5160-33-07 Assisted living home and community based services (HCBS) waiver rate setting.

(A) The purpose of this rule is to describe the methods used to determine provider rates for the assisted living HCBS waiver as set forth in appendix A to rule 5160-1- 06.5 of the Administrative Code.

(B) Provider rates will be determined for the following categories:

(1) Per job bid rate or deposit made.

(2) Unit rate.

(C) A per job bid rate or deposit made shall be determined on a per job basis for the community transition service as set forth in rule 173-39-02.17 of the Administrative Code. The cost per job shall be reimbursed at a per job bid rate that is negotiated and approved by Ohio department of aging's (ODA) designee and accepted by the individual. The per job bid rate includes the cost of the purchase, delivery, and set-up of items. Deposits made include set-up fees or deposits for utility service access.

(D) A unit rate shall be based on a three-tiered model, and shall not exceed the amounts in appendix A to rule 5160-1- 06.5 of the Administrative Code. These rates will be used for assisted living services as set forth in rule 173-39-02.16 of the Administrative Code.

(1) The rate for assisted living services for each individual shall be determined by the ODA's designee through an assessment of the individual's service needs in four areas:

(a) Cognitive impairments,

(b) Medication administration,

(c) Nursing services, and

(d) Functional impairments.

(2) The assisted living HCBS waiver provider must agree to provide the services in the individual's person-centered service plan at the rate determined by the assessment.

(E) ODA certified assisted living providers shall only be reimbursed for assisted living services authorized by ODA's designee and reflected on the individual's person-centered service plan.

(F) Assisted living service payment constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's charge. The provider may not bill the individual of assisted living HCBS waiver program services for any difference between the medicaid payment and the provider's charge or request that the individual share in the cost through a co-payment or other similar charge.

(G) The assisted living service payment is for assisted living services as defined in rule 173-39-02.16 of the Administrative Code and does not include payment for room and board as calculated pursuant to rule 5160-33-03 of the Administrative Code, which is the responsibility of the individual.

Effective: 4/1/2017
Five Year Review (FYR) Dates: 12/27/2016 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/06, 3/22/08, 9/19/09, 9/29/2011