Idaho

The Department provides public notice of significant reimbursement changes in accordance with 42

CFR § 447.205 (made applicable to waivers through 42 CFR § 441.304(e)). Pursuant to 42 CFR

§447.205, the State publishes public notice of proposed reimbursement changes in multiple

newspapers throughout the State and on the Department’s website at www.healthandwelfare.idaho.gov.

Copies of public notices and text of proposed significant reimbursement changes are made available

for public review on Department’s website and during regular business hours at agency locations in

each Idaho county as identified in each public notice. Additionally, payment rates are published on

the Department’s website at for the public to access.

The Adult Developmental Disabilities Waiver Services fee schedule is found in the Provider

Resources folder under > Medicaid > Fee Schedules > Provider Reimbursement Rates folder located at:

https://publicdocuments.dhw.idaho.gov/WebLink/Browse.aspx?id=3488&dbid=0&repo=PUBLIC-DOCUMENTS Select the link for year desired to view waiver provider rates by that year.

The Department provides opportunity for meaningful public input related to proposed reimbursement

changes in accordance with 42 CFR § 441.304(f). The Department solicits comments from the public

(including beneficiaries, providers and other stakeholders) through its public notice process and

through public hearings related to the proposed reimbursement changes. The public is given the

opportunity to comment on the proposed reimbursement changes for at least thirty (30) days prior to

the submission of any waiver amendment to CMS. Additionally, when Administrative Rules are

promulgated in connection with reimbursement changes, the proposed rules are published in the Idaho

Administrative Bulletin and the public is given at least twenty-one (21) days after the date of

publishing to comment.

Waiver service providers will be paid on a fee for service basis as established by the Department

depending on the type of service provided. The state collaborates with providers on rate reviews

for the services outlined below through direct outreach via email or phone, meetings and

Information Releases. Oversight of the rate determination process is conducted by a third-party

accounting firm, a provider workgroup, legislative joint finance committee and state Medicaid

staff. The Bureau of Financial Operations is responsible for rate determinations. Main Section 6-I

describes the state’s process for soliciting public comments on rate determination methods.

Review and rebasing reimbursement rates are initiated through cost surveys and/or when an access or

quality indicator reflects a potential issue as outlined in IDAPA 16.03.10, “Medicaid Enhanced Plan

Benefits” Sections 037-038. Rebasing is finalized through the approval of Idaho budget requests as

authorized by the Idaho State Legislature. Providers and participants with questions about pricing

should contact Medicaid’s Office of Reimbursement by phone (208) 287-1180 or email

MedicaidReimTeam@dhw.idaho.gov

Service Rate Methodology Information:

A. General Rate Provisions.

1. The state reimburses services at the same rate statewide, and

2. Rates may vary by provider type under this waiver. Differences are indicated by provider type on

the published Adult Developmental Disabilities Waiver Services Fee Schedule.

Differences are driven by provider-specific cost surveys that review wage and cost data collected

from providers directly, the Bureau of Labor Statistics, and the Internal

Revenue Service.

B. Fee-For-Service Rates.

1. Rates Developed by the Cost Survey Model.

a. Adult Day Health. Rates were last reviewed and rebased SFY 2022.

b. Residential Habilitation. Rates were last reviewed SFY 2022 and last rebased SFY 2018. Rates for

Residential Habilitation vary by level of Supported Living and/or Certified Family Home (CFH) service provided, but do not vary by provider type.

c. Supported Employment Services. Rates were last reviewed and rebased SFY 2020.

d. Behavioral Consultation/Crisis Management. Rates were last reviewed SFY 2020 and rebased SFY

2008. Rates vary by provider qualifications as indicated on the published fee

schedule.

e. Respite Care. Rates were last reviewed and rebased SFY 2022. Rates vary by provider type as

indicated on the published fee schedule.

2. Manually Priced Rates.

a. Chore Services. Items are manually priced based on the submitted invoice price.

b. Environmental Accessibility Adaptations. for adaptations over $500, three (3) bids are required

if it is possible to obtain three (3) bids. The lowest bid which meets the participant’s needs is selected.

c. Specialized Medical Equipment and Supplies. For equipment and supplies that are manually priced,

including miscellaneous codes, a copy of the manufacturer’s suggested retail pricing (MSRP) or an invoice or quote from the manufacturer is required. Reimbursement is seventy-five percent (75%) of MSRP. If pricing documentation is the invoice, reimbursement is at cost plus ten percent (10%), plus shipping (if that documentation is provided).

