Chapter 5160-31 Medicaid Home and Community Based Services Waiver Portion of the PASSPORT Program

5160-31-02 Pre-admission screening system providing options and resources today (PASSPORT) HCBS waiver program definitions.

(A) The purpose of this rule is to define the terms used in Chapter 5160-31 of the Administrative Code governing the preadmission screening system providing options and resources today (PASSPORT) home and community-based services (HCBS) waiver program.

As used in this chapter:

(B) "Activities of Daily Living (ADL)" means activities of daily living as defined in rule 5160-3-05 of the Adminstrative Code.

(C) "Assessment" means a face-to-face evaluation used to obtain information about an individual including his or her condition, personal goals and preferences, functional limitations, health status and other factors that are relevant to the authorization and provision of services. Assessment information supports the determination that an individual requires waiver services as well as the development of the person-centered services plan.

(D) "Authorized representative" has the same meaning as defined in rule 5160-1-33 of the Administrative Code.

(E) "C.F.R." means the code of federal regulations.

(F) "Caregiver" means relatives, friend, and/or significant others who voluntarily provide assistance to the individual enrolled in PASSPORT and are responsible for the individual's care on a continuing basis.

(G) "Case manager" means the registered nurse, licensed social worker or licensed independent social worker that ODA's designee employs to plan, coordinate, monitor, evaluate, and authorize services received by individuals enrolled in PASSPORT.

(H) "Case management" means the administrative activities to assess, plan, coordinate, monitor, evaluate, and authorize services, supports and resources provided to an individual enrolled in PASSPORT.

(I) "Centers for medicare and medicaid services (CMS)" means the federal agency that is part of the U.S. department of health and human services, and that administers the medicaid program and approves home and community-based services waivers.

(J) "Certification" means providers are approved by the Ohio department of aging (ODA) to provide services for PASSPORT as established in Chapter 173-39 of the Administrative Code.

(K) "Financial management service (FMS)" is a support provided to waiver participants who direct some or all of their waiver services. In the PASSPORT waiver, this support is conducted as an administrative activity through an entity under contract with the state of Ohio. When used in conjunction with the participant-directed authorities available to individuals enrolled in PASSPORT, this support includes operating a payroll service for participant-employed workers and making required payroll withholdings.

(L) "HCBS" or " Home and community-based services (HCBS)" means services provided under the provisions set forth in 42 C.F.R. 441 Subpart G ( October 1, 2018) that permit individuals to live in a home setting rather than a nursing facility (NF) or hospital. HCBS waiver services are approved by CMS for specific populations and are not otherwise available under the medicaid state plan.

(M) "Home First" means the component of the PASSPORT HCBS waiver program that offers priority enrollment for certain individuals in accordance with section 173.521 of the Revised Code.

(N) "Individual" means a medicaid recipient, a medicaid recipient enrolled in a HCBS program, or person with pending medicaid eligibility who is applying for HCBS waiver enrollment, or other long-term care services

(O) "Individual provider" means a person with a signed medicaid provider agreement with ODM to provide PASSPORT services in rule 5160-31-05 of the Administrative Code, and who meets the PASSPORT waiver program's conditions of participation set forth in rule 5160-31-06 of the Administrative Code and who is not the spouse, parent, stepparent, and/or legal guardian of the individual.

(P) "Instrumental activities of daily living (IADL)" has the same meaning as defined in rule 5160-3-05 of the Administrative Code.

(Q) "Level of care" or "LOC" means the designation describing a person's functional levels and nursing needs pursuant to the criteria defined in rule 5160-3-05 of the Administrative Code.

(R) "Nursing Facility (NF)" has the same meaning as defined in section 5165.01 of the Revised Code.

(S) "ODA's designee" means an entity to which ODA delegates one or more of daily waiver operations. ODA's current designees include the area agencies on aging that ODA lists in rule 173-2-04 of the Administrative Code and catholic social services of the Miami Valley.

