Ohio Admin. Code 5123-9-18 - Home and community-based services waivers - non-medical transportation under the individual options, level one, and self-empowered life funding waivers
(A) Purpose
This rule defines non-medical transportation and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions
(17)(18)
"Participant-directed homemaker personal care" has the same meaning as in rule
5123-9-32 of the Administrative
Code.
(18)(19) "Passenger" means
a traveler in a vehicle who does not participate in operation of the
vehicle.
(19)(20) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule
5123-5-02 of the Administrative
Code.
(20)(21) "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 includes the items delineated in paragraph (H) of this
rule to validate payment for medicaid services.
For the purposes of this rule, the following definitions apply:
(1) "Adult day support" has the
same meaning as in rule
5123-9-17 of the Administrative
Code.
(2) "Agency provider" means
an entity that directly employs at least one person in addition to a director
of operations for the purpose of providing services for which the entity is
certified in accordance with rule
5123-2-08 of the Administrative
Code.
(3) "Career planning" has the
same meaning as in rule
5123-9-13 of the Administrative
Code.
(4) "Commercial transportation"
means transportation provided by a public bus transit system, a public light
rail transit system, or a taxicab that:
(a) Transports passengers in
accordance with an established fare schedule; and
(b) Has auditable records
demonstrating that the transportation provided is available to, and used
primarily by, the general public (i.e., not solely persons who receive services
and supports for persons who are aged, blind, or disabled).
(4)
"Commercial transportation" means an entity that transports
passengers in accordance with a published usual and customary fare schedule and
is either:
(a)
A
bus or rail system owned or operated by a government authority;
or
(b)
An on-demand taxicab service as defined in paragraph
(B)(17) of this rule.
(5) "Commute" means the number of miles
driven when one or more individual is riding in a vehicle while non-medical
transportation at the per-mile rate is being provided.
(6) "Competitive integrated
employment" has the same meaning as in rule 5123-2-05 of the Administrative
Code.
(6)
"Competitive integrated employment" means work
(including self-employment) that is performed on a full-time or part-time
basis:
(a)
For
which an individual is:
(i)
Compensated:
(a)
At a rate that is
not less than the higher of the rate specified in the Fair Labor Standards Act
of 1938, 29 U.S.C.
206(a)(1), as in effect on
the effective date of this rule, or the rate specified in the applicable state
or local minimum wage law and is not less than the customary rate paid by the
employer for the same or similar work performed by other employees who do not
have disabilities, and who are in similar occupations by the same employer and
who have similar training, experience, and skills; or
(b)
In the case of an
individual who is self-employed, yields an income that is comparable to the
income received by persons without disabilities, who are self-employed in
similar occupations or similar tasks and who have similar training, experience,
and skills.
(ii)
Eligible for the level of benefits provided to other
full-time and part-time employees;
(b)
At a location
where the individual interacts with persons without disabilities to the same
extent as employees who are not receiving home and community-based
services;
(c)
That is not performed in:
(i)
Dispersed
enclaves in which individuals work in a self-contained unit within a company or
service site in the community or perform multiple jobs in the company, but are
not integrated with nondisabled employees of the company; or
(ii)
Mobile work
crews comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the
community.
(d)
That, as appropriate, presents opportunities for career
advancement that are similar to those for persons without disabilities who have
similar positions.
(7) "County board" means a county board of
developmental disabilities.
(8)
"Department" means the Ohio department of developmental disabilities.
(9) "Group employment support" has the same
meaning as in rule
5123-9-16 of the Administrative
Code.
(10) "Homemaker/personal
care" has the same meaning as in rule
5123-9-30 of the Administrative
Code.
(11) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule
5123-2-09 of the Administrative
Code and does not employ, either directly or through contract, anyone else to
provide the services.
(12)
"Individual" means a person with a developmental disability or for purposes of
giving, refusing to give, or withdrawing consent for services, the person's
guardian in accordance with section
5126.043 of the Revised Code or
other person authorized to give consent.
(13) "Individual employment support" has the
same meaning as in rule
5123-9-15 of the Administrative
Code.
(14) "Individual service
plan" means the written description of services, supports, and activities to be
provided to an individual.