For equipment and supplies that are not manually priced, the rate is based on the published Medicaid fee schedule price.

d. Transition Services. Service is manually priced; projected amount for this benefit is calculated

based on an average of actual expenses for this service over the previous waiver cycle (for this renewal, actual expenses were averaged for waiver years 2 through 5 (FFY2019 through FFY2022) of the previous waiver cycle as Transition Services was not added to this waiver until FFY 2019).

3. Other Rate Models.

a. Home Delivered Meals. The initial rate was set in 1999 based on time studies in nursing

facilities. Rates related to Home Delivered Meals were last reviewed SFY 2020 and rebased

SFY 2011.

b. Non-Medical Transportation (NMT). A study was conducted evaluating the actual costs of fuel

reasonably incurred by the typical non-commercial transportation provider whose

personal vehicle averages fifteen (15) miles per gallon. Rates vary by provider type and service

offered as indicated on the published fee schedule. Rates were last reviewed and

rebased SFY 2010.

c. Personal Emergency Response System (PERS). The rate was developed by surveying PERS vendors in

all seven (7) regions of the State to calculate a state-wide average. The state-wide average is the rate paid for this service. Rates were last reviewed and rebased SFY 2011.

d. Skilled Nursing. These services are paid on a uniform reimbursement rate based on an annual

survey conducted by the Department. Rates were last reviewed SFY 2022 and rebased SFY

2014. Rates vary by provider type and license of direct care staff as indicated on the published

fee schedule.

3. Self-Direction Rates.

a. Non-Medical Transportation, Skilled Nursing Services, Specialized Medical Equipment and

Supplies, Support Broker Services, and Community Support Services. Rates are set by the participant based on the specific needs of the participant through negotiation with the Department.

The identified rates may not exceed prevailing market rates, identified using Bureau of Labor and Statistics wage data. The Department provides training and resource materials to assist the participant, Support Broker, and circle of supports to make this determination. The participant and their Support Broker monitor this requirement each time the participant enters into an employment agreement. The Department ensures that the proposed plan of service does not exceed the overall budget at the time of plan review and approval. The Department also reviews a statistically valid sample of participant

employment agreements during the annual retrospective quality assurance reviews.

b. Financial Management Services (FMS). Reimbursement methodology for FMS is based on a market

study of other state Medicaid program rates for FMS to gather a range which allows the Department to accept a Per Member Per Month (PMPM) rate within the range determined from the market study.

The established PMPM payment rates for each Department approved qualified FMS provider is published on a fee schedule by the Department. This fee schedule is updated at least yearly, and when new providers are approved. This information is published for consumer convenience the Department’s website.

c. Transition Services. Rates are set by the participant based on the specific needs of the

participant through negotiation with the Department. Expenses for Transition Services

may not exceed $2,000 per qualifying transition.

A. Rate Update Process. The State provides public notice of significant rate changes in accordance with 42 CFR §

447.205 and 42 CFR § 441.304(e). The State publishes public notice of proposed changes in multiple newspapers throughout the state and on the Department’s website. Copies of public notices and text of proposed significant rate changes are made available for public review on the Department’s website and during regular business hours at agency locations in each Idaho county as identified in the public notice. Additionally, payment rates are published on the Department’s website for participants, the public, and providers to access. Current Aged & Disabled (A&D) Waiver Services fee schedules are found in the Provider Resources folder under > Medicaid > Fee Schedules > Provider Reimbursement Rates > HCBS and LTSS folder located at https://publicdocuments.dhw.idaho.gov/WebLink/Browse.aspx?id=25868&dbid=0&repo=PUBLIC-DOCUMENTS Select the appropriate link for specific provider type desired to view current rates.

The State provides opportunity for meaningful public input related to proposed rate changes in accordance with 42 CFR

§ 441.304(f). The State solicits comments from the public (beneficiaries, providers, and other stakeholders) through its public notice process and through public hearings related to the proposed rate changes. The public is given the opportunity to comment for at least thirty (30) days prior to the submission of any waiver amendment to the Centers for Medicare and Medicaid Services (CMS). Additionally, the State solicits comments at public hearings when Administrative Rules are promulgated in connection with rate changes, proposed rules are published in the Idaho Administrative Bulletin and the public has the opportunity to comment on proposed rules for at least twenty-one (21) days after the publish date.

