5123:2-9-06 Home and community-based services waivers - documentation and payment for services under the individual options and level one waivers.

 

 

 

5123:2-9-06                 Waiver reimbursement methodology.

 

 

 

(A)Purpose

 

The purpose of this rule is to establish the standards governing payment for home and community-based services (HCBS) as defined in section 5126.01 of the Revised Code provided to individuals enrolled in HCBS waivers administered by the department pursuant to section 5111.871 of the Revised Code.

 

(B)Definitions

 

(1)"Agency provider" means a person or government entity that has been certified to provide services under HCBS waivers administered by the department other than a non-agency provider.

 

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

 

(3)"Fifteen minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or greater than eight minutes of service delivery time.

 

(4)"Funding range" means one of the dollar ranges within which an individual's funding level must fit for the individual options (IO) waiver, residential facility waiver (RFW), and any other waiver administered by the department excluding the level one waiver. The funding range applicable to an individual is determined subsequent to an assessment using the Ohio developmental disabilities profile (ODDP). Funding ranges are not applicable for individuals enrolled in the level one waiver.

 

(5)"Individual" means a person with mental retardation or other developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for the mentally retarded under the applicable HCBS waiver. A guardian or authorized representative as defined in rule 5101:1-2-01 of the Administrative Code may take any action on behalf of the individual, may make choices for an individual or may receive notice on behalf of an individual to the extent permitted by applicable law.

 

(6)"Individual funding level" means the total funds available for an individual under the IO waiver, RFW, level one waiver, or any other waiver administered by the department for all waiver services they receive. Except for the level one waiver, the individual funding level is determined through the ISP development process and must fall within a funding range. The individual funding level for the level one waiver is determined through the ISP development process and must fall within the parameters established in rule 5123:2-8-16 of the Administrative Code.

 

(7) "Individual funding cap" means:

 

 

 

(a) The maximum funds available for any individual enrolled in the IO waiver or RFW for all waiver services they receive. The individual funding cap is the limit specified in the applicable waiver as approved by the centers for medicare and medicaid (CMS).

(b) The maximum funds available for any individual enrolled in the level one waiver for all waiver services they receive. The individual funding cap is set forth in rule 5123:2-8-16 of the Administrative Code.

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

(9) "MLAA" means a county board with medicaid local administrative authority pursuant to section 5126.055 of the Revised Code.

(10) "Ohio developmental disabilities profile (ODDP)" means the assessment instrument utilized by the department to collect consumer-specific information for purposes of establishing a statewide fee schedule as required by section 5111.873 of the Revised Code.

(11) "Non-agency provider" means a self-employed person who has been certified to provide services under HCBS waivers administered by the department and does not employ, either directly, or through a contract, anyone else to provide such services.

(12) "Payment authorization for waiver services (PAWS)" means the process followed and form used by the MLAA to communicate the amount of payment for each waiver service on the approved individual service plan (ISP) for an eligible enrollee.

(13) "Transition period" means the period during which the statewide payment rates shall be phased-in for individuals enrolled in the IO waiver, RFW, and level one waiver on the implementation date of this rule and, in the case of the IO waiver and RFW, the period during which the individual funding levels shall be phased-in for individuals enrolled on the implementation date of this rule. The transition period shall not apply to individuals whose enrollment in the IO waiver, RFW, or level one waiver is subsequent to the implementation date of this rule.

(C)Statewide payment rates

The department shall establish, pursuant to section 5111.873 of the Revised Code, statewide payment rates for waiver services that assures that the fees are consistent with efficiency, economy and quality of care; consider the intensity of consumer resource needs; recognize variations in different geographic areas regarding the resources necessary to assure the health and welfare of consumers through the

monitoring and compliances processes; and recognize variations in environmental supports available to consumers. The rates are listed in appendix A to this rule.

(1) Statewide payment rates shall be established in accordance with the methods and standards set forth in this rule for each waiver service except for one-time expenses including environmental modifications and certain assistive devices and as defined in this rule.

(2) Payment rates for homemaker/personal care (HPC) services shall be established separately for services provided through agency providers and for services provided by non-agency providers. Payment rates for HPC services shall be based on:

(a) Wages for similar services paid in Ohio as published by the bureau of labor statistics (BLS) as the base plus;

(b) An adjustment for the supervision of agency providers plus;

(c) An adjustment for employment related expenses plus;

(d)An adjustment for productive work time plus;

(e) An adjustment for administrative expenses plus;

(f)An adjustment for geography based on the county cost of doing business category. The county cost of doing business category for an individual is the category assigned to the county board that is listed on the individual's payment authorization for waiver services (PAWS).

