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

5160-31-02 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 providingoptions and resources today (PASSPORT) home and community based services(HCBS) waiver program.

As used in this chapter:

(B) "ADL" means activities of daily living including bathing; grooming; toileting; dressing; eating; and mobility which refers to bed mobility, transfer, andlocomotion as defined in rule 5160-3-08 of theAdministrative 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, functionallimitations, health status and other factors that are relevant to the authorization andprovision of services. Assessment information supports the determination that anindividual requires waiver services as well as the development of the service plan.

(D) "Authorized representative" means a person, eighteen years of age or older, who is chosen by and acts on behalf of an individual who is applying for, or receiving,medical assistance. In accordance with rule 5160:1-2- 01.2 of theAdministrative Code, the individual must provide a written statement naming theauthorized representative and the duties that the named authorized representativemay perform on the individual's behalf.

(E) "CDJFS" means a county department of job and family services.

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

(G) "Caregiver" means relatives, friend, and/or significant others who voluntarilyprovide assistance to the individual enrolled in PASSPORT and areresponsible for the individual's care on a continuing basis.

(H) "Case management" means a set of person centered activities provided by thePASSPORT administrative agency (PAA) that are undertaken to ensure that the individual enrolled in PASSPORT receives appropriate andnecessary services. Under a HCBS waiver, these activities may include, but are notnecessarily limited to, assessment, service plan development, service planimplementation and service monitoring as well as assistance in accessing waiver,state plan, and other services and resources as needed.

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

(J) "HCBS" or "home and community-based services" means services furnished under theprovisions set forth in 42 C.F.R. 441 Subpart G (October 1, 2009) that permitindividuals 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 nototherwise available under the medicaid state plan.

(K) "CMS" means the centers for medicare and medicaid services (CMS), a federalagency that is part of the U.S. department of health and human services, andadministers the medicaid program and approves home and community-basedservices waivers.

(L) "FMS" or "financial management service" is a support provided to waiverparticipants who direct some or all of their waiver services. In the PASSPORTwaiver, this support is conducted as an administrative activity through an entityunder contract with the state of Ohio. When used in conjunction with the self-direction authorities available to individualsenrolled in PASSPORT, this support includes operating a payroll service forparticipant-employed workers and making required payroll withholdings.

(M) "Home first" means the component of the PASSPORT HCBS waiver program thatoffers priority enrollment in the waiver for certain individuals in accordance withsection 173.521 of the Revised Code.

(N) "IADL" means an instrumental activity of daily living as defined in rule 5160-3-08 of the Administrative Code and includes shopping; mealpreparation; laundry; community access activities including telephoning,transportation, legal or financial; and environmental activities including housecleaning, heavy chores, yard work or maintenance.

(O) "Individual" means a medicaid recipient, a medicaid recipient enrolled in a HCBSprogram, or person with pending medicaid eligibility who is applying forHCBS waiver enrollment , or other long-term care services.

(P) "Individual provider" means a person with a signed medicaid provider agreementwith ODM to provide PASSPORT services in rule 5160-31-05 of theAdministrative Code, and who meets the PASSPORT waiver program's conditionsof participation set forth in rule 5160-31-06 of the Administrative Code and who isnot the spouse, parent, stepparent, and/or legal guardian of the consumer.

(Q) "Keys amendment facility", as found in section 1616(e) of the Social Security Act(as in effect on January 1, 2014), includes, but is not limited to, aninstitution, foster home or group living arrangement, including those licensed bythe state, in which a significant number of recipients of supplemental securityincome benefits are residing or are likely to reside.

(R) "Level of care" or "LOC" means the designation describing a person'sfunctional levels and nursing needs pursuant to the criteria set forth in rules 5160-3-05, 5160-3-06, 5160-3-07 and 5160-3-08 of the Administrative Code.

(S) "NF" means a nursing facility as defined in section 5165.01 of the RevisedCode.

(T) "ODA" means the Ohio department of aging.

