Rule 5160-31-07 | PASSPORT HCBS waiver program rate setting.
The purpose of this rule is to describe the methods used to determine provider rates for the pre-admission screening system providing options and resources today (PASSPORT) program.
(A) Rates determined under this rule will not exceed the maximum allowable rates for PASSPORT services in appendix A to rule 5160-1-06.1 of the Administrative Code. Payment for PASSPORT waiver services constitutes payment in full and will not be construed as a partial payment when the payment amount is less than the provider's usual and customary rate. In accordance with rule 5160-1-13.1 of the Administrative Code, the provider will not bill the individual for any difference between the medicaid payment and the provider's rate or request the individual to share in the cost through a co-payment or other similar charge.
(B) PASSPORT rates are established for the services in rule 5160-31-05 of the Administrative Code under the following categories:
(1) Per-job bid rate;
(2) Per-item rate; and
(3) Unit rate.
(C) Rates set within the categories in paragraph (B) of this rule may be:
(1) Participant-directed, in which the individual or a designated authorized representative, who is acting on the individual's behalf, may negotiate the rate for services furnished by providers as specified in paragraphs (D)(3), (E)(3), and (G)(1) of this rule.
(2) Statewide, in which the state establishes a rate used on a statewide basis to pay for services specified in paragraph (F)(1) of this rule.
(3) Group rates which are seventy-five per cent of the rate the provider would be paid for providing PASSPORT services as specified in paragraphs (D)(2), (F)(2), and (F)(3) of this rule.
(D) For the services listed in this paragraph, the provider and the Ohio department of aging or its designee negotiate a per-job rate.
(1) A per-job bid rate applies to the following services:
(a) Community transition;
(b) Home maintenance and chores;
(c) Home modification;
(d) Non-medical transportation.
(2) Non-medical transportation rendered simultaneously by the same provider to more than one individual enrolled in the PASSPORT program, who reside in the same home and who travel in the same vehicle to the same destination is paid at a group rate of seventy-five per cent of the provider's per-job bid rate.
(3) Home modification and home maintenance and chores may be participant-directed services in which the individual enrolled in the PASSPORT program, or their authorized representative, acting on the individual's behalf, may negotiate rates.
(a) The negotiated rate is reviewed by Ohio department of aging's (ODA) designee and reflected on the individual's person-centered service plan prior to service delivery.
(b) Should the individual choose not to negotiate a rate the service may be paid at a rate proposed by the provider and accepted by the individual and ODA's designee. The accepted rate is reflected on the individual's person-centered service plan.
(E) A per-item rate applies to home medical equipment and supplies.
(1) No per-item rate may exceed the medicaid state plan rate.
(2) A home medical equipment and supplies item that does not have an established medicaid rate may be paid at a per-item bid rate from the provider which has been agreed to in writing by ODA's designee prior to delivery of the item.
(3) Home medical equipment and supplies may be participant-directed in which the individual enrolled on PASSPORT or the authorized representative acting on the individual's behalf, may negotiate rates.
(a) The negotiated rate is reviewed by ODA's designee and reflected on the individual's person-centered services plan prior to service delivery.
(b) Should the individual choose not to negotiate a rate, the service may be paid at a rate agreed upon between the provider, the individual, and ODA's designee. The agreed upon rate is reflected on the individual's person-centered services plan.
(F) ODA will establish unit rates for the services listed in this paragraph.
(1) Statewide unit rates are established and used for the following services:
(a) Adult day;
(b) Adult day transportation;
(c) Community integration;
(d) Enhanced community living;
(e) Home care attendant;
(f) Home delivered meals;
(g) Homemaker;
(h) Nutritional consultation;
(i) Out-of-home respite;
(j) Personal care;
(k) Personal emergency response system;
(l) Social work or counseling;
(m) Structured family caregiving; and
(n) Waiver nursing.
(2) The services in paragraphs (F)(1)(e), (F)(1)(j), and (F)(1)(m) of this rule, when rendered consecutively during the same visit to more than one but fewer than four PASSPORT individuals in the same household, and identified in the individuals' person-centered service plans, are paid to one hundred per cent of the provider's per unit rate set in accordance with paragraph (C) of this rule for one PASSPORT individual and paid a group rate for each subsequent PASSPORT individual in the household receiving services during the visit.
(3) Adult day transportation rendered simultaneously by the same provider to more than one individual residing in the same household and traveling in the same vehicle to the same destination is paid using a group rate equal to seventy-five per cent of the provider's rate.
(G) The services in this paragraph are participant directed and the individual may negotiate unit rates with providers.
(1) The participant directed services include:
(a) Alternative meals; and
(b) Choices home care attendant.
(2) The individual will have in effect, before choices home care attendant services are delivered, a signed provider agreement with each ODA-certified participant-directed individual provider delivering services to the individual. The provider agreement will:
(a) Include the rate negotiated with the provider;
(b) Specify the time period the rates are in effect;
(c) Base rates on the units of service as set forth in Chapter 173-39 of the Administrative Code; and
(d) Be signed by the individual receiving the choices home care attendant service and the home and community based services (HCBS) provider.
(3) The rates negotiated by the individual with providers of services in paragraph (G)(1) of this rule will not exceed the maximum allowed per unit of service as specified in appendix A to rule 5160-1-06.1 of the Administrative Code. The negotiated rate is reviewed by ODA's designee, and reflected on the individual's person-centered service plan prior to service delivery.
(4) Should the individual choose not to negotiate a rate for any of the services in paragraph (G)(1) of this rule, the service may be paid at a rate agreed upon by the provider, the individual and the individual's case manager. The agreed upon rate is reflected on the individual's person-centered services plan.
(H) The Ohio department of medicaid, or its designee,will evaluate unit rates within two years of the effective date of this rule and every two years thereafter.
Last updated October 1, 2024 at 9:07 AM
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