(T) "ODM's administrative agency" has the same meaning as "administrative agency" in rule 5160:1-1-01 of the Administrative Code.

(U) "Participant-directed individual provider" means a person with a signed medicaid provider agreement with ODM to provide PASSPORT services in rule 5160-31-05 of the Administrative Code, and who meets the PASSPORT waiver program's conditions of participation set forth in rule 5160-31-06 of the Administrative Code and who is not the spouse, parent, stepparent, and/or legal guardian of the consumer individual.

(V) "PASSPORT" or "PASSPORT HCBS waiver program" means the medicaid-funded component of the PASSPORT program created under section 173.52 of the Revised Code.

(W) "Person-centered services plan" has the same meaning as in rule 5160-44-02 of the Administrative Code.

(X) "Region" means the geographic area in which ODA's designee operates the PASSPORT program.

(Y) "Subregion" means a geographic area located within ODA's designee's region for the purpose of establishing PASSPORT unit rates in rule 5160-31-07 of the Administrative Code.

(Z) "Waiver service provider" means an agency or person with a signed medicaid provider agreement with ODM to provide HCBS waiver services, and who meets the conditions of participation set forth in rule 5160-31-06 of the Administrative Code.

Replaces: 5160-31-02

Effective: 1/1/2019
Five Year Review (FYR) Dates: 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 07/16/1984, 12/22/1986 (Emer.), 03/23/1987, 07/01/1990, 01/14/1996, 09/01/1998, 03/01/2000, 03/03/2001, 07/01/2006, 03/17/2011, 09/29/2011, 03/06/2014

5160-31-03 Eligibility for enrollment in the PASSPORT HCBS waiver program.

(A) To be eligible for the medicaid-funded component of the pre-admission screening system providing options and resources today (PASSPORT) program, an individual must meet all of the following requirements:

(1) The individual must have been determined eligible for medicaid in accordance with Chapters 5160:1-1 to 5160:1- 6 of the Administrative Code.

(2) The cost of waiver services in the person-centered services plan does not exceed the individual cost limit at the time of initial enrollment. The individual cost limit is equal to fourteen thousand and seven hundred dollars per month for waiver services.

(a) If ODA's designee determines that the applicant's waiver service needs cannot be met within the individual cost limit, the individual shall not be enrolled.

(b) Once enrolled in PASSPORT, additional waiver services may be authorized in excess of the individual cost limit with prior approval from ODA .

(c) When additional waiver services that exceed the individual cost limit are not approved , the individual shall be disenrolled from the waiver.

(3) The needed services are not readily available through another source at the level required to allow the individual to live in the community.

(4) The individual agrees to participate in PASSPORT and while enrolled in PASSPORT, shall not be simultaneously enrolled in the state-funded component of the PASSPORT program, the state-funded component of the assisted living program, another medicaid home and community-based program, the residential state supplement (RSS) program, or the program of all inclusive care for the elderly (PACE) .

(5) The individual's health related needs can be safely met in a home and community-based setting as determined by ODA's designee.

(6) The individual will participate in the development of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(7) The individual must require the provision of at least one waiver service on a monthly basis as documented in the individual's approved person-centered services plan.

(8) The individual's attending physician must approve that the services in the person-centered services plan are appropriate to meet the individual's needs. The physician's approval may be either verbal or written. If the approval is verbal, written approval must be obtained within thirty days of the enrollment date. ODA's designee shall be responsible for obtaining the physician's approval.

(9) While enrolled in PASSPORT, the individual must reside in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code and not reside in a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act ( 42 U.S.C. 1382e(e) (July 1, 2018)) residential care facility, adult foster home or another group living arrangement subject to state licensure or certification .

(10) The individual is age sixty or older at the time of enrollment.

(11) The individual must be determined to meet the criteria for an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code and, in the absence of PASSPORT, would require NF services as defined in 42 C.F.R. 440.40 (as in effect on October 1, 2018).

