Section 16.03.10.307 - PERSONAL CARE SERVICES: PROVIDER REIMBURSEMENT01.Reimbursement Rate. Personal assistance providers will be paid a uniform reimbursement rate for service as established by the Department. Provider claims for payment will be submitted on claim forms provided or approved by the Department. Billing instructions will be provided by the Department.02.Calculated Fee. The fee calculated for personal care provider reimbursement includes a basic rate for services and mileage. No separate charges for mileage will be paid by the Department for non-medical transportation, unless approved by the Department or its contractor under a Home and Community-Based Services (HCBS) waiver, or provider transportation to and from the participant's home. Fees will be calculated as provided in Subsections 307.03 through 307.08 of this rule.03.Weighted Average Hourly Rate Methodology. Annually Medicaid will conduct a poll of all Idaho nursing facilities and ICFs/IID, and establish the weighted average hourly rates (WAHR) for nursing facility industry employees in comparable positions (i.e. RN, certified and non-certified nurse's aides) in Idaho to be used in calculating the reimbursement rate to be effective on July 1st of that year.04.Payment for Personal Assistance Agency. Payment for personal assistance agency services will be paid according to rates established by the Department. a. The Department will establish Personal Assistance Agency rates for personal assistance services based on the WAHR. Click here to view image
b. The Department will calculate a supplemental component using costs reported for travel, administration, training, and all payroll taxes and fringe benefits. The survey data is the cost information collected during the prior State Fiscal Year.c. The Department will survey one hundred percent (100%) of PCS providers. Cost surveys are unaudited, but a provider that refuses or fails to respond to the periodic state surveys may be disenrolled as a Medicaid provider. The Department will derive reimbursement rates using direct care staff costs, employment related expenditures, program related costs, and indirect general and administrative costs in the reimbursement methodology, when these costs are incurred by a provider.05.Payment Levels for Adults in a RALF or CFH. Adult participants living in RALFs or CFHs will receive PCS at a rate based on their care level. Each level will convert to a specific number of hours of PCS. a. Reimbursement Level I -- One point twenty-five (1.25) hours of PCS per day or eight point seventy-five (8.75) hours per week.b. Reimbursement Level II -- One point five (1.5) hours of PCS per day or ten point five (10.5) hours per week.c. Reimbursement Level III -- Two point twenty-five (2.25) hours of PCS per day or fifteen point seventy-five (15.75) hours per week.d. Reimbursement Level IV - One point seventy-nine (1.79) hours of PCS per day or twelve point five (12.5) hours per week. This level will be assigned based on a documented diagnosis of mental illness, intellectual disability, or Alzheimer's disease. If an individual is assessed as Level III with a diagnosis of mental illness, intellectual disability, or Alzheimer's disease the provider reimbursement rate will be the higher amount as described in Subsection 307.05.c. of these rules.06.Attending Physician Reimbursement Level. The attending physician or authorized provider are reimbursed for services provided using current payment levels and methodologies for other services provided to eligible participants.07.Supervisory RN and QIDP Reimbursement Level. The supervisory RN and QIDP are reimbursed at a per visit amount established by the Department for supervisory visits. Participant evaluations and Care Plan Development will be reimbursed at a rate established by the Department, following authorization by the Department or its contractor. a. The number of supervisory visits by the RN or QIDP to be conducted per calendar quarter will be approved as part of the PCS care plan by the Department or its contractor.b. Additional evaluations or emergency visits in excess of those contained in the approved care plan will be authorized when needed by the Department or its contractor.08.Payment for PCS Family Alternate Care Home. The Department will establish PCS Family Alternate Care Home rates for personal assistance services based on the WAHR. Based on the survey conducted, the Department will calculate a supplemental component using costs reported for administration, and training. The survey data is the cost information collected during the prior State Fiscal Year. Click here to view image
09.EVV Compliance. Provider claims for PCS require EVV compliance as described in Section 041 of these rules in order to be eligible for payment.Idaho Admin. Code r. 16.03.10.307