The eight cost of doing business categories and the counties assigned to each are as follows:

(i) Category one: Adams, Athens, Belmont, Gallia, Guernsey, Harrison, Jefferson, Meigs, Monroe, Pike, Ross, Scioto, Tuscarawas, Vinton, and Washington.

(ii) Category two: Carroll, Crawford, Defiance, Highland, Hocking, Jackson, Lawrence, Mercer, Morgan, Muskingum, Noble, Paulding, Perry, VanWert, and Wyandot.

(iii) Category three: Allen, Auglaize, Brown, Clinton, Columbiana, Coshocton, Fayette, Hancock, Holmes, Knox, Marion, Morrow, Putnam, Richland, Seneca, Shelby, and Williams.

(iv) Category  four:  Ashland,  Darke,  Erie,  Fairfield,  Fulton,  Hardin, Henry, Huron, Licking, Logan, Mahoning, Pickaway, Sandusky,

Stark, Trumbull, and Wood.

(v) Category five: Asthabula, Champaign, Clark, Delaware, Greene, Lucas, Madison, Miami, Montgomery, Ottawa, Preble,  Union, and Wayne.

(vi) Category six: Clermont, Franklin, Geauga, Lake, Lorain, Medina, Portage, and Summit.

(vii) Category seven: Butler, Cuyahoga, and Warren.

(viii) Category eight: Hamilton.

(3) The department shall collect cost information periodically for a comprehensive statistically valid sample of persons from the providers providing HCBS at the time the information is collected and use that information to review the adjustments in paragraph (C)(2) of this rule used in calculating rates.

(4) Payment rates for HPC may be modified to reflect the needs of individuals requiring medical assistance and individuals with behavior support needs. Only individuals meeting criteria established by the department as specified in paragraphs (C)(5) and (C)(6) of this rule shall be eligible for these rate modifications. Upon determination by the service and support administrator (SSA) that the individual meets the criteria established by the department, the MLAA shall recommend and implement rate modifications for behavior support and medical assistance. Rate modifications are subject to review by the department. Approval for medical assistance and/or behavior support rate modifications shall be limited to one year, however, rate modifications may be renewed annually if the assessment indicates the individual continues to meet the criteria established by the department. A rate modification to the HPC rate will be applied for each individual in a congregate setting meeting the criteria, and will be paid from the funding allocation of the individuals meeting the criteria only. Individuals in a congregate setting not meeting the criteria will not have their funding range, individual funding level nor the rate paid for services impacted by the medical assistance or behavior support rate modification of others in the setting meeting the criteria.

(5) The purpose of the behavior support rate modification for HPC services is to provide funding for the implementation of behavior support plans with specially trained staff under the direction of a licensed or certified professional with specialized training or experience in behavior supports. The behavior support rate modification is fifty-nine cents per fifteen minute unit of service. To qualify for the behavior support rate modification to the HPC rate, the individual served shall have a behavior support plan and meet at least one of the following criteria:

(a) A minimum of four specific items in the behavior section of the ODDP as

determined by the department.

(b) Routine utilization of clinical services from a certified professional with specialized training or experience in behavior supports related to the design, development and implementation of the behavior support plan. The department reserves the right to review the qualifications of any provider of these services. The department has final approval authority on this issue.

(6) The purpose of the medical assistance rate modification for HPC services is to provide funding for individuals with medical needs that require staff to be trained in special health care procedures. The medical assistance rate modification is eleven cents per fifteen minute unit of service. To qualify for the medical assistance rate modification to the HPC rate, the individual served must have medical needs which have been determined by a licensed nurse to require staff to be trained in special health care procedures, and the licensed nurse has agreed to delegate this task to an unlicensed worker in accordance with section 5123.42 of the Revised Code and rules adopted under that section as part of specialized services.

(7) The department shall establish on-site/on-call payment rates for HPC services provided on an on-call basis within the individual's residential setting. On-site/on-call HPC services are provided during periods of time when the individual is asleep and requires monitoring to assure health, safety and welfare.

