5123-9-31. Home and community-based services waivers - homemaker/ personal care daily billing unit for sites where individuals enrolled in the individual options waiver share services

(A) Purpose

This rule establishes a daily billing unit for homemaker/personal care when individuals share the services of the same agency provider at the same site as part of the home and community-based services individual options waiver administered by the Ohio department of developmental disabilities. The daily billing unit for individuals/sites that qualify shall be used by agency providers instead of the fifteen-minute billing unit established in rule 5123-9-30 of the Administrative Code. Requirements set forth in paragraphs (C) and (D) of rule 5123-9-30 of the Administrative Code apply to the homemaker/personal care daily billing unit.

(B) Definitions

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

(1) "Agency provider" means an entity that directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(2) "Cost projection tool" means the web-based analytical tool, that is a component of the medicaid services system, developed and administered by the department, used to project the cost of home and community-based services identified in an individual service plan.

(3) "County board" means a county board of developmental disabilities.

(4) "Daily billing unit" means an agency provider's payment amount for homemaker/personal care services for each individual sharing services at a site in a calendar month. The daily billing unit is calculated based on projected service utilization entered in the medicaid services system by the county board and direct service hours entered in the medicaid services system by the agency provider of homemaker/personal care services.

(5) "Date of service" means a date on which an individual resides at the site where homemaker/personal care services are shared. "Date of service" excludes any date on which an individual is admitted to an intermediate care facility for individuals with intellectual disabilities or a nursing facility.

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

(7) "Direct service hours" means the direct staff time spent delivering homemaker/personal care services. A direct service hour is comprised of four fifteen-minute billing units.

(8) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(9) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code.

(10) "Independent provider" means a self-employed person who provides services for which he or she must be certified in accordance with rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(11) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

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

(13) "Medicaid services system" means the comprehensive information system that integrates cost projection, prior authorization, daily rate calculation, and payment authorization of waiver services.

(14) "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 the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(15) "Shared living" has the same meaning as in rule 5123-9-33 of the Administrative Code.

(16) "Site" means a residence in which two or more individuals share homemaker/personal care services of the same agency provider.

(17) "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) Circumstances excluded from the daily billing unit approach

(1) Individuals who receive services and supports in shared living settings shall do so in accordance with rule 5123-9-33 of the Administrative Code.

(2) Individuals who do not share the homemaker/personal care services of the same agency provider at the same site shall remain on the fifteen-minute billing unit approach established in rule 5123-9-30 of the Administrative Code.

(3) Individuals who receive homemaker/personal care services from an independent provider shall remain on the fifteen-minute billing unit approach established in rule 5123-9-30 of the Administrative Code.

(4) Individuals sharing homemaker/personal care services of an agency provider at a residential site may also receive occasional or time-limited homemaker/ personal care services delivered outside of the site by a secondary provider. When this occurs, the secondary provider shall submit claims for payment using the fifteen-minute billing unit approach established in rule 5123-9-30 of the Administrative Code.

(5) Individuals who live alone and share homemaker/personal care services with a neighbor or other eligible person shall remain on the fifteen-minute billing unit approach established in rule 5123-9-30 of the Administrative Code.

(6) The director of the department reserves the right to allow an agency provider of homemaker/personal care services to continue to use the fifteen-minute billing unit approach established in rule 5123-9-30 of the Administrative Code in the event of a unique and/or extenuating circumstance. This right shall be exercised in consultation with the Ohio department of medicaid.

(D) Calculation of the individual daily billing unit

(1) The process for assigning a funding range, determining an individual funding level, and projecting the cost of an individual's services, set forth in rule 5123-9-06 of the Administrative Code, shall be followed.

(2) The process for establishing applicable rate modifications, set forth in paragraph (F) of rule 5123-9-30 of the Administrative Code, shall be followed.

(3) Using the cost projection tool, the service and support administrator or other county board designee, with input from members of an individual's team, shall project the service utilization for the full waiver eligibility span of each individual sharing homemaker/personal care services at a site. The projected service utilization shall be based on factors including, but not limited to:

(a) The typical usage pattern;

(b) Adjustments based on past history, holidays, day service program closings, and weekends; and

(c) Other anticipated changes to direct service hours.