(15)
"Modified vehicle" means:
(a) A motor vehicle
to be used upon public streets and highways that has been structurally modified
in a permanent manner to meet the physical or behavioral needs of the
individual being transported; or
(b) A motor vehicle that has been designed,
constructed, or fabricated and equipped to be used upon public streets and
highways for transportation of individuals who require use of a wheelchair and
that:
(i) Has permanent fasteners to secure a
wheelchair to the floor or side of the vehicle to prevent wheelchair
movement;
(ii) Has safety harnesses
or belts in the vehicle for the purpose of securing individuals in
wheelchairs;
(iii) Is equipped with
a stable access ramp specifically designed for wheelchairs or a hydraulic lift
specifically designed for wheelchairs; and
(iv) Is inspected, on each day the vehicle is
used to provide non-medical transportation, by the first driver of the vehicle
and prior to transporting an individual in a wheelchair, to ensure the
permanent fasteners, safety harnesses or belts, and access ramp or hydraulic
lift are working. The inspection will be documented by the driver that conducts
the inspection.
(16) "Non-medical transportation" means
transportation used by an individual to get to,
from, between, or among:
(a)
To get to, from, between, or among:
(a)(i) A
place of employment;
(b)(ii) A location where
adult day support, career planning, group employment support, individual
employment support, or vocational habilitation is provided to the
individual;
(c)(iii) A volunteer
activity;
(d)(iv) A post-secondary
educational program;
(e)(v) An internship or
practicum; and/or
(f)(vi) A drop-off or
transfer location from which the individual is then transported to or from one
of the places specified in paragraphs (B)(16)(a) to
(B)(16)(e)
(B)(16)(a)(i) to
(B)(16)(a)(v) of this rule.
(b)
Via one of the
following modes:
(i)
Transport provided by an agency provider or an
independent provider in a modified vehicle or a non-modified vehicle at a
per-trip rate or a per-mile rate;
(ii)
Transport
provided by an agency provider or an independent provider that is an operator
of "commercial transportation" as defined in paragraph (B)(4) of this rule at
the provider's published usual and customary fare; or
(iii)
Purchase by a
county board of a prepaid card, pass, token, or voucher used by an individual
to access commercial transportation.
(17)
"On-demand
taxicab service" means an entity that:
(a)
Operates one or
more motor vehicles to transport passengers between locations and at times of
the day or night determined by the passengers (i.e., not on fixed or
pre-determined routes or schedules established by the operator) and in
accordance with a published usual and customary fare schedule;
(b)
Is licensed or
otherwise authorized to operate as a taxicab by a municipality, county, or
other local authority; and
(c)
Derives more than
fifty per cent of its revenue from operating in the manner described in
paragraphs (B)(17)(a) and (B)(17)(b) of this rule.
(21) "Taxicab" means a motor vehicle
that carries passengers for a fare, and which is licensed or otherwise
authorized to operate as a taxicab by a municipality, county, or other local
authority.
(22)
"Vocational habilitation" has the same meaning as in rule
5123-9-14 of the Administrative
Code.
(23) "Volunteer activity"
means an activity performed by an individual for which the individual receives
no payment.
(C) Provider
qualifications
(1) Non-medical transportation
will be provided by an independent provider, an agency provider, or an operator
of commercial transportation that meets the requirements of this rule and, with the exception of a bus or rail system owned or
operated by a government authority, that has a medicaid provider
agreement with the Ohio department of medicaid.
(2) An applicant seeking approval to provide
non-medical transportation will complete and submit an application and adhere
to the requirements of as applicable, rule
5123-2-08 or
5123-2-09 of the Administrative
Code.
(3) An applicant seeking
approval to provide non-medical transportation as an independent provider will
present the applicant's driving record prepared by the bureau of motor vehicles
no earlier than fourteen calendar days prior to the date of application for
initial or renewal provider certification. A person having six or more points
on the person's driving record is prohibited from providing non-medical
transportation.
(4) An independent
provider of non-medical transportation will:
(a) Hold a valid driver's license as
specified by Ohio law.
(b) Have
valid liability insurance as specified by Ohio law.
(c) Immediately notify the department, in
writing, if the independent provider accumulates six or more points on the
independent provider's driving record or has a driver's license suspended or
revoked.
(d) Complete testing for
controlled substances by a laboratory certified for such testing within
thirty-two hours and complete testing for blood alcohol level by an entity
certified for such testing within eight hours of a motor vehicle accident
involving the driver while the driver was providing non-medical transportation
when:
(i) The accident involves the loss of
human life; or
(ii) The driver
receives a citation under state or local law for a moving traffic violation
arising from the accident, if the accident involved:
(a) Bodily injury to any person who, as a
result of the injury, immediately receives medical treatment away from the
scene of the accident; or
(b) One
or more motor vehicles incurred disabling damage as a result of the accident,
requiring the motor vehicle to be transported away from the scene by a tow
truck or other motor vehicle.
