OAC 5101:3-31-11 Passport HCBS waiver rate setting. 

 

      (A) Subject to the limits set forth in rule 5101:3-1-06 of the Administrative Code, rate-setting methodologies shall be established for the following categories:

 

      (1) Per job bid rate;

 

      (2) Per item rate; and

 

      (3) Unit rate.

 

      (B) A per job bid shall be used to determine the rate for the following services:

 

      (1) Minor home modification services as set forth in paragraph (H) of rule 5101:3-31-09 of the Administrative Code;

 

      (2) Chore services as set forth in paragraph (B) of rule 5101:3-31-09 of the Administrative Code.

 

      (3) Transportation services as set forth in paragraph (L) of rule 5101:3-31-09 of the Administrative Code; and

 

      (C) A per item rate shall be determined on a per item basis for the following services:

 

      (1) Home medical equipment and supplies as set forth in paragraph (C) of rule 5101:3-31-09 of the Administrative Code.

 

      (a) The cost of the item shall not exceed the medicaid state plan rate.

 

      (b) The cost of an item that does not have an established medicaid rate shall be reimbursed at a per item bid rate submitted and agreed to in writing by the PAA prior to delivery of the item.

 

      (2) Emergency response system services as set forth in paragraph (D) of rule 5101:3-31-09 of the Administrative Code.

 

      (D) Unit rates shall be established by the PAA.

 

      (1) Unit rates shall be used by the PAA for the following services:

 

      (a) Adult day services transportation as set forth in paragraph (A) of rule 5101:3-31-09 of the Administrative Code;

 

      (b) Home delivered meal services as set forth in paragraph (E) of rule 5101:3-31-09 of the Administrative Code;

 

      (c) Homemaker services as set forth in paragraph (F) of rule 5101:3-31-09 of the Administrative Code;

 

      (d) Social work counseling services as set forth in paragraph (K) of rule 5101:3-31-09 of the Administrative Code;

 

      (e) Nutritional consultation services as set forth in paragraph (I) of rule 5101:3-31-09 of the Administrative Code;

 

      (f) Personal care services as set forth in paragraph (J) of rule 5101:3-31-09 of the Administrative Code; and

 

      (g) Independent living assistance services as set forth in paragraph (G) of rule 5101:3-31-09 of the Administrative Code which includes:

 

      (i) In-person activities; or

 

      (ii) Telephone support; or

 

      (iii) Travel attendant activities.

 

      (2) The PAA shall contract for the services specified in paragraph (D)(1) of this rule with providers who are certified to provide the specified service in the region/subregions for which the rate will be established.

 

      (3) The PAA shall:

 

      (a) Specify the time period for which the rates shall be in effect;

 

      (b) Specify the timelines for contracting;

 

      (c) Define the region/subregions for which the rates will be established;

 

      (d) Base rates on the units of service as set forth in rule 5101:3-31-09 of the Administrative Code;

 

      (e) Require that the contract reflects the rate the provider is willing to accept as set forth in paragraph (D)(5) of this rule; and

 

      (f) Require that the contracted rate be evenly divisible by four, out to two decimal places.

 

      (4) Each PAA shall establish a regional rate for each service. The regional rate shall be determined as follows:

 

       (a) The regional rate for each service shall be the weighted average rate paid in the region using cost and unit data either from the most recently completed state fiscal year or the most recent twelve calendar months for which complete data is available, whichever is later; and

 

      (b) For contracting purposes, the PAA shall adjust the regional rate up to the nearest number that is divisible by four, out to two decimal places.

 

      (5) Contract rates shall be established as follows:

 

      (a) No provider shall have a contract rate which exceeds the rate for that service as established in rule 5101:3-1-06 of the Administrative Code.

 

      (b) Providers with rates less than or equal to the regional rate as set forth in paragraph (D)(4) of this rule shall accept a contract rate equal to the regional rate or elect a contract rate lower than the regional rate.

 

      (c) Providers with rates greater than the regional rate as set forth in paragraph (D)(4) of this rule may keep the greater than regional rate or may elect to accept a lower contract rate.

 

      (d) Providers who are certified after the regional rate is established shall have a contract rate less than or equal to the regional rate set forth in paragraph (D)(4) of this rule.

 

      (e) If there is not sufficient data available to establish a regional rate as set forth in paragraph (D)(4) of this rule for a service, the regional rate for that service shall be equal to the statewide average rate for that service.

 

      (E) The unit rates for the enhanced level and the intensive level of adult day services, as defined in paragraph (A) of rule 5101:3-31-09 of the Administrative Code, are set forth in appendix A of rule 5101:3-1-06 of the Administrative Code.

 

      (F) Passport 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 the recipient for any difference between the medicaid payment and the provider's charge or request the recipient to share in the cost through a co-payment or other similar charge. The provider shall consider medicaid payment as payment in full.

 

      (G) The department shall evaluate unit rates within two years of the effective date of this rule and every two years thereafter.

 

 

 HISTORY: Eff 9-1-98; 3-1-00 

 

Rule promulgated under: RC Chapter 119.

 

Rule authorized by: RC 173.40, 5111.02

 

Rule amplifies: RC 173.40, 5111.01, 5111.02

 

Review Date: 01 SEP 2003