrative Code and must be appropriately certified by ODMRDD in order to bill for these services.
(H) Documentation of service delivery
Documentation for the provision of adult day support services provided through contract with an ODA-certified provider shall occur in accordance with the provisions of rule 173-39- 02.1 of the Administrative Code.
(I) Applicability of other rules
Except as otherwise provided in this rule, all of the provisions in rules 5123:2-9-17 and 5123:2-9-19 of the Administrative Code are applicable to adult day support services provided through contract with an ODA-certified provider.
APPENDIX
SERVICE CODES AND PAYMENT RATES FOR ADULT DAY SUPPORT
SERVICES PROVIDED THROUGH CONTRACT
WITH ODA-CERTIFIED PROVIDERS
See Appendix at http://www.registerofohio.state.oh.us/pdfs/5123/2/9/5123$2-9-20_PH_FF_N_APP1_20080310_0820.pdf
Replaces: 5123:2-9-20
Effective: 03/20/2008
R.C. 119.032 review dates: 03/20/2013
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.045, 5111.871, 5111.873
Rule Amplifies: 5123.04, 5123.045, 5111.871, 5111.873
Prior Effective Dates: 12/21/2007 (Emer.)