Long-term Care Agency Provider (PASSPORT Waiver)
Application Fee Required Beginning April 15, 2016
In accordance with federal requirements described in 42 CFR 445.460 and per Ohio Administrative Code 5160-1-17.8, the Ohio Department of Aging (ODA) will begin collecting a Medicaid application fee. The fee is currently $560 per application and is
. The fee applies to non-refundable . The fee will not be required if the agency applicant has paid the fee to either Medicare or another state’s Medicaid provider enrollment program (such as the Ohio Department of Medicaid, the Ohio Department of Developmental Disabilities, or outside of Ohio) within the past two years. However, ODA requires the agency applicant submit proof of payment with their application. agency applicants
Prior to apply for certification, please read and understand the conditions of participation and service requirements for which you are seeking certification.
View this information as well as all current effective rules.
Applicants applying to the Ohio Department of Aging to be certified as an agency provider for the PASSPORT Medicaid Waiver Program may request certification for the following services:
Adult Day Services: Enhanced
Independent Living Assistance: Telephone Support
Adult Day Services: Intensive
Independent Living Assistance: Travel Attendant
Minor Home Modification
Choices Home Care Attendant
Non-Emergency Medical Transportation
Emergency Response System
Enhanced Community Living
Personal Care Service
Home Delivered Meals
Home Medical Equipment/Supplies
Independent Living Assistance: In-Person Activities
Documentation you will be required to submit:
Evidence of Services Provided. Documentation you have provided services to two adults for a minimum of three months for all services you are requesting certification. (Example: requesting certification as a personal care provider, please provide time sheets or task sheets that clearly show the duties completed in the consumer's home.)
Evidence of Payment for Services. Documentation you have received payment for services provided to two adults for a minimum of three months (Example: copy of invoice used to bill consumer for services and evidence you received payment for those services.) Payment for services can be from private pay, insurance, other Medicaid/Medicare programs, etc.
Registration with the Ohio Secretary of State. A copy of registration certificate with the Ohio Secretary of State.
Ohio Bureau of Workers’ Compensation Certificate. A copy of current certification in good standing with the Ohio Bureau of Workers’ Compensation.
Certificate of Commercial Liability Insurance. A copy of current policy of minimum of one million dollars in commercial liability insurance.
Employee Dishonesty or Property Damage Insurance. A copy of current policy for employee dishonesty or property damage to others. This requirement can be a warranty, surety or business services bond.
Table of Organization: A copy of a table of organization that includes the full name of each position and indicates lines of authority.
Completed and Signed W-9: This for will be automatically completed and available to download for signature during the online application process.
Proof of Residency: Evidence that applicant/CEO has been resident of Ohio for the last five consecutive years. Acceptable documentation includes: valid driver's license; notification of registration as an elector; a copy of an officially filed federal or state tax form identifying the applicant's permanent residence; any other documentation the responsible entity considers acceptable showing evidence the applicant has been a resident of Ohio for the past five years. If you currently live or have lived outside of Ohio anytime in the past five years, you are required to submit an FBI background check.
FBI record check (if lived outside of Ohio in past 5 years): If you currently live or have lived outside of Ohio anytime in the past five years, you are required to submit an FBI background check.
Non-Disclosure Statement: This form will be available to download for signature during the online application process.
Required documentation can be submitted by:
Upload directly to application
to submission prior
Fax to 614-466-9812 or 614-466-5741
Ohio Department of Aging
246 N. High St./1st Fl.
Columbus, Ohio 43215-2406
PLEASE NOTE: documentation emailed to our office will not be accepted and can delay the processing of your application.
I acknowledge I have read and understand the above information.