(12) PASSPORT has not reached the CMS-authorized limit on the number of individuals who may enroll on the waiver during the current year.

(B) If, at any time, the individual does not meet any of the eligibility requirements identified in this rule, the individual shall be denied or disenrolled from PASSPORT. In such instances, the individual shall be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

Effective: 1/1/2019
Five Year Review (FYR) Dates: 10/16/2018 and 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 12/22/1986 (Emer.), 03/23/1987, 01/14/1996, 02/22/2001, 01/31/2005, 07/01/2008, 03/17/2011, 03/01/2014, 04/01/2015, 11/25/2016

5160-31-04 Enrollment process for PASSPORT HCBS waiver program.

(A) The Ohio department of aging (ODA) is responsible for the daily operation of the pre-admission screening system providing options and resources today (PASSPORT) home and community- based services (HCBS) waiver. ODA will operate this waiver pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code. ODA will establish processes and procedures to enroll individuals on this waiver.

(B) Individuals who wish to enroll in PASSPORT must have his/her medicaid eligibility determination made by ODM's administrative agency and an assessment of his/her PASSPORT eligibility made by ODA's designee.

(C) If the individual has been determined eligible and a waiver slot is available, the individual shall be enrolled in accordance with the PASSPORT HCBS waiver program's home first component, if applicable, and rule 173-42-03 of the Administrative Code.

(D) ODA's designee shall make the determination of PASSPORT eligibility using the requirements set forth in rule 5160-31-03 of the Administrative Code. .

(E) Any applicant for PASSPORT HCBS waiver program services is entitled to notice and hearing rights as set forth in section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

Replaces: 5160-31-04

Effective: 1/1/2019
Five Year Review (FYR) Dates: 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 07/16/1984, 12/22/1986 (Emer.), 03/23/1987, 07/01/1990, 01/14/1996, 02/22/2001, 10/03/2005 (Emer.), 01/01/2006, 03/17/2011, 09/29/2011, 03/06/2014

5160-31-05 PASSPORT HCBS waiver program covered services.

(A) The purpose of this rule is to establish the services covered by the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) program.

(B) The PASSPORT program benefit package is limited to the following services:

(1) Adult day as set forth in rule 173-39-02.1 of the Administrative Code;

(2) Alternative meals as set forth in rule 173-39-02.2 of the Administrative Code;

(3) Choices home care attendant as set forth in rule 173-39-02.4 of the Administrative Code;

(4) Chore as set forth in rule 173-39-02.5 of the Administrative Code;

(5) Community transition as set forth in rule 173-39-02.17 of the Administrative Code;

(6) Enhanced community living as set forth in rule 173-39-02.20 of the Administrative Code;

(7) Homemaker as set forth in rule 173-39-02.8 of the Administrative Code;

(8) Home care attendant as set forth in rule 173-39-02.24 of the Administrative Code;

(9) Home delivered meals as set forth in rule 173-39-02.14 of the Administrative Code;

(10) Home medical equipment and supplies as set forth in rule 173-39-02.7 of the Administrative Code;

(11) Independent living assistance as set forth in rule 173-39-02.15 of the Administrative Code;

(12) Minor home modification, maintenance and repair as set forth in rule 173-39-02.9 of the Administrative Code;

(13) Non-emergency medical transportation as set forth in rule 173-39-02.13 of the Administrative Code;

(14) Non-medical transportation as set forth in rule 173-39-02.18 of the Administrative Code;

(15) Nutrition consultation as set forth in rule 173-39-02.10 of the Administrative Code;

(16) Out-of-home respite as set forth in rule 173-39-02.23 of the Administrative Code;

(17) Personal care as set forth in rule 173-39-02.11 of the Administrative Code;

(18) Personal emergency response system as set forth in rule 173-39-02.6 of the Administrative Code;

(19) Pest control as set forth in rule 173-39-02.3 of the Administrative Code;

(20) Social work counseling as set forth in rule 173-39-02.12 of the Administrative Code; and

(21) Waiver nursing as set forth in rule 173-39-02.22 of the Administrative Code.

