Rural Differential Rates 535-05-38

(NEW 5/1/2015 ML#3444)

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Purpose

The purpose of the rural differential rate is to create greater access to home and community based services for clients who reside in rural areas of North Dakota by offering a higher rate to 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 client’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 Medicaid State Plan Personal Care Services.

Service Activities, Authorized

The rural differential rate must be identified on the Personal Care Service Plan, SFN 662 and the Authorization to Provide Personal Care Services, SFN 663. The SFN 662 and SFN 663 must be sent to the HCBS State office for all cases where the rural differential has been authorized. The SFN 663 must also include the clients physical address (PO Box is not acceptable). A printed copy of the map quest results must be maintained in the clients file, and send into the HCBS State office. If more than one provider is authorized and not all have Rural Differential Rate or different Rural Differential Rates a separate SFN 663 must be completed for each rate.

Service Eligibility, Criteria for

An HCBS client receiving services paid at the rural differential rates will meet the following criteria:

1. Must be eligible for Medicaid State Plan personal Care (MSP-PC).
2. 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.

3. Needs personal care 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 rural differential 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 because of distance) whichever is closer.

• If an agency employee is not required to report to the home office each day because of distance and they live 21 or more miles (round trip) from the client’s home the rural differential rate may be used. If the employee lives less than 21 miles (round trip) from the client’s home than the rural differential may not be used.

• Rural differential rates are based on the distance it takes to travel to each individual client’s home even if the QSPs serve more than one recipient in the community or in the same home.

Addresses:

Case Managers must use the physical address (PO BOX is not acceptable) listed on the QSP list when determining which rural differential 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 because of distance must make their address available to the HCBS office for verification. This address must be entered on the SFN 663 under QSP physical address. If a QSP states that 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 case 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 changes to Rural Differential eligibility for the QSP.

If the QSP’s new address does not change the tier they have previously been approved for, the Case Manager must only make corrections to the authorization and Map Quest. A copy of the unchanged care plan, updated authorization and Map Quest must be forwarded to the Department. In addition, a copy of the revised authorization must be forwarded to the QSP.

If the address change does affect the tier previously authorized, the Case Manager must make corrections to the care plan, authorization and Map Quest and send to the Department. A copy of the revised authorization must also be forwarded to the QSP.

If the QSP no longer qualifies for an RD rate, the Case Manager must update the SFN 662 and SFN 663 by putting the DATE RD Removed on both forms and submit the SFN 662 and 663 with the state. The updated SFN 663 must be sent to the QSP.