Waiver providers are paid on a fee-for-service (FFS) basis as established by the State and the type of service provided. The State collaborates with providers on rate reviews for the services outlined below through direct outreach via email or phone, meetings, and Information Releases. Rate determination process is reviewed by a third-party accounting firm, provider workgroups, legislative joint finance committee and Medicaid staff. The Bureau of Financial Operations (BFO) is responsible for rate determinations. The State ensures that Managed Care Entities (MCE) reimburse providers at a rate no less than the current Medicaid Provider rates. Main Section 6-I describes the process for soliciting public comments on rate determination methods.

Review and rebasing rates are initiated through cost surveys every 5 (five) years, the provider rate review process, the weighted average hourly wage survey, and/or when an access or quality indicator reflects a potential issue as outlined in IDAPA 16.03.10, “Medicaid Enhanced Plan Benefits” Section 037. Rebasing is finalized through the approval of budget requests as authorized by the Idaho State Legislature. Contact Medicaid’s Office of Reimbursement for questions by phone (208) 287-1180 or email MedicaidRateReview@dhw.idaho.gov

B. Service Rate Methodology.

1. General Rate Provisions:

The State pays the same rates for services provided under the self-directed model using a Fiscal Intermediary (FI) Agency as it pays for rates provided by a Personal Assistance Agency (PAA).

The State reimburses services at the same rate statewide.

Service rates may vary by provider type under this waiver. Differences are indicated by provider type on the published Fee Schedules and as described below. Differences are driven by provider-specific cost surveys reviewing wage and cost data collected from providers throughout the state directly, the Bureau of Labor Statistics, and the Internal Revenue Service.

FFS Rates:

Adult Day Health (ADH). The initial rate was set in 1999 based on time studies in nursing facilities. Rates in Waiver Year 1 of the Workbook include enhanced payments for all provider types ($2.79 per 15-minute unit) authorized under an approved Emergency Appendix K Amendment related to the Coronavirus Public Health Emergency (PHE). When the PHE rate increases expire, ADH services provided by Developmental Disability Agencies (DDA) will continue to be paid at $2.79 per 15-min. unit. All other provider types will return to the $1.50 per 15-min. unit rate. Rates related to ADH were last reviewed and rebased SFY 2022.

Home Delivered Meals. The initial rate was set in 1999 based on time studies in nursing facilities. Rates were last reviewed SFY 2020 and rebased SFY 2011.

Residential Habilitation (ResHab) and Supported Employment. The rate model used to develop these rates is described in Idaho Code 16.03.10, “Medicaid Enhanced Plan Benefits,” Section 038.04, “Reimbursement Rate Setting Methodology.” ResHab rates were last reviewed SFY 2022 and last rebased SFY 2018. Supported Employment rates were last reviewed and rebased SFY 2020.

Consultation Services, Personal Emergency Response System (PERS), and Day Habilitation. The initial rates were set back in 1999 based on time studies in nursing facilities. Ongoing rates are set based on a labor model using a Staff Support Hour (SSH) rate approach, which involves developing a single rate for a unit of staff time spent providing services for a participant. Rates related to these services were last reviewed and rebased SFY 2011.

Attendant Care, Homemaker Services, Companion Services, Chore Services, and Respite Care. The rate model used to develop rates for these services is described in Idaho Code (IDAPA) 16.03.10, “Medicaid Enhanced Plan Benefits”. These services are identified as Personal Care Services (PCS) where methodology is described in Section 307, “Personal Care Services: Provider Reimbursement,” under Subsections .01 through .04. In addition, Section .037 “General Reimbursement: Participant Services,” Subsection 02 requires the state to conduct a cost survey when there are identified access issues. The current hourly rate calculation was determined when the state followed Idaho Code 16.03.10.307.04.a in calculating a direct care wage. This section says the state will establish Personal Assistance Agency (PAA) rates for personal assistance services based on the Weighted Average Hour Rate (WAHR). The state then followed Idaho Code 16.03.10.307.04.b in calculating a supplemental component. This section says the state will calculate a supplemental component using costs reported for travel, administration, training, payroll taxes and fringe benefits (employment related expenditures, program related costs, and indirect general and administrative costs). Rates for these services were last reviewed and rebased SFY 2022.

Respite provided by a PAA is paid at $4.99 per 15-min. unit, while the rate for Respite provided by an Adult Residential Care provider is $2.64 per 15-min. unit.

