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

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 rate for services furnished by providers as specified in paragraphs (D)(3), (E)(3), , and (H)(1) of this rule.

(2) Statewide, in which the state establishes a rate used on a statewide basis to pay for services specified in paragraph (F)(1) of this rule.

(3) Regional, in which the state establishes a regional rate for services specified in paragraph (G)(1) 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 are 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 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) Community transition;

(b) Home maintenance and repair;

(c) Home modification,

(d) Non-emergency medical transportation;

(e) Non- medical transportation;

(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) Home modification and and

home maintenance and chore 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 rates.

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

(b) Should the individual choose not to negotiate a rate the service shall be paid at a rate proposed by the provider and accepted by the individual and ODA's designee. 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 rates.

(a) The negotiated rate shall be reviewed by ODA's designee 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 ODA's designee. 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) Community integration;

(c) Enhanced community living;

(d) Home care attendant;

(e) Home delivered meals

(f) Out-of-home respite;

(g) Personal care

(h) Personal emergency response system; and

(i) Waiver nursing.

(2) The services in paragraphs (F)(1)(d), (F)(1)(g), and (F)(1)(i) 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;and

(d) Nutritional consultation

(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)(1) 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 ODA's designee 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)(1) 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: 7/1/2019
Five Year Review (FYR) Dates: 4/9/2019 and 07/01/2024
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, 01/01/2019