(U) " ODM" means the Ohio department of medicaid.

(V) "PAA" means PASSPORT administrative agency.

(W) "PASSPORT" or "PASSPORT HCBS waiver program" means an HCBS waiverprogram that serves individuals who are aged sixty and over who have a LOCrequired for placement in a NF if the waiver program were not available, and meetthe PASSPORT eligibility criteria and enrollment requirements in Chapter 5160-31 of the Administrative Code.

(X) "Region" means the geographic area in which a PAA administers thePASSPORT program.

(Y) "Service plan" means a written, person centered plan between the individual, the individual's case manager at the PAA and, asapplicable, the individual's caregiver(s). The service plan specifies theservices that are provided to the individual, regardless of funding source,to address the individual's care needs as identified in the individual's assessment.

(Z) "Subregion" means a geographic area located within a PAA region for the purposeof establishing PASSPORT unit rates as set forth in rule 5160-31-07of the Administrative Code.

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

Effective: 03/06/2014
R.C. 119.032 review dates: 11/29/2013 and 03/06/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02, 173.52
Prior Effective Dates: 7/16/84, 12/22/86 (Emer.), 3/23/87, 7/1/90, 1/14/96, 9/1/98, 3/1/00, 3/3/01, 7/1/06, 3/17/11, 9/29/11

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

(A) Before an individual can be eligible for enrollment in the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) waiver program, all of the following criteria must be met:

(1) The individual must have been determined eligible for medicaid in accordance with rules 5160:1-2-03 and 5160:1-1-58 of the Administrative Code.

(2) The waiver service cost of the twelve-month service plan does not exceed the individual cost limit. The individual cost limit is equal to fourteen thousand and seven hundred dollars per month for waiver services.

(a) If the PASSPORT administrative agency (PAA) 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 not be authorized in excess of the fourteen thousand and seven hundred dollars per month individual cost limit. When a change in condition occurs that necessitates the provision of additional waiver services, referrals to other community services, including institutional services, will be explored.

(c) If the individual's waiver service needs exceed the individual cost limit of fourteen thousand seven hundred dollars per month, 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 shall not be simultaneously enrolled in another HCBS medicaid waiver, the residential state supplement (RSS) program, or the program of all inclusive care for the elderly (PACE) while enrolled in PASSPORT.

(5) The individual's health related needs can be safely met in a home setting as determined by the PAA.

(6) Prior to PASSPORT enrollment, the attending physician must approve that the services 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. The PAA shall be responsible for obtaining the physician's approval.

(7) While receiving PASSPORT, the individual must not be a resident of either a Keys amendment facility, a hospital or a nursing facility (NF) as defined in rule 5160-31-02 of the Administrative Code. For purposes of this rule, a resident of a Keys amendment facility is an individual who receives services from the facility and is not a family member of the owner or operator of the facility.

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

(9) 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 and 42 C.F.R. 440.150 ( as in effect on October 1, 2014).

(10) PASSPORT has not reached the centers for medicare and medicaid services (CMS)-authorized limit on the number of individuals who may enroll on the waiver during the current year.

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

(B) If, at any time, the individual fails or ceases to meet any of the eligibility criteria 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: 4/1/2015
Five Year Review (FYR) Dates: 12/08/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02, 173.52
Prior Effective Dates: 12/22/86 (Emer.), 3/23/87, 1/14/96, 2/22/01, 1/31/05, 7/1/08, 3/17/11, 3/1/14

5160-31-04 Enrollment process for the pre-admission screening system providing options and resources today (PASSPORT) HCBS waiver program.

(A) The Ohio department of aging (ODA) is responsible for the daily operation of the PASSPORT home and community based services (HCBS) waiver. ODA willoperate this waiver pursuant to an interagency agreement with the Ohio departmentof medicaid in accordance with sections 5162.35 and 5166.21 of the Revised Code. ODA will establishprocesses and procedures to enroll individuals on this waiver.

