Section 51.141. Organized health care delivery system

(a) An OHCDS shall:

(1) Be an enrolled MA waiver provider.

(2) Be enrolled in the Department’s MMIS.

(3) Provide at least one direct MA service.

(4) Agree to provide the identified vendor goods or services to participants.

(5) Bill the Department’s MMIS for the amount of the vendor goods or services.

(6) Pay the vendor which provided the vendor goods or services the amount billed for in the MMIS.

(b) An OHCDS may bill a separate administrative fee under the following:

(1) The administrative per transaction fee may not exceed $25 or 15% of the cost of the HCBS, whichever is less.

(2) The administrative activities must be required to deliver the vendor good or HCBS to a participant and must be documented to support the separate administrative fee.

(c) An OHCDS will not be reimbursed for the HCBS or the Department-established administrative fee if it contracts with a provider who is listed on the LEIE, EPLS or Medicheck list.

(d) An OHCDS will not be reimbursed for rendering OHCDS if it contracts with a provider who employs staff who is listed on the LEIE or EPLS.

(e) The OHCDS is responsible for ensuring that each vendor with which it contracts meets the applicable provisions of this chapter and in accordance with the requirements specified in the approved applicable waiver, including approved waiver amendments.

(f) Only vendor goods and services may be subcontracted through the OHCDS. A provider who subcontracts shall have written agreements specifying the duties, responsibilities and compensation of the subcontractor.

(g) An OHCDS shall provide the SC, the Department or the Department’s designee with a signed statement including the following:

(1) Attestation that the cost of the good is the same cost charged to the general public.

(2) Identification of the administrative fee that is in accordance with the Department’s established administrative fee.

(h) Subsections (c)(1) and (2) and (h)(2) do not apply to an OHCDS under the Adult Autism Waiver.