Adult Residential Care. Services are paid per diem based on the number of hours and types of assistance required by each individual participant as identified in the Uniform Assessment Instrument (UAI). Individual component rates for services that factor into these per diem rates (Attendant Care and Homemaker) were last reviewed and rebased SFY 2022.

Non-Medical Transportation (NMT). A study is conducted that evaluates the actual costs of fuel reasonably incurred by the typical non-commercial transportation provider whose personal vehicle averages fifteen (15) miles per gallon. Agency providers are paid $0.44 per mile. Commercial providers are paid $4.20 for the first mile of their first trip in the day, plus $1.17 per mile. Commercial Bus passes are manually priced. NMT rates were last reviewed and rebased SFY 2010.

Specialized Medical Equipment & Supplies. Service items are manually priced (including miscellaneous codes), require a copy of the manufacturer’s suggested retail pricing (MSRP), an invoice, and/or quote from the manufacturer. Reimbursement is for seventy-five percent (75%) of MSRP. When pricing documentation includes the invoice, reimbursement is at cost plus ten percent (10%), plus shipping (when documentation is provided). For codes that are not manually priced, the rate is based on the currently posted Medicaid fee schedule price.

Environmental Accessibility Adaptations. Service is manually priced; for adaptations over $500, three (3) bids are required whenever possible. The lowest bid which meets the participant’s needs is selected.

Skilled Nursing. Services are paid on a uniform reimbursement rate based on an annual survey conducted by the Department. Individual services provided by direct care nursing staff are reimbursed by license and/or service. Registered Nurses (RN) are reimbursed at $10.19 per 15-min. unit, Licensed Practical Nurses (LPN) are reimbursed at

$7.31 per 15-min. unit, and Nursing oversight activities are paid at $50.95 per visit. Rates were last reviewed SFY 2022 and rebased SFY 2014.

Transition Services. Service is manually priced; projected usage amount for this benefit is calculated based on an average of actual expenses for this service over the previous waiver cycle starting FFY 2019 when Transition Services were added to the waiver.

3. MCE Rates.

The Contracts between the State and the MCEs shall be a firm fixed fee, indefinite quantity contract for services specified in the Scope of Work. For payment purposes, a capitated payment is calculated based on the current eligible Medicare Medicaid Coordinated Plan (MMCP) or Idaho Medicaid Plus participant count multiplied by the Per Member Per Month (PMPM) figure and is intended to adequately to support participant access to, and utilization of covered services, including administrative costs. The total PMPM payment is comprised of two (2) components; the medical capitation and the blended Long Term Services and Supports (LTSS) costs. Once the eligible Enrollee count by enrollment status is determined for the contract, the blended LTSS rate will remain in effect through the contract period.

Initial projections used for population distribution between the MMCP, Idaho Medicaid Plus, and Fee-For-Service mix was derived using the following assumptions as we did not have sufficient enrollment data to project how the Dual Population would distribute out in the mix:

i.Counties with Mandatory Enrollment, the State assumed that Idaho Medicaid Plus would have the largest group, with MMCP second largest and FFS smallest. Estimated a 50-40-10 distribution.

ii. Counties with Voluntary Enrollment, the State assumed that largest group would be comprised of MMCP, with some FFS and no Idaho Medicaid Plus. Estimated a 25-75-0 distribution.

iii. Counties with Passive Enrollment, the State assumed that Idaho Medicaid Plus would have the largest group, with MMCP second largest and FFS smallest. Estimated a 60-25-15 distribution.

For this waiver renewal, the State had sufficient enrollment data over the last waiver cycle (SFY2018-2021) to predict with reasonable confidence that the population mix is much more even than expected.

Amendment R07.01 Effective 4/1/2024:

Skilled Nursing rates were reviewed in SFY 2023. The following services were reviewed and rebased in SFY 2023: ADH, Adult Residential Care – Certified Family Home (CFH), Attendant Care, Chore, Companion, Home Delivered Meals, Homemaker, PERS, ResHab, Respite, and Supported Employment,

ADH rates related to the PHE expired November 2023. DDA rates remain at $2.79 per 15-min. unit and rates for ADH provided by CFHs now pay at $1.95 per 15-min. unit as approved in the 2023 Idaho Legislature. All other ADH providers returned to the $1.50 per 15-min. unit rate effective November 12, 2023.

Attendant Care is reimbursed at the same rate whether a spouse caregiver is used or not.