Ohio Admin. Code 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 (
(A)
Rates determined
under this rule will 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 will not be construed as a partial payment when the payment amount
is less than the provider's usual and customary rate. In accordance with rule
5160-1-13.1 of the
Administrative Code, the provider will 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 a
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 (G)(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)
Group rates which
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), and (F)(3) of this
rule.
(D)
For the services listed in this paragraph, the provider
and the Ohio department of aging or its designee negotiate a per-job
rate.
(1)
A
per-job bid rate applies to the following services:
(a)
Community
transition;
(b)
Home maintenance and chores;
(c)
Home
modification;
(d)
Non-medical transportation.
(2)
Non-medical
transportation rendered simultaneously by the same provider to more than one
individual enrolled in the PASSPORT program, who reside in the same home and
who travel in the same vehicle to the same destination is paid at a group rate
of seventy-five per cent of the provider's per-job bid rate.
(3)
Home modification
and home maintenance and chores may be participant-directed services in which
the individual enrolled in the PASSPORT program, or their authorized
representative , acting on the individual 's behalf, may negotiate rates.
(a)
The negotiated
rate is reviewed by Ohio department of aging's (ODA) 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 may be paid at a rate proposed by the provider and accepted by the
individual and ODA's designee . The accepted rate is reflected on the
individual 's person-centered service plan.
(E)
A
per-item rate applies to home medical equipment and supplies.
(1)
No per-item rate
may exceed the medicaid state plan rate.
(2)
A home medical
equipment and supplies item that does not have an established medicaid rate may
be paid at a per-item bid rate from the provider which has been agreed to in
writing by ODA's designee prior to delivery of the item.
(3)
Home medical
equipment and supplies 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 is 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 may be paid at a rate
agreed upon between the provider, the individual , and ODA's designee . The
agreed upon rate is reflected on the individual 's person-centered services
plan .
(F)
ODA will
establish unit rates for the services listed in this paragraph.
(1)
Statewide unit
rates are established and used for the following services:
(a)
Adult
day;
(b)
Adult day transportation;
(c)
Community
integration;
(d)
Enhanced community living;
(e)
Home care
attendant;
(f)
Home delivered meals;
(g)
Homemaker;
(h)
Nutritional
consultation;
(i)
Out-of-home respite;
(j)
Personal
care;
(k)
Personal emergency response system;
(l)
Social work or
counseling;
(m)
Structured family caregiving; and
(n)
Waiver
nursing.
(2)
The services in paragraphs (F)(1)(e), (F)(1)(j), and
(F)(1)(m) of this rule, when rendered consecutively during the same visit to
more than one but fewer than four PASSPORT individuals in the same household,
and identified in the individuals' person-centered service plans, are 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.
(3)
Adult day transportation 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 is paid using a group
rate equal to seventy-five per cent of the provider's rate.
(G)
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
will 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 will:
(a)
Include the rate negotiated with the
provider;
(b)
Specify the time period the rates are 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 home and
community based services (HCBS ) provider.
(3)
The rates
negotiated by the individual with providers of services in paragraph (G)(1) of
this rule will 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 is 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 (G)(1) of this rule, the service may be
paid at a rate agreed upon by the provider, the individual and the individual 's
case manager . The agreed upon rate is reflected on the individual 's
person-centered services plan .
(H)
The Ohio
department of medicaid, or its designee, will evaluate unit rates within two
years of the effective date of this rule and every two years
thereafter.
Notes
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.52
Prior Effective Dates: 9/1/1998, 3/1/2000, 7/1/2006, 7/1/2008, 3/17/2011, 7/1/2011 (Emer.), 9/29/2011, 3/1/2014, 7/1/2014, 1/1/2017, 1/1/2019, 7/1/2019, 8/6/2023
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