(5) An agency provider of non-medical
transportation will:
(a) Ensure that each
driver holds a valid driver's license as specified by Ohio law.
(b) Ensure that each driver is covered by
valid liability insurance as specified by Ohio law.
(c) Obtain, for each driver, a driving record
prepared by the bureau of motor vehicles no earlier than fourteen calendar days
prior to the date of initial employment as a driver and at least once every
three years thereafter. A person having six or more points on the person's
driving record is prohibited from providing non-medical
transportation.
(d) Require each
driver to immediately notify the agency provider, in writing, if the driver
accumulates six or more points on the driver's driving record or has a driver's
license suspended or revoked.
(e)
Ensure that each driver completes testing for controlled substances by a
laboratory certified for such testing within thirty-two hours and completes
testing for blood alcohol level by an entity certified for such testing within
eight hours of a motor vehicle accident involving the driver while the driver
was providing non-medical transportation when:
(i) The accident involves the loss of human
life; or
(ii) The driver receives a
citation under state or local law for a moving traffic violation arising from
the accident, if the accident involved:
(a)
Bodily injury to any person who, as a result of the injury, immediately
receives medical treatment away from the scene of the accident; or
(b) One or more motor vehicles incurred
disabling damage as a result of the accident, requiring the motor vehicle to be
transported away from the scene by a tow truck or other motor
vehicle.
(f)
Develop and implement written policies and procedures regarding vehicle
accessibility, vehicle maintenance, and requirements for vehicle
drivers.
(6) An
agency provider or an independent provider submitting
claims for payment as an operator of commercial transportation will
demonstrate ownership and operation of an enterprise that meets the definition
of "commercial transportation" in paragraph (B)(4) of this rule.
(D)
Meeting an individual's needs for non-medical transportation
(5)(6) Nothing in this
rule will be interpreted to prevent a provider of homemaker/personal care or
participant-directed homemaker/personal care from transporting an individual
to, from, between, or among the venues described in paragraph (B)(16)
paragraphs (B)(16)(a)(i) to (B)(16)(a)(vi) of this
rule and billing for homemaker/personal care in accordance with rule
5123-9-30 of the Administrative
Code or participant-directed homemaker/personal care in accordance with rule
5123-9-32 of the Administrative
Code and transportation in accordance with rule
5123-9-24 of the Administrative
Code.
(1) There are three modes of
non-medical transportation:
(a) Non-medical transportation at
the per-trip rate;
(b) Non-medical transportation at
the per-mile rate; and
(c) Non-medical transportation
provided by operators of commercial transportation at the published usual and
customary fare.
(1)
An individual's non-medical transportation needs may be
met through a combination of the modes of non-medical transportation described
in paragraph (B)(16)(b) of this rule.
(2)
An
individual's non-medical transportation needs may be met through a combination
of non-medical transportation at the per-trip rate, non-medical transportation
at the per-mile rate, and/or non-medical transportation provided by operators
of commercial transportation at the published usual and customary
fare. Unless otherwise specified in an individual service plan:
(a) Non-medical transportation at the
per-trip rate will be authorized for transporting an individual between the
individual's residence and a location specified in paragraphs
(B)(16)(a) to (B)(16)(f)
(B)(16)(a)(i) to (B)(16)(a)(vi) of this
rule.
(b) Non-medical
transportation at the per-mile rate will be authorized for transporting an
individual in circumstances other than circumstances described in paragraph
(D)(2)(a) of this rule.
(3) Non-medical transportation will be
provided pursuant to an individual service plan that conforms to the
requirements of rule
5123-4-02 of the Administrative
Code. Whenever possible, family, neighbors, friends, or community agencies that
transport people without charge are to be used to meet an individual's needs.
An individual's need for non-medical transportation to be provided in a
modified vehicle is to be documented in the individual service plan.
(4) The service and support administrator
will ensure that a budget limitation for non-medical transportation is
determined in accordance with rule
5123-9-19 of the Administrative
Code when the need for non-medical transportation has been identified through
development of the individual service plan for an individual enrolled in the
individual options waiver.
(5)
Prior to authorizing non-medical transportation at the
special per-trip payment rate to transport one individual to or from
competitive integrated employment as described in paragraph (I)(3) of this
rule, the service and support administrator will:
(a)
Verify that the
individual's employment meets the definition of "competitive integrated
employment" set forth in paragraph (B)(6) of this rule.
(b)
Estimate the
distance of a one-way trip between the individual's residence and the
individual's employer.
