Rural Differential Rates 525-05-38

(Revised 12/01/2024 ML #3885)

View Archives

Purpose

The purpose of the rural differential rate (RD) is to create greater access to home and community-based services for individuals who reside in rural areas of North Dakota by offering a higher rate to Qualified Service Providers (QSPs) who are willing to travel to provide services. QSPs that are willing to travel at least 21 miles round trip to provide care to authorized individuals in rural areas will be reimbursed at a higher rate for those cares. QSPs are not paid for the time they drive to or from the individual’s home; the rural differential rate may only be used for the time spent actually providing services.

Standards for Providers

Enrolled agency or individual QSPs, authorized to provide Respite Care, Homemaker, Personal Care, Nurse Education, Extended Personal Care, Chore Labor, Supervision, Companionship, Transitional Living services, Waiver Personal Care or Community Transition Services.

All individual QSPs and agency employees that are authorized to bill using the RD rate will be required to submit proof of address upon request to Aging Services/Home and Community Based Services. The only proof of address that will be accepted for North Dakota residents will be a valid North Dakota driver’s license. Once the driver’s license is received the Department will verify that the address is current with the Department of Transportation.

If the QSP or agency employee resides in another State, the Department will accept another form of address verification i.e. current utility bill etc. If out of state residents submit other forms of identification the decision to accept it for purposes of being eligible to receive the RD rate will be made on a case by case basis.

Service Activities, Authorized

A Rural Differential Unit Rate Authorization/Closure must be completed by the case manager in the web-based case management system for each provider eligible to bill a rural differential rate. The Rural Differential Unit Rate Authorization/Closure must be submitted with a mapped verification of distance to Aging Services/HCBS.

The RD rate must be identified on the Person-Centered Plan (PCP) and the rate must be entered on the preauthorization in Therap.

• Rural Differential Rates may not be authorized retroactively from the date the individual requests the RD rate for the provider.

• The effective date of the updated authorization will be the date the authorization is entered into the EVV System.

Service Eligibility, Criteria for

An individual receiving services paid at the RD rates will meet the following criteria:

1. Individual must be eligible for one of the following services: Medicaid Waiver, Service Payments to the Elderly & Physically Disable (SPED), Expanded Service Payments to the Elderly & Disabled (EX-SPED), Medicaid State Plan personal Care (MSP-PC). For MSP-PC please see Personal Care Services 535-05-40.
2. Individual must reside outside the city limits of Fargo, Bismarck, Grand Forks, Minot, West Fargo, Mandan, Dickinson, Jamestown, and Williston.

• Situations where there is a discrepancy in what is considered city limits must be prior approved by the Rural Differential Coordinator. The HCBS Case Manager must send a written request for verification to the HCBS Program Administer responsible for program oversight.
•  Exception may be requested to allow a QSP in a rural area to receive a rural differential rate when providing services in the city limits of Minot, West Fargo, Mandan, Dickinson, Jamestown, and Williston if the following criteria are met.
• The individual has at least two ADL impairments and will need at least 100 units of service or supervision needs met to assure health and safety.
• The HCBS case manager has reached out to a minimum of three QSPs in the local area who are unable or unwilling to serve the individual. The HCBS CM must outline the efforts made to find a local QSP. Include the name of the three providers and the date the providers were contacted in the case narrative with a brief description of the reason for the denial.
• QSP cannot be a family member.
• Case Managers must request prior approval from RD Program Administrator.

A request for this exception can be made by sending an email to the program administrator outlining the efforts made to find a local QSP. Include the name of the three providers, the date the providers were contacted, and a brief description of the reason for the denial. The exception email must be kept in the consumer’s individual’s file and documented in the case narrative.

3. Individual needs any of the following services: respite care, homemaker, personal care, nurse education, extended personal care, chore labor, transitional living, supervision, companionship, waiver personal care, or community transition services and does not have access to a QSP of their choice, within 21 miles of their residence, that is willing to provide care.

Service Delivery

The RD rate is based on the number of miles (round trip) a QSP travels from their home base to provide services at the home of an authorized HCBS recipient.

• Home base is either the individual QSPs physical address, or the Agencies home office, satellite office, or employees physical address (if they are not required to report to the home office each day) whichever is closer.
• If an agency employee is not required to report to the home office each day and they live 21 or more miles (round trip) from the individual’s home, the RD rate may be used. If the employee lives less than 21 miles (round trip) from the individual’s home, the RD may not be used.
• Rural differential rates are based on the distance it takes to travel to each individual's home even if the QSPs serve more than one recipient in the community or in the same home.
• If the QSP travels to the individual’s home and remains in that community overnight or for a period of days, they are not eligible to claim the RD rate for those dates of service. The RD rate may only be claimed on the day the QSP travels to and from the individual’s home.
  • For example, if a QSP travels more than 21 miles round trip to provide care to their Mother, and then stays with their Mother for a few days, the RD rate would only be claimed on the first and last days they provide the care. The QSP must use the standard QSP rate for the days they do not travel to and from their home base.

Addresses:

Case Managers must use the physical address (PO BOX is not acceptable) listed on the QSP list when determining which RD rate to use for individual QSPs and Agency providers. A QSP list including the provider’s physical addresses will be provided to the HCBS Case Managers monthly.

Agency employees who are not required to report to their agency each day must make their address available to the HCBS office for verification. This address must be entered on the Rural Differential Unit Rate Authorization/Closure under QSP physical address. If a QSP states the physical address on the QSP list is incorrect, they must contact the HCBS office to change it before an authorization can be provided that includes a rural differential rate. It is not sufficient to notify the individual manager.

If the QSP’s address changes, the provider must notify HCBS and their Case Manager within 14 days. Once the Case Manager receives a notification of address change, they must recalculate a Map Quest to determine if there are any the case manager must submit the Rural Differential Unit Rate Authorization/Closure noting the change of address and an updated Map Quest with the current address.

If the QSP’s new address changes the tier the provider is eligible to bill, the case manager must update the tier and rate on the Rural Differential Unit Rate Authorization/Closure and develop a new authorization with the correct rate and provide it to the client and QSP.

If the QSP no longer qualifies for an RD rate, the Case Manager must complete and submit a Rural Differential Unit Rate Authorization/Closure in the web-based case management system.

Determining Distance:

Case managers are required to verify distance between the HCBS individual’s home and the QSP's home base by using a reputable internet-based mapping service. The Case Manager is responsible to choose the most reasonable route and print a copy of the mapped verification of distance, a copy must be kept in the individual’s file and submit to Aging Services/HCBS along with the Rural Differential Unit Rate Authorization/Closure.

• If there is a discrepancy when calculating distance, the final decision will be made by the Rural Differential Coordinator charged with program oversight. The HCBS Case Manager must send a written request explaining the issue to the Rural Differential Coordinator responsible for program oversight.