(C) Services shall be delivered by providers in a manner that is consistent with the individual's person-centered services plan as documented in the PASSPORT information management system (PIMS).

(D) If an individual enrolled on PASSPORT is also a participant in the helping ohioans move, expanding (HOME) choice program in accordance with Chapter 5160-51 of the Administrative Code, the individual may, at the individual's discretion, use the HOME choice community transitions service in lieu of, but not in addition to, the community transition service available through the PASSPORT waiver program.

(E) In accordance with the federally approved PASSPORT waiver, the services identified in this paragraph are subject to employer and/or budget authority if elected by the individual. Services shall be provided in accordance with the requirements in paragraph (B) of this rule:

(1) The following services are subject to employer authority, including the ability to hire, fire, and train employees:

(a) Choices home care attendant ; and

(b) Personal care .

(2) The following services are subject to budget authority, including the ability to negotiate reimbursement rates paid to providers furnishing services:

(a) Alternative meals ;

(b) Choices home care attendant;

(c) Home medical equipment and supplies ;

(d) Minor home modification, maintenance and repair ; and

(e) Pest control.

(F) An individual who elects to participant-direct any of the services provided in paragraph (E) of this rule shall be assessed by their case manager to determine the individual's ability to self-direct their services as set forth in rule 173-42-06 of the Administrative Code.

(1) If an individual demonstrates the ability to self-direct their services , the case manager may initiate the orientation process to familiarize the individual with the self-direction of services including the role of the financial management service (FMS).

(2) If an individual is unable to demonstrate the ability to self-direct his or her care and to assume the responsibilities associated with the self-direction authorities in paragraph (E) of this rule, the individual may choose an authorized representative to act on his or her behalf.

(3) If no authorized representative is available, the case manager will assist the individual with obtaining services through ODA-certified long-term care agency providers.

(G) If an individual who is seeking to participant-direct his or her services chooses an authorized representative to act on his or her behalf in accordance with paragraph (F)(2) of this rule, the authorized representative shall not simultaneously serve as the individual's authorized representative and the individual's provider.

Effective: 1/1/2019
Five Year Review (FYR) Dates: 10/16/2018 and 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 07/16/1984, 12/22/1986 (Emer.), 03/23/1987, 07/01/1990, 01/14/1996, 09/01/1998, 07/01/2006, 07/01/2008, 06/28/2009, 03/17/2011, 03/01/2014, 07/01/2014

5160-31-06 Provider conditions of participation for the PASSPORT HCBS waiver program.

(A) The purpose of this rule is to establish the conditions under which providers are able to participate in the preadmission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) waiver program.

(B) In order to obtain a medicaid provider agreement to be a PASSPORT provider furnishing services in rule 5160-31-05 of the Administrative Code the provider shall be certified by the Ohio department of aging (ODA) in accordance with the provisions of Chapter 173-39 of the Administrative Code.

(C) Individuals enrolled in the PASSPORT HCBS waiver shall be given a free choice of qualified providers in accordance with rule 173-42-06 of the Administrative Code.

Effective: 1/1/2019
Five Year Review (FYR) Dates: 10/16/2018 and 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 119.03
Rule Amplifies: 173.52
Prior Effective Dates: 07/16/1984, 12/22/1986 (Emer.), 03/23/1987, 07/01/1990, 01/14/1996, 09/01/1998, 07/01/2006, 03/17/2011, 07/01/2014

5160-31-07 PASSPORT HCBS waiver program rate setting.

The purpose of this rule is to describe the methods used to determine provider rates for the PASSPORT program.