(c)
Make the individual aware of the potential impact of
the special per-trip payment rate for competitive integrated employment on the
individual's budget.
(E) Requirements
for service delivery of non-medical transportation at the per-trip rate or
non-medical transportation at the per-mile rate in a modified vehicle or a
vehicle equipped to transport five or more passengers
When a modified vehicle or a vehicle equipped to transport five or more passengers is used for non-medical transportation at the per-trip rate or non-medical transportation at the per-mile rate, the vehicle will:
(1) Be equipped with:
(a) Secure storage space for removable
equipment and passenger property;
(b) A communication system, which may include
cellular communication, capable of two-way communication; and
(c) A fire extinguisher and an emergency
first-aid kit that are safely secured.
(2) Be inspected, on each day the vehicle is
used to provide non-medical transportation, by the first driver of the vehicle
and prior to transporting an individual, to ensure the lights, windshield
washer/wipers, emergency equipment, mirrors, horn, tires, and brakes are
working. The inspection will be documented by the driver that conducts the
inspection.
(3) Be inspected and
determined to be in good working condition at a frequency of at least once
every twelve months by the Ohio state highway patrol safety inspection unit or
by a mechanic certified by an automotive dealership or the national institute
for automotive service excellence.
(F) Requirements for service delivery of
non-medical transportation at the per-trip rate
(1) Individuals must be in the vehicle during
the times the provider bills non-medical transportation at the per-trip
rate.
(2) A provider will not bill
for:
(a) Adult day support, career planning,
group employment support, individual employment support, or vocational
habilitation during the same time non-medical transportation at the per-trip
rate is provided.
(b)
Homemaker/personal care or participant-directed homemaker/personal care
provided by the driver during the same time non-medical transportation at the
per-trip rate is provided.
(G) Requirements for service delivery of
non-medical transportation at the per-mile rate
(1) Individuals must be in the vehicle during
the times the provider bills non-medical transportation at the per-mile rate
except that billing may occur when non-medical transportation is being provided
on behalf of an individual who is receiving individual employment support or
the job development or worksite accessibility components of career
planning.
(2) A provider may bill
for:
(a) Adult day support, career planning,
group employment support, individual employment support, or vocational
habilitation during the same time non-medical transportation at the per-mile
rate is provided.
(b)
Homemaker/personal care or participant-directed homemaker/personal care
provided by the driver during the same time non-medical transportation at the
per-mile rate is provided.
(H) Documentation of services
(2)(3) Service
documentation for non-medical transportation at the per-mile rate will include,
in addition to the items required in paragraph (H)(1) of this rule, the number
of miles in each distinct commute, as indicated by recording beginning and
ending odometer readings or via tracking or mapping by a global positioning
system.
(3)(4) Service
documentation for non-medical transportation by operators of commercial
transportation will include each of the following to validate payment for
medicaid services:
(1) Service documentation for non-medical
transportation at the per-trip rate and non-medical transportation at the
per-mile rate will include each of the following to validate payment for
medicaid services:(h)(j)
Signature
Written or
electronic signature of the driver of the
vehicle or initials of the driver of the vehicle
if the signature and corresponding initials are on file with the
provider.
(i)(k) Names of all
passengers, including paid staff and
volunteers,
individuals who were in the
vehicle during any portion of the trip and/or commute.
(a) Mode of non-medical
transportation provided (i.e., per-trip or per-mile).
(b) Date of service.
(c) License plate number of vehicle used to
provide service.
(d) Name of
individual receiving service.
(e)
Medicaid identification number of individual receiving service.
(f) Name of provider.
(g) Provider identifier/contract
number.
(h)
Origination and destination points of non-medical
transportation provided.
(i)
Times the trip or commute started and
stopped.
(j) Times the trip or commute
started and stopped.
(2)
Service
documentation for non-medical transportation at the special per-trip payment
rates to transport one individual at a time to or from competitive integrated
employment as described in paragraph (I)(3) of this rule will include, in
addition to the items required in paragraph (H)(1) of this rule:
(a)
The name and
address of the individual's employer.
(b)
The number of
miles in each one-way trip, as indicated by recording beginning and ending
odometer readings or via tracking or mapping by a global positioning
system.
(a) Mode of non-medical
transportation provided (i.e., commercial transportation) and specific type
(i.e., by public bus transit system, public light
rail transit system, or taxicab
bus, rail, or
on-demand taxicab service).
(b) Date of service or, in the case of a
purchase of bus or light rail fares, taxicab tokens,
or similar types of travel
prepaid cards,
passes, tokens, or vouchers to be used on more than one date, date of
purchase.
