5123:2-9-31 Home and community-based services waivers - homemaker/ personal care daily billing unit for sites where individuals enrolled in the individual options waiver share services.

(A) Purpose

This rule establishes a daily billing unit for homemaker/personal care when individuals share the services of the same provider at the same site as part of the home and community-based services individual options waiver administered by the Ohio department of developmental disabilities. The daily billing unit for individuals/sites that qualify shall be used instead of the fifteen-minute billing unit established in rule 5123:2-9-30 of the Administrative Code. Requirements set forth in paragraphs (C) and (D) of rule 5123:2-9-30 of the Administrative Code apply to the homemaker/personal care daily billing unit.

(B) Definitions

(1) "Adult family living" has the same meaning as in rule 5123:2-9-32 of the Administrative Code.

(2) "Adult foster care" has the same meaning as in rule 5123:2-9-33 of the Administrative Code.

(3) "Business day" means a day of the week, excluding Saturday, Sunday, or a legal holiday as defined in section 1.14 of the Revised Code.

(4) "Cost projection tool" means the web-based analytical tool, developed and administered by the department, used to project the cost of home and community-based services identified in the individual service plans of individuals enrolled in individual options and level one waivers. The department shall publish any changes to the cost projection tool thirty calendar days prior to implementation.

(5) "County board" means a county board of developmental disabilities.

(6) "Daily billing unit" means the amount of a provider's payment that is apportioned to each individual who lives at the site and shares homemaker/personal care services with others. The daily billing unit is determined via the daily rate application in accordance with planning information entered by the county board and actual service information entered by the provider of homemaker/personal care services.

(7) "Daily rate application" means the web-based analytical tool, developed and administered by the department, used by county boards to apportion the cost of homemaker/personal care services identified in the individual service plans of individuals enrolled in the individual options waiver who share the services of the same provider at the same site.

(8) "Department" means the Ohio department of developmental disabilities.

(9) "Direct service hours" means the direct staff time spent delivering homemaker/personal care services. A direct service hour is comprised of four fifteen-minute billing units.

(10) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(11) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(12) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(14) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (F) of this rule to validate payment for medicaid services.

(15) "Site cost span" means a period of time for which the projected total costs or direct service hours for a site where individuals share homemaker/personal care services of a provider are not expected to change. An individual may have one or more site cost spans during one waiver eligibility span.

(16) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Circumstances excluded from the daily billing unit approach

(1) Individuals who receive services and supports in adult family living settings shall do so in accordance with rule 5123:2-9-32 of the Administrative Code.

(2) Individuals who receive services and supports in adult foster care settings shall do so in accordance with rule 5123:2-9-33 of the Administrative Code.

(3) Individuals who do not share the homemaker/personal care services of the same provider at the same site shall remain on the fifteen-minute billing unit approach established in rule 5123:2-9-30 of the Administrative Code.

(4) Individuals who share occasional or time-limited services of a provider in addition to their primary residential provider shall remain on the fifteen-minute billing unit approach established in rule 5123:2-9-30 of the Administrative Code for the occasional or time-limited homemaker/personal care services of their non-primary provider. Examples include but are not limited to:

(a) Individuals who live together and share homemaker/personal care services of a provider and who use a second homemaker/personal care provider for recreational activities; and

(b) Individuals who live in different homes who travel with a provider who is not their residential provider to a recreational event such as bowling, respite, or camp on a monthly or weekly basis.

(5) Individuals who live alone and share services with a neighbor or other eligible person shall remain on the fifteen-minute billing unit approach established in rule 5123:2-9-30 of the Administrative Code.

(D) Calculation of the individual daily billing unit

(1) The process for assigning a funding range, determining an individual funding level, and projecting the cost of an individual's services, set forth in rule 5123:2-9-06 of the Administrative Code, shall be followed.

(2) The process for establishing behavioral support and/or medical assistance rate modifications, set forth in rule 5123:2-9-30 of the Administrative Code, shall be followed.

(3) For situations where there is at least one staff person serving more than one individual during sleep hours and of those individuals, at least one individual's individual service plan calls for routine homemaker/personal care during the sleep hours, while at the same time at least one other individual has a need for on-site/on-call homemaker/personal care, the provider shall be paid at the routine homemaker/personal care rate as set forth in rule 5123:2-9-30 of the Administrative Code, which shall be determined by the number of awake staff and the number of individuals who are receiving routine homemaker/personal care. The cost of that rate shall be apportioned so that the individuals receiving on-site/on-call homemaker/personal care shall be charged the on-site/on-call rate as set forth in rule 5123:2-9-30 of the Administrative Code and the individuals receiving routine homemaker/personal shall be charged an equal share of the remainder of the cost. The following examples are provided to illustrate how the rates are determined and how the cost of those rates is apportioned. The examples utilize rates in rule 5123:2-9-30 of the Administrative Code for cost-of-doing-business category one.

(a) Example 1. Four individuals live together and have one staff person during sleep hours. One individual receives routine homemaker/personal care and the other three individuals receive on-site/on-call homemaker personal care.

Example 1

Routine homemaker/personal care base rate 1:1

$ 4.84

On-site/on-call homemaker/personal care 1:4

$ 3.60

Individual 1 (1/4 of on-site/on-call homemaker/personal care 1:4)

$ 0.90

Individual 2 (1/4 of on-site/on-call homemaker/personal care 1:4)

$ 0.90

Individual 3 (1/4 of on-site/on-call homemaker/personal care 1:4)

$ 0.90

Individual 4 (routine homemaker/personal care base rate -remainder)

$ 2.14

Total payment for 1 staff

$ 4.84

(b) Example 2. Five individuals live together and have one staff person during sleep hours. Two individuals receive routine homemaker/personal care and the other three individuals receive on-site/on-call homemaker/personal care.

