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

  • Text Box: ACTION: Revised Text Box: DATE: 05/21/2013 4:38 PM

     

     

     

    Rule Summary and Fiscal Analysis (Part A)

     

    Department of Developmental Disabilities

    Agency Name

     

    Community Services                                           Becky Phillips

    Division                                                                  Contact

     

    30 East Broad Street, 12th Floor Columbus OH 43215-3414

    (614) 644-7393     (614)

    644-5013

    Agency Mailing Address (Plus Zip)                                       Phone                     Fax

    becky.phillips@dodd.ohio.gov

    Email

    5123:2-9-06

    Rule Number

    NEW

    TYPE of rule filing

    Rule Title/Tag Line              Home and community-based services waivers - documentation

    and  payment  for  services  under  the  individual  options  and level one waivers.

    RULE SUMMARY

    1.  Is the rule being filed consistent with the requirements of the RC 119.032 review? No

    2.  Are you proposing this rule as a result of recent legislation? No

    3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

    4.  Statute(s) authorizing agency to adopt the rule: 5111.871, 5111.873, 5123.04

    5.  Statute(s) the rule, as filed, amplifies or implements: 5111.871, 5111.873, 5123.04

    6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

    Revisions to existing rule 5123:2-9-06 are necessary to reflect changes being made to the Level One Waiver benefit package and to correct references to other rules of the Administrative Code. The Department is taking this opportunity to improve

    readability of the rule by eliminating the use of acronyms and is rescinding the existing rule and bringing forth a new rule of the same number in order to achieve a new "clean" rule.

    7.  If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

    The rule establishes the standards governing documentation and payment for home and community-based services under components of the Medicaid program that the Ohio Department of Developmental Disabilities administers pursuant to section 5111.871 of the Revised Code.

    8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

    121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

    This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

    9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

    This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

    10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

    Not Applicable.

    11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so. If applicable, indicate each specific paragraph of the rule that has been modified:

    First sentence of paragraph (B)(3) revised from:

    "Cost projection tool" means the web-based analytical tool, developed and administered by the department, used to project the cost of home and

    community-based services waiver services identified in the individual service plans of individuals enrolled in individual options and level one home and

    community-based services waivers. to:

    "Cost projection tool" means the web-based analytical tool, developed and administered by the department, used to project the cost of home and

    community-based services waiver services identified in the individual service plans of individuals enrolled in individual options and level one waivers.

    Third sentence of paragraph (C)(4) revised from:

    Paid services should be used in conjunction with the natural supports an indivdiual has in his or her family home.

    to:

    Paid services should be used in conjunction with available natural supports. Second sentence of paragraph (C)(8) revised from:

    The service and support administrator shall inform the individual in writing and in a form and manner the individual can understand of his/her due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

    to:

    The service and support administrator shall inform the individual in writing and in a form and manner the individual can understand of the individual's due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

    Paragraph (C)(9)(a) revised from:

    The county board shall inform the individual of his/her right to request a prior authorization to obtain services that result in an individual funding level that exceeds the funding range using the process described in rule 5123:2-9-07 of the Administrative Code.

    to:

    The county board shall inform the individual of the individual's right to request prior authorization to obtain services that result in an individual funding level that exceeds the funding range using the process described in rule 5123:2-9-07 of the Administrative Code.

    Paragraph (C)(9)(c)(ii) revised from:

    If an individual service plan that meets these conditions cannot be developed, the county board shall propose to deny the individual's initial or continuing enrollment in the waiver and inform the individual of his/her due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

    to:

    If an individual service plan that meets these conditions cannot be developed, the county board shall propose to deny the individual's initial or continuing enrollment in the waiver and inform the individual of the individual's due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

    Paragraph (G)(1) revised from:

    Prior to the beginning of an individual's waiver eligibility span, the individual's service and support administrator or other county board designee shall prepare a projection of the annual cost of every individual options or level one waiver service that is authorized in the individual service plan for the waiver eligibility span using the cost projection tool developed by the department.

    to:

    Prior to the beginning of an individual's waiver eligibility span, the individual's service and support administrator or other county board designee shall prepare a projection of the annual cost of every individual options or level one waiver service that is authorized in the individual service plan for the waiver eligibility span using the cost projection tool.

    First sentence of paragraph (G)(2) revised from:

    The cost projection shall be based on staffing ratios and the total estimated number of service units the individual is expected to recieve in accordance with his/her individual service plan during the waiver eligibility span.

    to:

    The cost projection shall be based on staffing ratios and the total estimated number of service units the individual is expected to recieve in accordance with his or her individual service plan during the waiver eligibility span.

    Paragraph (G)(3) revised from:

    The total number of service units shall be determined with input from the individual's team as part of the individual service plan development process.

    to:

    The total number of service units shall be determined with input from the individual

    and his or her team as part of the individual service plan development process. Paragraph (H)(1) revised from:

    Providers of services shall... to:

    Providers shall...

