Ohio Admin. Code 5123-9-26 - Home and community-based services waivers - self-directed transportation under the individual options, level one, and self-empowered life funding waivers

(A) Purpose

This rule defines self-directed transportation and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

For the purposes of this rule, the following definitions apply:

(1) "Agency provider" has the same meaning as in 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.

(2) "Department" means the Ohio department of developmental disabilities.

(3) "Financial management services entity" means a governmental entity and/or another third-party entity designated by the department to perform necessary financial transactions on behalf of individuals who receive participant-directed services.

(4) "Independent provider" has the same meaning as in 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.

(5) "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.

(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(7) "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 shall:

(i) Have Has permanent fasteners to secure a wheelchair to the floor or side of the vehicle to prevent wheelchair movement;

(ii) Have Has safety harnesses or belts in the vehicle for the purpose of securing individuals in wheelchairs;

(iii) Be Is equipped with a stable access ramp specifically designed for wheelchairs or a hydraulic lift specifically designed for wheelchairs; and

(iv) Be Is inspected, on each day the vehicle is used to provide self-directed 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 shall be documented by the driver that conducts the inspection.

(8) "Participant-directed budget" means the total amount of annual waiver funding available for participant-directed services in the individual service plan of an individual who chooses to receive participant-directed services. An individual may reallocate funds among participant-directed services as long as reallocation is preceded by a corresponding revision to the individual service plan.

(9) "Self-directed transportation" means a service purchased through the participant-directed budget, that enables an individual to access activities and opportunities available in the broader community such as competitive integrated workplaces, integrated community participation and contribution (e.g., advocacy activities and events), community resources, and businesses consistent with the individual service plan. Self-directed transportation enhances independence as it is available around the clock, including on weekends and holidays, to accommodate an individual's scheduled and spontaneous transportation needs.

(a) Self-directed transportation includes:

(i) Purchase of prepaid vouchers, cards, passes, or tokens to access modes of ground transportation available to the general public such as modes available from regional transit authorities and ride-hailing services (e.g., taxicab, "Lyft," or "Uber") at the usual and customary rate or fare; and

(ii) Per-mile or per-trip reimbursement made to a person who meets the provider qualifications in paragraph (C) of this rule and who has a written agreement for provision of self-directed transportation with the individual being transported.

(b) An individual's self-directed transportation budget for a waiver eligibility span is determined based on the individual's needs and consideration of the individual's preferences and available funds.

(10) "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 shall include includes the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(11) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Rules 5123-2-08 and 5123-2-09 of the Administrative Code do not apply to providers of self-directed transportation.

(2) Self-directed transportation shall will be provided by:

(a) A vendor of ground transportation available to the general public; or

(b) A person who receives per-mile or per-trip reimbursement in accordance with a written agreement for provision of self-directed transportation with the individual being transported; or

(c) An agency provider or independent provider certified by the department to provide non-medical transportation in accordance with rule 5123-9-18 of the Administrative Code or transportation in accordance with rule 5123-9-24 of the Administrative Code that agrees to provide self-directed transportation in accordance with this rule.

(3) A person or entity that provides self-directed transportation shall will:

(a) Meet the requirements of this rule; and

(b) Be determined qualified to provide self-directed transportation by the financial management services entity; and

(c) Hold a medicaid provider agreement with the Ohio department of medicaid or operate under the medicaid provider agreement held by the financial management services entity.

(4) A person seeking authorization to receive per-mile or per-trip reimbursement for self-directed transportation shall will apply to the financial management services entity in the manner prescribed by the financial management services entity. The financial management services entity is to ensure that each person seeking authorization:

(a) Presents the person's driving record prepared by the bureau of motor vehicles no earlier than fourteen calendar days prior to the date of the person's application. A person having six or more points on the person's driving record is prohibited from providing self-directed transportation.

(b) Holds a valid driver's license as specified by Ohio law.

(c) Has valid liability insurance as specified by Ohio law.

(d) Completes a background investigation in accordance with rule 5123-2-02 of the Administrative Code and:

(i) Is not included in one or more of the databases described in paragraphs (C)(2)(a) to (C)(2)(f) of rule 5123-2-02 of the Administrative Code; and

(ii) Does not have a conviction for, has not pleaded guilty to, or has not been found eligible for intervention in lieu of conviction for any of the offenses listed or described in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code if the corresponding exclusionary period as specified in paragraph (E) of rule 5123-2-02 of the Administrative Code has not elapsed.

(5) A person authorized by the financial management services entity to receive per-mile or per-trip reimbursement for self-directed transportation shall will immediately notify the financial management services entity, in writing, if the person accumulates six or more points on the person's driving record or if the person's driver's license is suspended or revoked.

(6) Failure to comply with this rule may result in denial, suspension, or revocation of authorization to provide self-directed transportation.

(D) Requirements for service delivery

(1) Self-directed transportation shall will be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code.

(2) An individual's need for self-directed transportation to be provided in a modified vehicle is to be documented in the individual service plan.

(E) Documentation of services

(1) Service documentation for self-directed transportation provided by vendors of ground transportation available to the general public shall will include each of the following to validate payment for medicaid services:

(a) Mode of self-directed transportation for which voucher, card, pass, or token may be used (e.g., bus, light rail transit, livery vehicle, or ride-hailing service) provided.

(b) Date of purchase of voucher, card, pass, or token.

(c) Name of individual receiving service.

(d) Medicaid identification number of individual receiving service.

(e) Name of provider.

(f) Provider identifier number or provider contract number.

(g) Receipt indicating the amount paid.

(2) Service documentation for self-directed transportation via per-mile or per-trip reimbursement made to a person who meets the provider qualifications in paragraph (C) of this rule and who has a written agreement for provision of self-directed transportation with the individual being transported shall will include each of the following to validate payment for medicaid services:

(a) Type of motor vehicle used to provide self-directed transportation (i.e., modified vehicle or non-modified vehicle).

(b) Date of service.

(c) Name of individual receiving service.

(d) Medicaid identification number of individual receiving service.

(e) Name of provider.

(f) Provider identifier number or provider contract number.

(g) Origination and destination points of self-directed transportation provided.

(h) Total number of miles of self-directed transportation provided.

(i) Number of individuals being transported.

(j) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the financial management services entity.

(F) Payment standards

(1) The billing units, service codes, and payment rates for self-directed transportation provided January 1, 2024 through June 30, 2024 are contained in the appendix A to this rule. The billing units, service codes, and payment rates for self-directed transportation provided on or after July 1, 2024 are contained in appendix B to this rule.

(2) Payment rates for vouchers, cards, passes, or tokens to access modes of ground transportation available to the general public shall will be at the usual and customary rate or fare.

(3) Reimbursement made to a person who has a written agreement for provision of self-directed transportation with the individual being transported may be per-mile or per-trip:

(a) Per-mile reimbursement is 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 shall will be billed for each individual being transported when at least one individual requires the use of a modified vehicle, as specified in the individual service plan.

(b) Per-trip reimbursement may be negotiated by an individual being transported and the person providing self-directed transportation up to an amount not to exceed twelve dollars sixteen dollars and fifty-six cents for each one-way trip.

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Notes

Ohio Admin. Code 5123-9-26

Effective: 1/1/2024
Five Year Review (FYR) Dates: 7/1/2027
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: 07/01/2022