CMS Approves Individual Options (IO) Waiver Amendment

The Centers for Medicare and Medicaid Services (CMS), the federal office that oversees the Medicaid program, has approved Ohio's amendment to the Individual Options (IO) waiver. The effective date of the amendment is October 1, 2007.

The IO waiver amendment increased the maximum number of participants to be served and made changes to the new waiver reimbursement methods, specifically for individuals who "share" IO waiver services. The IO waiver amendment also incorporated changes to the Adult Day Services, and included the new service of Adult Foster Care.

Number of waiver participants increased

The amendment increased the maximum number of people that can be served on the IO waiver. This is good news for those individuals who will receive IO waivers through the Martin v Taft litigation. Ohio is currently in the fourth year of a five year renewal of the IO waiver. The maximum number approved in the fourth year is 15,255. The amendment increased the number of individuals served by 900 in the last year of the waiver to a total of 16,155.

IO Waiver changes for those who "share" services

The IO waiver amendment changed the billing process for the Homemaker/Personal Care (HPC) service for those who share services. This change was designed to pay a fixed hourly rate to the waiver provider and that is apportioned by the individuals' level of service. The hourly rate is based on a combination of planning information and the individuals' days of service. While the changes were technical in nature, they were intended, in part, to simplify documentation for payment. Before this amendment HPC had to be billed in 15 minute units.

County boards of Mental Retardation and Developmental Disabilities (MRDD) are working to transition the remaining people on the waiver to the new reimbursement system. For people on the IO waiver who share services and whose costs exceed the funding range they received on the Ohio Developmental Disabilities Profile (ODDP), they may be asked to make changes to their plans or to submit prior authorization requests for services over the ODDP funding range.

Adult foster care and adult day services

The waiver was amended to include adult foster care as a service for IO waiver recipients who live in the home of the principal care provider and is not a relative. This service is billed on a daily rate.

Also included in the amendment were changes to adult day services. The changes will be effective January 1, 2008, and include how these services are to be billed to the IO waiver. Changes were also made to transportation services that enable a person to get to their adult day services provider.

Timelines

The following timelines were given by ODMRDD. Exceptions include individuals who are currently in the Medicaid appeal process.

• For individuals who do not share HPC services, transition to the new waiver reimbursement will occur by December 31, 2007.
• People receiving Adult Foster Care will transition by December 31, 2007.
• People sharing HPC services will be transitioned by March 1, 2008. (Ohio has requested this extension from CMS, but it is not yet granted.)

There are 607 people across the state who need to transition by December 31st.

Prior authorization

Now that CMS has approved the IO waiver amendment, there is much to be done for people already on the waiver who have not yet switched to the new waiver reimbursement system. Part of that process may include prior authorization. For those whose needs are more than the funding range provided by the ODDP, prior authorization will be required. It is not necessary for the county board of MRDD to agree with you that more services are needed. However, it is important to find out if your county board of MRDD agrees with your request. If the county board disagrees, you should include additional information about why the services are needed. The prior authorization form gives you the criteria that the state will use to consider your request. You should try to provide the information that covers this criteria. Information from doctors or other people supporting your request can also be attached.

Article posted December 11, 2007

• Waivers