    Paragraph (H)(2) revised from:

    Invoices a provider of services submits... to:

    Invoices a provider submits... Paragraph (H)(3) revised from: Each provider of services shall... to:

    Each provider shall... Paragraph (H)(4) revised from:

    If a provider of services discontinues operations, the provider shall, within seven days of discontinuance, notify the county boards for the counties in which individuals to whom the provider has provided services reside, of the location where the service documentation will be stored, and provide the county board with the name and telephone number of the person responsible for maintaining the records.

    to:

    If a provider discontinues operations, the provider shall, within seven days of discontinuance, notify the county boards for the counties in which individuals to whom the provider has provided services reside, of the location where the service documentation will be stored and provide the county board with the name and telephone number of the person responsible for maintaining the service documentation.

    First sentence of paragraph (K)(1) revised from: Any recipient or applicant for waiver services... to:

    Any applicant for or recipient of waiver services...

    12.  119.032 Rule Review Date:

    (If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

    NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

    FISCAL ANALYSIS

    13.  Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

    This will have no impact on revenues or expenditures.

    $ 0

    Changes being made from the existing rule (i.e., updating references to the Level One Waiver benefit package, correcting references to other rules of the Administrative Code, and eliminating the use of acronyms) have no effect on revenues or expenditures for the agency.

    14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

    Not applicable.

    15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

    Not applicable.

    16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? Yes

    You must complete Part B of the Rule Summary and Fiscal Analysis in order to comply

    with Am. Sub. S.B. 33 of the 120th General Assembly.

    17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No

    S.B. 2 (129th General Assembly) Questions

    18.  Has this rule been filed with the Common Sense Initiative Office pursuant to

    R.C. 121.82? Yes

    19.  Specific to this rule, answer the following:

    A.) Does this rule require a license, permit, or any other prior authorization to engage in or operate a line of business? No

    B.) Does this rule impose a criminal penalty, a civil penalty, or another sanction, or create a cause of action, for failure to comply with its terms? Yes

    Paragraph (J)(7) sets forth that overpayments, duplicate payments, payments for services not rendered, and payments for which documentation is nonexistent or incomplete are recoverable by the Department, the Ohio Department of Medicaid, the Auditor of State, or the Office of the Attorney General.

    Paragraph (J)(8) sets forth that providers of services that fail to produce records requested by the Department, the Ohio Department of Medicaid, the Centers for Medicare and Medicaid Services, or the Auditor of State within thirty days shall be subject to decertification and/or loss of their Medicaid provider agreement.

    C.) Does this rule require specific expenditures or the report of information as a condition of compliance? Yes

    Paragraph (C)(7) requires providers of services to verify to the county board of developmental disabilities the number of units of each waiver service delivered during the individual's current waiver eligibility span when an individual service plan is revised and a new funding level is determined.

    Paragraph (H) sets forth requirements for providers of services to maintain service documentation.

    Paragraph (I) establishes that proividers of services shall communicate their usual and customary rates to the Department.

    Paragraph (J)(2) sets forth that claims for payment by providers of services shall be

    submitted to the Department in the format prescribed by the Department.

    Paragraph (J)(3) sets forth that providers of services shall submit claims for payment within three hundred fifty days after the waiver service is provided and that claims shall include the number of units of services, the number of staff providing the service, and the number of individuals sharing the service.

    Paragraph (J)(4) requires providers of services to take reasonable measures to identify and file claims with any third-party health care providers.

    Paragraph (J)(5) requires providers of services that have been assigned monthly patient liability to report the waiver service to which the patient liability was assigned and the applicable amount on the claim for payment using the format prescribed by the Department.

    Paragrah (J)(8) requires providers of services to maintain and make available records necessary and in such form to disclose fully the extent of services provided for a period of six years or until an audit is resolved, whichever is longer.

    Text Box: ACTION: Revised                                                                                                                                              Text Box: DATE: 05/21/2013 4:38 PM

    Page B-1                                                                                  Rule Number: 5123:2-9-06

    Rule Summary and Fiscal Analysis (Part B)

    1.  Does the Proposed rule have a fiscal effect on any of the following?

    (a)  School Districts

    (b)    Counties                                 (c) Townships           (d) Municipal

    Corporations

    No                                Yes                              No                                No

    2.  Please provide an estimate in dollars of the cost of compliance with the proposed rule for school districts, counties, townships, or municipal corporations. If you are unable to provide an estimate in dollars, please provide a written explanation of why it is not possible to provide such an estimate.