(8) The base rate paid to a provider for HPC services shall be adjusted based on the number of individuals sharing the services. If two individuals share the service, the base rate shall be one hundred twenty per cent of the base rate for one-to-one service. If three individuals share the service, the base rate shall be one hundred forty per cent of the base rate for one-to-one service. If four or more individuals share the service, the base rate shall be one hundred sixty per cent of the base rate for one-to-one service. The base rate established is divided by the number of individuals sharing the service to determine the rate paid per individual. In cases where an agency provider has multiple staff serving multiple individuals, the provider shall be paid based on ratios of one staff to the appropriate number of individuals. For example, if two staff serve four individuals, the provider would be paid at the one to two ratio for all four individuals. For individuals that share services, their ISP must clearly state ratios at which services are to be delivered.

(9) Statewide payment rates for other waiver services

(a) For the IO waiver, statewide payment rates for other waiver services shall be established by the department and published annually including payment rates for:

(i) Interpreter services;

(ii) Nutritional services;

(iii) Institutional respite;

(iv) Social work services;

(v) Supported employment;

(vi) Transportation; and

(vii) Home delivered meals.

(b) The rates for interpreter services, nutritional services, and social work services shall follow the methodology established in paragraph (C)(2) of this rule.

(c) The rate for supported employment services shall be adjusted to reflect geographic variations.

(d)The rate for transportation shall consider the internal revenue service (IRS) mileage allowance but may differ from that amount.

(e) The rate for institutional respite shall be the rates established for the level one waiver.

(f)The rate for home delivered meals is a set rate per meal.

(g) Rate modifications for behavior supports and medical assistance only apply to HPC services and shall not apply to the other waiver services listed in paragraph (C)(8) of this rule.

(h) For the IO waiver, the department shall develop a statewide payment method for adaptive and assistive equipment subject to a ten thousand dollar limit per item, and for environmental modifications subject to a limit of seven thousand five hundred dollars per modification.

(i) For the RFW, statewide payment rates for other waiver services shall be established by the department and published annually, including payment rates for supported employment.

(j) For the RFW, the department shall develop a statewide payment method for adaptive and assistive equipment subject to a ten thousand dollar limit per item.

(k) For the level one waiver, statewide payment rates for other waiver services shall be established by the department and published annually, including payment for:

(i) Informal respite;

(ii) Institutional respite; and

(iii) Transportation.

(l) For the level one waiver, environmental accessibility adaptations, specialized medical equipment and supplies, and personal emergency response systems are subject to the limitations set forth in rule 5123:2-8-16 of the Administrative Code.

(10) The department shall review rates at least once per biennium. Based upon the results of the review and subject to state appropriation, the department shall adjust the rates accordingly.

(D) Funding range, individual funding level and individual funding cap under the IO waiver and the RFW

(1) For each individual enrolled in the IO waiver or RFW, the department shall establish funding ranges for waiver services based on an assessment and methodology that is applied consistently statewide. The funding ranges shall consider:

(a) The unpaid care available to the individual;

(b) The individual's living arrangement;

(c) The individual's behavior support needs;

(d)The individual's need for support to take prescription medication;

(e) The individual's mobility;

(f)The individual's ability for self care; and

(g) Any other variable that significantly impacts the individuals needs as determined by the department through statistical analysis.

(2) Each individual enrolled in the IO waiver or the RFW shall be assigned a funding range based on his/her individual assessment. The ISP for the individual must be developed within this funding range beginning with the bottom of the range for planning purposes. The individual funding level is the

dollar value established for the individual within the assigned funding range.

(3) For any individual enrolled in the IO waiver or the RFW, in no case will the individual funding level assigned to an individual exceed the individual funding cap established for each applicable waiver. Applicants who cannot be served within these individual funding caps will not be enrolled. Individuals enrolled in the RFW who convert to the IO waiver are not considered to be new applicants for purposes of this rule. Individuals whose authorized services upon implementation of this rule exceed these individual caps will be allowed to transition down to the limitation during the transition period.

(E) Changes to individual funding levels and funding ranges under the IO waiver and RFW

(1) If an individual requests a change in individual funding level, the individual funding level may increase or decrease based on the outcome of the ISP development process. The MLAA has the authority to make changes to individual funding levels which result from the ISP development process and do not exceed the maximum value or fall below the minimum value of the funding range assigned by the ODDP assessment process for the individual. Changes to individual funding levels are subject to review by the department.