(B) Individuals who wish to enroll in PASSPORT must have a medicaid eligibility determination made by the county department of job and family services (CDJFS)and an assessment of PASSPORT waiver eligibility made by the PASSPORTadministering agency (PAA). The individual may contact either the CDJFS or thePAA to start the enrollment process and the two agencies shall coordinateprocessing the request for enrollment into the PASSPORT HCBS waiver program:

(1) Individuals initially contacting the CDJFS will complete the JFS 07200 "Request for Cash, Food , and Medical Assistance" (rev. 12/2012) and the JFS 02399 "Request for Medicaid Home andCommunity Based Services" (rev. 5/2013) in accordance with rules 5160:1-2- 01.2 and 5160:1-2- 01.6 of theAdministrative Code. The CDJFS will notify the PAA of the individual'sapplication for waiver services. The PAA will initiate contact with theindividual to complete the enrollment process.

(2) Individuals initially contacting the PAA will receive an in-person assessment to determine eligibility for the PASSPORT HCBS waiver program. The PAAmay assist the individual in applying for medicaid if not already initiated bycompleting the JFS 07200 and JFS 02399.

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

(D) The PAA shall make the determination of PASSPORT eligibility using the criteria set forth in rule 5160-31-03 of the Administrative Code. The PAAshall notify the CDJFS of the results of the PASSPORT eligibility determination.

(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 division5101:6 of the Administrative Code.

Effective: 03/06/2014
R.C. 119.032 review dates: 11/29/2013 and 03/06/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02, 173.52
Prior Effective Dates: 7/16/84, 12/22/86 (Emer.), 3/23/87, 7/1/90, 1/14/96, 2/22/01, 10/03/05 (Emer.), 1/1/06, 3/17/11, 9/29/11

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) wavier program.

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

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

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

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

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

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

(6) Emergency response system services as set forth in rule 173-39-02.6 of the Administrative Code;

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

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

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

(10) Home delivered meal services as set forth in rule 173-39-02.14 of the Administrative Code;

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

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

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

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

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

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

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

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

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

(20) Transportation services as set forth in rule 173-39-02.13 of the Administrative Code ; and

(21) Waiver nursing services 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 service 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 demonstration 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) If an individual receives enhanced community living services, per the federally approved waiver, the consumer may not receive either personal care or homemaker services available through the PASSPORT waiver program.

(F) 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 are to be furnished in accordance with the requirements in paragraph (B) of this rule:

(1) The following services are subject to employer authority, which includes but is not limited to, the ability to hire, fire, and train employees:

(a) Choices home care attendant service; and

(b) Personal care services.

(2) The following services are subject to budget authority, which includes but is not limited to, the ability to negotiate reimbursement rates paid to providers furnishing services:

(a) Alternative meals service;

(b) Choices home care attendant service

(c) Home medical equipment and supplies service;

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

(e) Pest control service

(G) An individual who elects to self-direct any of the services provided in paragraph (F) 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 care 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 the 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 (F) 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.

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

Effective: 07/01/2014
R.C. 119.032 review dates: 03/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02, 173.52
Prior Effective Dates: 7/16/84, 12/22/86 (Emer.), 3/23/87, 7/1/90, 1/14/96, 9/1/98, 7/1/06, 7/1/08, 6/28/09, 3/17/11, 3/1/14

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) or its designee 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: 07/01/2014
R.C. 119.032 review dates: 03/20/2014 and 07/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02, 173.39, 173.52
Prior Effective Dates: 7/16/84, 12/22/86 (Emer.), 3/23/87, 7/1/90, 1/14/96, 9/1/98,7/1/06,03/17/2011

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 pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) medicaid waiver program.

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

(B) PASSPORT reimbursement 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 their 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 that is 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 reimbursement 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 contract with providers in each region. The contract 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 rate the provider is willing to accept ; and

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

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

(i) No provider shall have a contract rate that exceeds the rate for that service as established in 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 reimbursed at the rate paid for services prior to the calculation of the regional rate.