(A) Rates determined under this rule shall not exceed the maximum allowable rates for PASSPORT services in appendix A to rule 5160-1-06.1 of the Administrative Code. Payment for PASSPORT waiver services constitutes payment in full and shall not be construed as a partial payment when the payment amount is less than the provider's usual and customary rate. The provider shall not bill the individual for any difference between the medicaid payment and the provider's rate or request the individual to share in the cost through a co-payment or other similar charge.

(B) PASSPORT rates are established for the services in rule 5160-31-05 of the Administrative Code under the following categories:

(1) Per-job bid rate;

(2) Per-item rate; and

(3) Unit rate.

(C) Rates set within the categories in paragraph (B) of this rule may be:

(1) Participant-directed, in which the individual or his/her designated authorized representative, who is acting on the individual's behalf, may negotiate the reimbursement rate for services furnished by providers as specified in paragraphs (D)(3), (E)(3), (G)(4) , and (H) of this rule.

(2) Statewide, in which the state establishes a rate used on a statewide basis to reimburse for services specified in paragraph (F) of this rule.

(3) Regional, in which the state establishes a regional rate for services specified in paragraph (G) of this rule. The regions in which applicable rates are calculated shall be designated by ODA.

(a) The regional rate for each service shall be the weighted average rate paid in the region using cost and unit data either from the most recently completed state fiscal year or the most recent twelve calendar months for which complete data is available, whichever is later.

(b) ODA or its designee shall enter into a provider agreement with providers in each region. The provider agreement shall do all of the following:

(i) Specify the time period for which the rates shall be in effect;

(ii) Specify the timelines for contracting;

(iii) Define the region/subregions for which the rates will be established;

(iv) Base rates on the units of service as set forth in appendix A to rule 5160-1-06.1 of the Administrative Code;

(v) Reflect the agreed upon rate ; and

(vi) Adjust the regional rate up to the nearest number that is divisible by four, out to two decimal places.

(c) Regional provider rates shall be established as follows:

(i) No provider shall have a rate exceeding the maximum allowable rate for the service as established in appendix A to rule 5160-1-06.1 of the Administrative Code.

(ii) If the state recalculates regional rates for the services in paragraph (G) of this rule, certified providers may either accept the new regional rate or continue to be paid at the rate paid for services prior to the calculation of the regional rate.

(iii) Providers certified after the regional rate is established shall have a provider rate less than or equal to the regional rate.

(4) Group rates are seventy-five per cent of the reimbursement rate the provider would be paid for providing PASSPORT services as specified in paragraphs (D)(2), (F)(2), (G) (2), and (G)(3) of this rule.

(D) For the services listed in this paragraph, a per-job bid rate shall be negotiated between the provider and the individual's case manager.

(1) A per-job bid rate shall be used for the following services:

(a) Chore ;

(b) Community transition ;

(c) Minor home modification, maintenance and repair ;

(d) Non-medical transportation ;

(e) Non-emergency medical transportation;

(f) Pest control ; and

(g) .

(2) Non-emergency medical transportation and non-medical transportation rendered simultaneously by the same provider to more than one individual enrolled in PASSPORT residing in the same household and traveling in the same vehicle to the same destination shall be paid using the group rate that is equal to seventy-five per cent of the provider's per-job bid rate. This shall apply to any combination of non-emergency medical transportation and/or non-medical transportation services.

(3) Minor home modification maintenance and repair and pest control services may be participant -directed services in which the individual enrolled on PASSPORT or his/her authorized representative, acting on the individual's behalf, may negotiate reimbursement rates.

(a) The negotiated rate shall be reviewed by the individual's case manager and reflected on the individual's person-centered service plan prior to service delivery.

(b) Should the individual choose not to negotiate a rate of reimbursement the service shall be reimbursed at a rate proposed by the provider and accepted by the individual and the individual's case manager. The accepted rate shall be reflected on the individual's person-centered service plan.

(E) A per-item rate shall be determined for home medical equipment and supplies service..

(1) The cost of the item shall not exceed the medicaid state plan rate.