Example 2

Routine homemaker/personal care base rate 1:2

$ 5.18

On-site/on-call homemaker/personal care 1:5

$ 3.60

Individual 1 (1/5 of on-site/on-call homemaker/personal care 1:5)

$ 0.72

Individual 2 (1/5 of on-site/on-call homemaker/personal care 1:5)

$ 0.72

Individual 3 (1/5 of on-site/on-call homemaker/personal care 1:5)

$ 0.72

Individual 4 (routine homemaker/personal care base rate - 1/2 remainder)

$ 1.51

Individual 5 (routine homemaker/personal care base rate - 1/2 remainder)

$ 1.51

Total payment for 1 staff

$ 5.18

(4) Using the cost projection tool, the service and support administrator or other county board designee, with input from members of the individual's team, shall project the service utilization for the individuals who share services based on factors including but not limited to: a typical usage pattern and identified waiver eligibility span; adjustments based on past history, holidays, day service site closings, and weekends; and other anticipated changes to direct service hours. The result shall include total planned homemaker/personal care costs based on individual service plans for the site and a total projected number of service hours for the site. These projections include any individual's prior authorization requests that have been approved pursuant to rule 5123:2-9-07 of the Administrative Code.

(5) The daily rate application shall include:

(a) Total planned homemaker/personal care costs for the site based on individual service plans for individuals who are sharing homemaker/personal care services of the same provider at the site;

(b) Total estimated homemaker/personal care hours for the site to be provided; and

(c) Each individual's authorized funding for homemaker/personal care services.

(6) After homemaker/personal care services are provided at the site, the provider shall enter into the daily rate application, the number of direct service hours rendered for all individuals for a specific seven-day time span, or up to a fourteen-day time span if the daily billing unit is expected to exceed the maximum medicaid payment rate for the seven-day time span, and the specific dates that each individual received homemaker/personal care services at the site. Using the results from the cost projection tool, the daily rate application determines the provider's direct service hourly rate for that site. The daily rate application then calculates the maximum homemaker/personal care payment to the provider for that period. The daily rate application then determines how the total payment to that provider for that period shall be apportioned to each individual's authorized budget, resulting in a daily billing unit for each individual for each day that services were provided. The provider then uses that information to prepare a claim for payment.

(7) When changes occur at the site that affect the total estimated direct service hours, total planned homemaker/personal care costs based on individual service plans, or an individual's predicted ongoing participation at the site, the county board shall enter changes into the cost projection tool for a new, prospective site cost span. These changes shall be made with any necessary changes to the individual service plan and the cost projection and payment authorization for the individual(s) living at the site who will be affected by these changes.

(a) If, during a site cost span, there is a change of service needs for an individual that may impact the total estimated direct service hours, total planned homemaker/personal care costs based on individual service plans, or an individual's predicted ongoing participation at the site, the provider shall notify the county board. The provider and the county board shall work together to identify potential solutions.

(b) If the individual, county board, or provider wishes to convene a meeting to discuss a change of service needs for an individual during a site cost span, that meeting shall occur within ten business days of the day the request was made. Discussion shall occur in accordance with paragraph (C)(7) of rule 5123:2-9-06 of the Administrative Code.

(E) The director of the department reserves the right to allow a provider of homemaker/personal care services to continue to use the fifteen-minute billing unit in the event of a unique and/or extenuating circumstance. This right shall be exercised in consultation with the Ohio department of medicaid.

(F) Documentation of services Service documentation for homemaker/personal care when individuals share the services of the same provider at the same site shall include each of following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individuals receiving services each day.

(5) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(6) Medicaid identification number of the individuals receiving services.

(7) Name of provider.

(8) Provider identifier/contract number.

(9) Written or electronic signature of the person delivering the service or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(G) Payment standards

(1) The billing process and payment for homemaker/personal care services when individuals share the services of the same provider at the same site shall be at the daily billing unit for each individual based on that individual's apportioned share of the services rendered at the site and the number of days each person receives services pursuant to the daily rate application. The service codes for the homemaker/personal care daily billing unit are contained in the appendix to this rule.

(2) Agency providers of homemaker/personal care may bill for each day the individual receives homemaker/personal care through the agency.

(3) Independent providers of homemaker/personal care may bill for each day the homemaker/personal care service is delivered by the provider.

(4) Payment for homemaker/personal care shall not include room and board, items of comfort or convenience, or costs for the maintenance, upkeep, and improvement of the home.

(H) Monitoring

(1) Providers, county boards, and the department shall have access to both utilization reports and reports generated by the daily rate application in order to monitor estimated services and actual services provided at each specific site. This information shall be made available to the Ohio department of medicaid upon request.

(2) The department shall monitor the ongoing progress of the daily billing unit approach through a series of fiscal control and quality assurance procedures including: validation of total expenditures and total hours that are entered by the county board into the cost projection tool; verification that daily billing units are supported by appropriate documentation; and verification that provider service hours rendered are reported appropriately. Each type of procedural monitoring shall take place in each region of the state and shall be summarized in a report to the Ohio department of medicaid every six months.

(3) The Ohio department of medicaid reserves the right to perform independent oversight reviews as part of its general oversight functions, in addition to the department's monitoring activities described in paragraph (H)(2) of this rule.

Replaces: 5123:2-9-31

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Effective: 1/1/2016
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.045, 5123.049, 5123.16, 5166.21
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5166.21
Prior Effective Dates: 12/21/2007 (Emer.), 03/20/2008, 07/01/2010