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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-33. Assisted living HCBS waiver program |
5160-33-07. Assisted living home and community based services (HCBS) waiver rate setting
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(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 are 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 paid 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 items and supports set forth in rule 173-39-02.17 of the Administrative Code and authorized on the person-centered services plan.
(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 are 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 ODA-certified assisted living 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 paid 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 an individual enrolled in the assisted living program 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.