(2) The cost of an item that does not have an established medicaid rate shall be paid at a per-item bid rate submitted and agreed to in writing by ODA's designee prior to delivery of the item.

(3) Home medical equipment and supplies services may be participant- directed in which the individual enrolled on PASSPORT or the authorized representative, acting on the individual's behalf, may negotiate reimbursement rates.

(a) The negotiated rate shall be reviewed by the individual's case manager and reflected on the individual's person-centered services plan prior to service delivery.

(b) Should the individual choose not to negotiate a rate the service shall be paid at a rate agreed upon between the provider, the individual and the individual's case manager. The agreed upon rate shall be reflected on the individual's person-centered services plan.

(F) ODA shall establish unit rates for the services listed in this paragraph. No service shall have both a regional and statewide rate set pursuant to this rule.

(1) Statewide unit rates shall be established and used for the following services:

(a) Adult day ;

(b) Enhanced community living ;

(c) Home care attendant ;

(d) Home delivered meals

(e) Out-of-home respite ;

(f) Personal care

(g) Personal emergency response system; and

(h) Waiver nursing .

(2) The services in paragraphs (F)(1)(c), (F)(1)(f), and (F)(1)(h) of this rule, when rendered consecutively during the same visit to more than one but fewer than four PASSPORT individuals in the same household, as identified in the individuals' person-centered service plans, shall be paid to one hundred per cent of the provider's per unit rate set in accordance with paragraph (C) of this rule for one PASSPORT individual and paid a group rate for each subsequent PASSPORT individual in the household receiving services during the visit.

(G) ODA shall establish regional unit rates for the services listed in this paragraph pursuant to the methodology in paragraph (C)(3) of this rule. No service shall have both a regional and statewide rate set pursuant to this rule.

(1) Regional unit rates shall be set for the following services:

(a) Adult day transportation;

(b) Homemaker ;

(c) Social work counseling ;

(d) Nutritional consultation ; and

(e) Independent living assistance .

(2) Adult day transportation services rendered simultaneously by the same provider to more than one individual residing in the same household and traveling in the same vehicle to the same destination shall be paid using a group rate equal to seventy-five per cent of the provider's regional unit rate.

(3) Personal care rendered during the same visit by the same provider to more than one but less than four PASSPORT individuals in the same household, as identified in the individuals' person-centered services plans, shall be paid one hundred per cent of the provider's per unit rate set in accordance with paragraph (C) of this rule for one PASSPORT individual and paid the group rate for each subsequent PASSPORT individual in the household receiving services during the visit.

(H) The services in this paragraph are participant directed and the individual may negotiate unit rates with providers.

(1) The participant directed services include:

(a) Alternative meals ; and

(b) Choices home care attendant .

(2) The individual shall have in effect, before choices home care attendant services are delivered, a signed provider agreement with each ODA-certified participant-directed individual provider delivering services to the individual. The provider agreement shall:

(a) Include the rate 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; and

(d) Be signed by the individual receiving the choices home care attendant service and the HCBS provider.

(3) The rates negotiated by the individual with providers of services in paragraph (H) of this rule shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5160-1-06.1 of the Administrative Code. The negotiated rate shall be reviewed by the individual's case manager and reflected on the individual's person-centered service plan prior to service delivery.

(4) Should the individual choose not to negotiate a rate for any of the services in paragraph (H) of this rule, the service shall be paid at a rate agreed upon by the provider and the individual and the individual's case manager. The agreed upon rate shall be reflected on the individual's person-centered services plan.

(I) The Ohio department of medicaid, or its designee, shall evaluate unit rates within two years of the effective date of this rule and every two years thereafter.

Effective: 1/1/2019
Five Year Review (FYR) Dates: 10/15/2018 and 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 09/01/1998, 03/01/2000, 07/01/2006, 07/01/2008, 03/17/2011, 07/01/2011 (Emer.), 09/29/2011, 03/01/2014, 07/01/2014, 01/01/2017