    Changes made to the Level One Waiver benefit package may increase the cost to county boards of developmental disabilities. A three-year cost cap on a specific group of services (i.e., Environmental Accessibility Adaptations, Home-Delivered Meals, Personal Emergency Response Systems, Remote Monitoring, Remote Monitoring Equipment, and Specialized Medical Equipment and Supplies) is being increased from $6,000 to $7,500. Based on utilization of the Environmental Accessibility Adaptations, Personal Emergency Response Systems, and Specialized Medical Equipment and Supplies services in Fiscal Year 2012 and projected annual utilization of the newly available services within the group (i.e., Home-Delivered Meals, Remote Monitoring, and Remote Monitoring Equipment), it is estimated that the annual cost per individual enrolled in the Waiver may increase as much as

    $35 per year. A county board is responsible for forty percent ($14) of this cost. The actual cost for a specific county board will vary depending on the actual utilization of services by individuals enrolled in the Waiver. The number of individuals enrolled in the Waiver varies among county boards, ranging from less than ten to more than 1,600. In any case, the impact of increasing the three-year cost cap is anticipated to be minimal.

    3.  If the proposed rule is the result of a federal requirement, does the proposed rule exceed the scope and intent of the federal requirement? No

    4.  If the proposed rule exceeds the minimum necessary federal requirement, please provide an estimate of, and justification for, the excess costs that exceed the cost of the federal requirement. In particular, please provide an estimate of the excess costs that exceed the cost of the federal requirement for (a) school districts, (b) counties, (c) townships, and (d) municipal corporations.

    Not Applicable.

    5.  Please provide a comprehensive cost estimate for the proposed rule that includes the procedure and method used for calculating the cost of compliance. This comprehensive cost estimate should identify all of the major cost categories including, but not limited to, (a) personnel costs, (b) new equipment or other capital costs, (c) operating costs, and (d) any indirect central service costs.

    Changes made to the Level One Waiver benefit package may increase the cost to county boards of developmental disabilities. A three-year cost cap on a specific group of services (i.e., Environmental Accessibility Adaptations, Home-Delivered Meals, Personal Emergency Response Systems, Remote Monitoring, Remote Monitoring Equipment, and Specialized Medical Equipment and Supplies) is being increased from $6,000 to $7,500. Based on utilization of the Environmental Accessibility Adaptations, Personal Emergency Response Systems, and Specialized Medical Equipment and Supplies services in Fiscal Year 2012 and projected annual utilization of the newly available services within the group (i.e., Home-Delivered Meals, Remote Monitoring, and Remote Monitoring Equipment), it is estimated that the annual cost per individual enrolled in the Waiver may increase as much as

    $35 per year. A county board is responsible for forty percent ($14) of this cost. The actual cost for a specific county board will vary depending on the actual utilization of services by individuals enrolled in the Waiver. The number of individuals enrolled in the Waiver varies among county boards, ranging from less than ten to more than 1,600. In any case, the impact of increasing the three-year cost cap is anticipated to be minimal.

    (a)  Personnel Costs

    It is not anticipated that personnel costs will be affected by changes made to the Level One Waiver benefit package.

    (b)  New Equipment or Other Capital Costs

    It is not anticipated that equipment or other capital costs will be affected by changes made to the Level One Waiver benefit package.

    (c)  Operating Costs

    Changes made to the Level One Waiver benefit package may increase the cost to county boards of developmental disabilities. A three-year cost cap on a specific group of services (i.e., Environmental Accessibility Adaptations, Home-Delivered Meals, Personal Emergency Response Systems, Remote Monitoring, Remote Monitoring Equipment, and Specialized Medical Equipment and Supplies) is being increased from $6,000 to $7,500. Based on

    utilization of the Environmental Accessibility Adaptations, Personal Emergency Response Systems, and Specialized Medical Equipment and Supplies services in Fiscal Year 2012 and projected annual utilization of the newly available services within the group (i.e., Home-Delivered Meals, Remote Monitoring, and Remote Monitoring Equipment), it is estimated that the annual cost per individual enrolled in the Waiver may increase as much as

    $35 per year. A county board is responsible for forty percent ($14) of this cost. The actual cost for a specific county board will vary depending on the actual utilization of services by individuals enrolled in the Waiver. The number of individuals enrolled in the Waiver varies among county boards, ranging from less than ten to more than 1,600. In any case, the impact of increasing the three-year cost cap is anticipated to be minimal.

    (d)  Any Indirect Central Service Costs

    It is not anticipated that indirect central service costs will be affected by changes made to the Level One Waiver benefit package.

    (e)  Other Costs

    It is not anticipated that other costs will be affected by changes made to the Level One Waiver benefit package.

    6.  Please provide a written explanation of the agency's and the local government's ability to pay for the new requirements imposed by the proposed rule.

    The estimated possible increase in cost to county boards of developmental disabilities is anticipated to be minimal.

    7.  Please provide a statement on the proposed rule's impact on economic development.

    Expanding the Level One Waiver benefit package positively impacts economic development in that it creates opportunities for providers of services to expand the volume of services they provide.