(2) Changes to an individual funding level which result from the ISP development process and exceed the maximum value or fall below the minimum value of the funding ranges assigned by the ODDP assessment process for the individual must be approved by the department. Changes to funding ranges shall be based on:

(a) Significant change in assessment variables such as mobility, self-care, prescription support, psychiatric diagnosis, caregiver days, and maladaptive behavior; or

(b) A number of alternative placements have been tried and the MLAA has determined through repeated attempts that a more costly placement is the only option as a result of behavior support needs.

(3) Neither the department, ODJFS, nor the MLAA may authorize a change in individual funding level within the funding range or assign a new funding range where:

(a) The individual challenges an initial assignment of a funding level, which is subject to appeal pursuant to section 5101.35 of the Revised Code;

(b) The individual requests to accelerate the transition schedule;

(c) The individual requests to live alone and/or the family makes a request for the individual to live alone;

(d)The family or the individual moves to a residential living arrangement not reflected on the ISP such that the individual now requests additional resources as a result of the move;

(e) The individual and/or the family do not carry out their responsibilities as identified in the ISP process;

(f)Changes in provider or provider rate;

(g) Changes in the number of units of service not associated with a major qualifying change or an emergency in the case of individuals in transition;

(h) Minor or short term changes in professional or therapeutic services;

(i) Minor or short term variations in caregiver support; or

(j) Minor changes in functional status.

(F) Authorization required

Each service identified in the approved ISP that is funded through the HCBS waiver and the payment rate for the service shall be authorized by the MLAA, or the contracting authority or administrative receiver, as applicable, for the MLAA if the MLAA's medicaid local administrative authority has been terminated pursuant to section 5126.056 of the Revised Code, and reported to the department through the PAWS process. The department shall authorize payment through the PAWS process. The aggregate payment amount for all HCBS waiver services received by an individual shall not exceed the amount authorized by the PAWS process and the individual funding level.

(G)Payment limitations for HCBS waiver services

No payment shall be made for HCBS waiver services unless:

(1) The service is identified in an approved ISP;

(2) The service is authorized for payment by the MLAA and by the department;

(3) The service is provided by an approved HCBS waiver service contractor to an eligible individual and does not exceed the statewide payment rate except during the transition period as provided in this rule;

(4) The total services authorized times the payment rate does not exceed the individual funding level assigned except as provided through the transition period;

(5) Payment for an HCBS waiver service constitutes payment-in-full; and

(6) Services do not result in payment per day greater than twenty-four hours.

(H)Claims for payment of HCBS waiver services

(1) Claims for payment of HCBS waiver services shall be submitted to the department in the format prescribed by the department in billing instructions for HCBS waiver services. Claims for payment shall be submitted within three hundred thirty days after the HCBS waiver service is provided. Payment shall be made in accordance with the requirements of rule 5101:3-1-197 of the Administrative Code, except that claims submitted beyond the three-hundred- thirty-day deadline shall be rejected. No claims shall be paid that do not provide both the number of units of services and the number of individuals sharing the service.

(2) Payment for HCBS waiver services is available only after all available third-party benefits are exhausted. An HCBS waiver service contractor shall take reasonable measures to ascertain any third-party health care coverage available to the individual and file a claim with that third party in accordance with the requirements of rule 5101:3-1-08 of the Administrative Code.

(3) For individuals with a monthly patient liability for the cost of HCBS waiver services, as defined in rule 5101:1-39-95 of the Administrative Code, and determined by the county department of job and family services for  the county in which the individual resides, payment is available only for the HCBS waiver service(s) delivered to the individual that exceeds the amount of the individual's monthly patient liability. Verification that patient liability has been satisfied shall be accomplished as follows:

(a) The department shall provide notification to the appropriate MLAA, if the MLAA administers the HCBS waiver, identifying each individual who has a patient liability for HCBS waiver services and the monthly amount of the patient liability.

(b) The MLAA, or the contracting authority or administrative receiver, as applicable, for the MLAA if the MLAA's medicaid local administrative authority has been terminated pursuant to section 5126.056 of the Revised Code, shall assign the HCBS waiver service(s) to which each individual's patient liability shall be applied and assign the corresponding monthly patient liability amount to an HCBS waiver service contractor. The county board or the contracting authority or administrative receiver, as applicable, shall notify each individual and HCBS waiver service contractor, in writing, of this assignment.

