Section 5160-41-19 - Level one waiver-payment standards(A) Purpose. The purpose of this rule is to establish the payment standards for the level one home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.
(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.(C) Individuals enrolled in the level one HCBS program administered by DODD are subject to payment standards set forth in this rule and the rules associated with the level one waiver program as established in Chapter 5123-9 of the Administrative Code.(D) Payment for level one waiver services will not exceed the maximum rates established in Chapter 5123-9 of the Administrative Code.(E) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-06 of the Administrative Code.(F) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:(1) The waiver service is provided to an individual who is enrolled in the level one waiver program at the time of service; and(2) The waiver service is provided within the limitations specified by the level one waiver program in which the individual is enrolled; and(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital unless otherwise permitted in other HCBS waiver program rules pertaining to acute care, and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID). (a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services will not be considered a resident of an ICF/IID if the ICF/IID is providing the residential respite service.(b) An ICF/IID providing residential respite services for any DODD administered waiver program that offers such services will not bill medicaid through the ICF/IID program. Payments for residential respite services will be made through the waiver program in which the individual is enrolled.(G) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.(H) ODM authority. ODM retains the final authority to establish payment rates for waiver services approved under the level one waiver and has final approval of any policies and rules that govern any component of the medicaid program.
Ohio Admin. Code 5160-41-19
Effective: 9/6/2024
Five Year Review (FYR) Dates: 5/31/2024 and 09/06/2029
Promulgated Under: 119.03
Statutory Authority: 5166.02, 5166.23
Rule Amplifies: 5166.02, 5166.23, 5162.35, 5166.21
Prior Effective Dates: 03/19/2012, 09/01/2013, 07/01/2014, 07/01/2019