(4) Based on the projected service utilization entered for the waiver eligibility span of each individual sharing services at a site, the medicaid services system will calculate the total projected homemaker/personal care hours and costs for the site for each calendar month. These projections include any individual's prior authorization requests that have been approved pursuant to rule 5123-9-07 of the Administrative Code.

(5) Using the cost projection tool, the service and support administrator or other county board designee, with input from members of an individual's team, may adjust the projected service utilization for a site only when:

(a) An individual moves to or from the site; or

(b) An individual living at the site starts or stops day programming; or

(c) Circumstances that cause an increase or decrease of more than three per cent in the hours of homemaker/personal care provided at the site during the calendar month.

(6) Using the results from the cost projection tool, the medicaid services system will calculate the agency provider's daily rate for each individual sharing homemaker/personal care services at a site. The agency provider shall use that information to prepare a claim for payment.

(7) Within thirty calendar days of the end of each calendar month, an agency provider shall enter in the medicaid services system, the direct service hours rendered during the calendar month and the dates of service for each individual. When the total direct service hours deviate from projected service utilization by more than three per cent, the medicaid services system will generate an alert to the agency provider and the county board. The agency provider may submit a written request with supporting documentation for a modification to the projected service utilization for that month and for future months, if the circumstances causing the increase in direct service hours are not temporary. When the supporting documentation indicates that an increase in direct service hours is necessary to meet an individual's needs, the county board shall revise the individual service plan within thirty calendar days. When circumstances exist that prevent an agency provider and a county board from making necessary adjustments to projected service utilization within sixty calendar days of the end of the calendar month in which services were rendered, a request for a retroactive adjustment may be submitted to the department by the county board upon agreement from the team.

(E) Documentation of services

Service documentation for homemaker/personal care when individuals share the services of the same agency provider at the same site shall include each of following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Names of individuals.

(5) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(6) Medicaid identification number of the individuals receiving services.

(7) Name of provider.

(8) Provider identifier/contract number.

(9) 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 provider.

(F) Payment standards

(1) The service codes for the homemaker/personal care daily billing unit are contained in the appendix to this rule.

(2) The medicaid services system will calculate the payment rate for the agency provider's daily billing unit for each date of service for each individual based on projected service utilization entered by the county board. The medicaid services system will adjust the payment rate for each individual and generate an alert to the agency provider and the county board when the total direct service hours entered by the agency provider in accordance with paragraph (D)(7) of this rule, are more than three per cent below the original projected service utilization entered by the county board.

(3) Agency providers of homemaker/personal care may bill for each date of service for each individual at the site.

(4) Payment for homemaker/personal care shall not include room and board, items of comfort or convenience, or costs for the maintenance, upkeep, and improvement of the home.

(G) Monitoring

(1) Agency providers, county boards, and the department shall have access to both utilization reports and reports generated by the medicaid services system in order to monitor projected services and actual services provided at each specific site. This information shall be made available to the Ohio department of medicaid upon request.

(2) The department shall monitor the ongoing progress of the daily billing unit approach through a series of fiscal control and quality assurance procedures including validation of total expenditures and total hours that are entered by the county board into the cost projection tool, verification that daily billing units are supported by appropriate documentation, and verification that agency provider service hours rendered are reported appropriately.

(3) The Ohio department of medicaid reserves the right to perform independent oversight reviews as part of its general oversight functions, in addition to the department's monitoring activities described in paragraph (G)(2) of this rule.

(H) Authority of director to suspend provisions of this rule

During the COVID-19 state of emergency declared by the governor, the director of the department may suspend paragraph (F)(2) of this rule so that the medicaid services system does not adjust the payment rate for each individual and generate an alert to an agency provider and a county board when the total direct service hours entered by the agency provider are more than three per cent below the original projected service utilization entered by the county board.

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Effective: 11/19/2020
Five Year Review (FYR) Dates: 1/1/2024
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: 12/21/2007 (Emer.), 03/20/2008, 07/01/2010, 01/01/2016, 04/01/2017, 02/15/2018, 01/01/2019, 06/11/2020 (Emer.)