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

(4) Group rates, in which a provider that is furnishing certain services to more than one individual enrolled on PASSPORT is reimbursed at a rate that is seventy-five per cent of the reimbursement rate the provider would be paid for furnishing 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 services;

(b) Community transition services;

(c) Minor home modification services;

(d) Non-medical transportation services;

(e) Pest control services; and

(f) Transportation services.

(2) Transportation and non-medical transportation services 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 reimbursed using a group rate that is equal to seventy-five per cent of the provider's per job bid rate. This applies to any combination of transportation and/or non-medical transportation services.

(3) Minor home modification and pest control services may be participant directed services in which the individual enrolled on PASSPORT or their 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 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 consumer and the consumer's case manager. The accepted rate shall be reflected on the consumer's 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 reimbursed at a per item bid rate submitted and agreed to in writing by the PASSPORT administrative agency (PAA) 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 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 consumer and the consumer's case manager. The accepted rate shall be reflected on the consumer's service plan.

(F) The Ohio department of aging (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 rates shall be established and used for the following services:

(a) Adult day services;

(b) Emergency response system services;

(c) Enhanced community living services;

(d) Home care attendant services;

(e) Out-of-home respite services;

(f) Personal care services provided by ODA-certified long-term care consumer-directed personal care provider; and

(g) Waiver nursing services.

(2) The services in paragraphs (F)(1)(d), (F)(1)(f), and(F)(1)(g) of this rule, when rendered during the same visit to more than one but less than four PASSPORT consumers in the same household, as identified in the consumers' service plans, shall be reimbursed using a group rate equal to one hundred per cent of the provider's per unit rate set in accordance with paragraph (C) of this rule for one PASSPORT consumer. The provider shall be reimbursed seventy-five per cent of the provider's per unit rate for each subsequent PASSPORT consumer 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, except personal care services provided under paragraph (F)(1)(f) of this rule, 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 services transportation;

(b) Home delivered meals services;

(c) Homemaker services;

(d) Social work counseling services;

(e) Nutritional consultation services

(f) Personal care services; and

(g) Independent living assistance services.

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

(3) Personal care services, except personal care services provided under paragraph (F) of this rule, that are rendered during the same visit by the same provider to more than one but less than four PASSPORT consumers in the same household, as identified in the consumers' service plans, shall be reimbursed using a group rate equal to one hundred per cent of the provider's regional per unit rate set in accordance with paragraph (C) of this rule for one PASSPORT consumer. The provider shall be reimbursed seventy-five per cent of their regional per unit rate for each subsequent PASSPORT consumer in the household receiving services during the visit.

(4) Homemaker services may be participant directed services in which the individual enrolled on PASSPORT or their 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 service plan prior to service delivery.

(b) Should the individual choose not to negotiate a rate of reimbursement the service shall be reimbursed in accordance with paragraph (G) of this rule. The accepted rate shall be reflected on the consumer's service plan.

(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 service; and

(b) Choices home care attendant services.

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

(a) Include the rate of reimbursement 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;

(d) Be signed by the choices HCBS waiver program participant and the HCBS provider.

(3) The rates negotiated by the choices HCBS waiver consumer with providers of services in this paragraph 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 consumer's case manager and reflected on the consumer's service plan prior to service delivery.

(4) Should the consumer choose not to negotiate a rate of reimbursement for any of the services in this paragraph, the service shall be reimbursed at a rate proposed by the provider and accepted by the consumer and the consumer's case manager. The accepted rate shall be reflected on the consumer's service 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.

Replaces: 5160-31-07

Effective: 07/01/2014
R.C. 119.032 review dates: 03/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02, 173.52
Prior Effective Dates: 9/1/98, 3/1/00, 7/1/06, 7/1/08, 7/1/11 (Emer.), 3/17/11, 9/29/11, 3/1/2014