(c) Name of individual
receiving service.
(d) Medicaid
identification number of individual receiving service.
(e) Name of provider.
(f) Provider identifier/contract
number.
(g) Receipt issued by
operator of commercial transportation indicating the amount paid.
(5)
A
county board that purchases prepaid cards, passes, tokens, or vouchers used by
an individual to access commercial transportation in accordance with this rule
will annually submit a report of the purchases to the department in a format
prescribed by the department.
(I) Payment standards
(3)(4) Payment rates for
non-medical transportation at the per-mile rate are established on a per-person
basis, depending on the number of individuals being transported, regardless of
funding source, and whether the service is provided in a modified vehicle or in
a non-modified vehicle. The modified vehicle rate will be applied for each
individual being transported when at least one individual requires the use of a
modified vehicle, as specified in the individual service plan.
(4)(5) An
operator of commercial transportation will be paid its published usual and
customary fare which is the same rate charged to the general public as
documented by auditable records. The published usual and customary fare will be
listed as a rate for a one-way trip or a prepaid card,
pass, token, or voucher and include defined surcharges, if
applicable.
(5)(7)
Payment for non-medical transportation provided to individuals enrolled in the
individual options waiver will not exceed the budget limitations contained in
appendix B to rule
5123-9-19 of the Administrative
Code.
(1) The billing units, service
codes, and payment rates for non-medical transportation provided January 1,
2024 through June 30, 2024 are contained in appendix A to this rule. The
billing units, service codes, and payment rates for non-medical transportation
provided on or after July 1, 2024 are contained in appendix B to this
rule.
(1)
The billing units, service codes, and payment rates for
non-medical transportation are contained in appendix A to this
rule.
(2) Payment rates for
non-medical transportation at the per-trip rate, except
the special per-trip payment rates described in paragraph (I)(3) of this
rule, are established on a per-person basis, irrespective of the number
of individuals being transported simultaneously, and based on the county
cost-of-doing-business category for the county in which the preponderance of
service was provided. The cost-of-doing-business categories are contained in
appendix C
B
to this rule.
(3)
Special per-trip payment rates may apply when an agency
provider or an independent provider transports one individual at a time to or
from competitive integrated employment. The special per-trip payment rates are
based on the distance of the one-way trip and whether the service is provided
in a modified vehicle or a non-modified vehicle. The modified vehicle rate will
be applied only for an individual who requires the use of a modified vehicle,
as specified in the individual service plan.
(6)
A county board that purchases prepaid cards, passes,
tokens, or vouchers used by an individual to access commercial transportation
in accordance with this rule will do so at the published usual and customary
fare and will not seek reimbursement for any administrative costs associated
with making the purchase on the individual's behalf.
(J) Transition period for complying
with requirements for operators of commercial transportation
(1) A provider of non-medical
transportation acting as an operator of commercial vehicles described in rule
5123-9-18 of the Administrative Code as it existed on July 15, 2023, that meets
the requirements for an operator of commercial transportation in accordance
with this rule, will be authorized by the department to provide non-medical
transportation as an operator of commercial transportation.
(2) A provider of non-medical
transportation acting as an operator of commercial vehicles described in rule
5123-9-18 of the Administrative Code as it existed on July 15, 2023 for
purposes of transporting individuals to or from competitive integrated
employment, that does not meet the requirements for an operator of commercial
transportation in accordance with this rule, will be afforded no less than one
year after July 16, 2023 to realign service delivery and billing practices with
this rule to be authorized by the department to provide non-medical
transportation as an operator of commercial transportation or will be
authorized by the department to provide non-medical transportation as either an
agency provider or an independent provider, as applicable.
(3) A provider of non-medical
transportation acting as an operator of commercial vehicles described in rule
5123-9-18 of the Administrative Code as it existed on July 15, 2023 for
purposes of transporting individuals to or from a destination described in
paragraph (B)(16) of this rule other than competitive integrated employment,
that does not meet the requirements for an operator of commercial
transportation in accordance with this rule, will be afforded no less than
ninety days after July 16, 2023 to realign service delivery and billing
practices with this rule to be authorized by the department to provide
non-medical transportation as an operator of commercial transportation or will
be authorized by the department to provide non-medical transportation as either
an agency provider or an independent provider, as applicable.
Notes
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 01/01/2007, 10/01/2007, 07/23/2012, 07/01/2014, 04/01/2017, 02/01/2020, 06/11/2020 (Emer.), 01/01/2022, 07/01/2022, 07/16/2023, 01/01/2024
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