(c) Upon submission of a claim for payment, the designated HCBS waiver

service contractor shall report the HCBS waiver service to which the patient liability was assigned and the applicable patient liability amount on the claim for payment using the format prescribed by the department in billing instructions for HCBS waiver services.

(4) Claims for payment of environmental modification services shall be submitted with verification that the project meets the requirements specified in the approved ISP, the project is satisfactorily completed, and the project is in compliance with all applicable state and local building codes. The verification submitted shall be in the format prescribed by the department.

(5) Errors in payment, caused by the HCBS waiver service contractor, the MLAA, or the department, must be corrected by advising the department through the completion of the appropriate adjustment in the format prescribed by the department. Adjustments may be made through a credit or debit of future payment or by remitting a check.

(6) Overpayments, duplicate payments, payments for services not rendered, payments for which there is no documentation of service delivered, or payments for services not in accordance with an approved ISP are recoverable by the department, the state auditor or the office of attorney general at the time of discovery. All recoverable amounts are subject to the application of interest in accordance with rule 5101:3-1-25 of the Administrative Code.

(7) The department may audit any funds a contractor of HCBS waiver services receives pursuant to this rule, including any source documentation supporting the receipt of such funds.

(8) An HCBS waiver service contractor shall maintain the records necessary and in such form to disclose fully the extent of HCBS waiver services provided, for a period of six years from the date of receipt of payment or until an initiated audit is resolved, whichever is longer. The records shall be made available upon request. No payment for outstanding HCBS waiver service claims will be made if a request for records is refused.

(I) Transition period for individuals enrolled in the IO waiver or the RFW prior to January 1, 2004

For any individual, transition years begin upon the effective date of this rule, and are transitioned based on the individual's annual date of redetermination. For redeterminations occurring in calendar year 2004, payment rates and individual funding levels will remain at levels reflected in PAWS for calendar year 2003.

(1) Transition period for statewide individual funding levels

(a) In calendar year 2005, individuals whose individual funding level differs

by five thousand one dollars or less than the funding level reflected in PAWS for calendar year 2004 shall transition to their individual funding level at the time of the redetermination for each individual. For all other individuals, their individual funding levels reflected in PAWS for calendar year 2004 shall move one-third of the difference between the dollar amount of the individual's funding level, as determined by their ISP and within the range established by the ODDP, and the individual's funding level reflected in PAWS for calendar year 2004 at the time of the redetermination for each individual.

(b) In calendar year 2006, for all individuals that transitioned one-third of the amount toward their individual funding level in 2005, their individual funding levels reflected in PAWS for calendar year 2004 shall move an additional one-third of the difference between the dollar amount of the individuals funding level, as determined by their ISP and within the range established by the ODDP, and the individual's funding level reflected in PAWS for calendar year 2004 at the time of the redetermination for each individual.

(c) In calendar year 2007, statewide individual funding levels shall be fully implemented beginning with calendar year 2007 upon redetermination of each individual.

(2) Transition period for statewide rates for the IO waiver, RFW, and level one waiver

Rates paid for services prior to calendar year 2004 are specific to both the provider and the individual receiving services. The transition period is designed to move away from that structure to a statewide rate for each service.

(a) In calendar year 2005, the department shall develop three payment bands below the payment rate and three payment bands above the payment rate for each waiver service listed in paragraph (C) of this rule such that all current provider payment rates will fall within a band. Each band will have one payment rate assigned to it that will be the dollar value closest to the statewide rate for the band. At an individual's redetermination, the rate for each service will be the rate assigned to the band that the provider's rate for serving the individual fell into.

(b) In calendar year 2006, the payment bands will be reduced from three above and below the payment rates to two bands above and below the payment rates. This will be done by moving the payment rate from the outermost band to the second outermost band, and moving the payment rate from the second outermost band to the innermost band. At an individual's redetermination, the rate for each service will be the rate

assigned to the band that the provider's rate for serving the individual fell into.

(c) In calendar year 2007, the payment bands will be eliminated, and all individuals and providers will use the statewide rates for services at an individual's redetermination.

Effective:

R.C. 119.032 review dates:

WITHDRAWN ELECTRONICALLY

Certification

04/26/2004

Date

Promulgated Under:	119.03
Statutory Authority:	5123.04, 5111.871
Rule Amplifies:	5123.04, 5111.871