Chapter 173-38 Medicaid-Funded Assisted Living Program

173-38-01 Assisted living program (medicaid-funded component): introduction and definitions.

(A) Introduction: Chapter 173-38 of the Administrative Code regulates the medicaid-funded component of the assisted living program created under section 173.54 of the Revised Code. (See Chapter 173-51 of the Administrative Code for rules on the state-funded component of the assisted living program.)

(B) Definitions for this chapter:

"Assisted living program" (program) means the home and community-based medicaid waiver program created under section 173.54 of the Revised Code that provides individuals enrolled in the program with the assisted living service under rule 173-39-02.16 of the Administrative Code and, in some cases, the community transition service under rule 173-39-02.17 of the Administrative Code, if the individuals reside in a residential care facility and would otherwise receive services in a nursing facility if the waiver program was not available.

"Authorized representative" has the same meaning as in rule 5160-1-33 of the Administrative Code.

"ODA" means "the Ohio department of aging.

"ODA's designee" has the same meaning as in rule 173-39-01 of the Administrative Code.

"ODM" means "the Ohio department of medicaid."

"ODM's administrative agency" has the same meaning as "administrative agency" in rule 5160:1-1-01 of the Administrative Code.

"Person-centered services plan" means the written outline of the services that a case manager authorizes a provider to provide to an individual, regardless of the funding source for those services. It includes the person-centered planning in rule 5160-44-02 of the Administrative Code.

"Residential care facility" (RCF) has the same meaning as in section 3721.01 of the Revised Code.

Replaces: 173-38-01

Effective: 11/1/2018
Five Year Review (FYR) Dates: 11/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.54, 173.01, 173.02
Rule Amplifies: 173.54; 42 C.F.R 441.352
Prior Effective Dates: 07/16/2006, 09/18/2009, 03/12/2011, 09/29/2011, 02/16/2012, 03/01/2014, 07/01/2016, 02/01/2017, 04/01/2018

173-38-02 Assisted living program (medicaid-funded component): eligibility requirements for individuals.

A person is only eligible for the medicaid-funded component of the assisted living program if he or she meets the eligibility requirements under rule 5160-33-03 of the Administrative Code.

Effective: 11/1/2018
Five Year Review (FYR) Dates: 8/14/2018 and 11/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.54, 173.02, 173.01
Rule Amplifies: 173.54; 42 C.F.R 441.352
Prior Effective Dates: 07/16/2006, 09/18/2009, 09/29/2011, 03/01/2014

173-38-03 Assisted living program (medicaid-funded component): enrollment and reassessment of individuals.

(A) Initial contact: To determine if an individual who applies for the medicaid-funded component of the assisted living program meets all eligibility requirements for the program under rule 5160-33-03 of the Administrative Code, ODM's administrative agency shall determine if the individual meets all medicaid financial eligibility requirements required by that rule and ODA's designee shall determine if the individual meets all non-financial eligibility required by that rule. An individual may initially contact either ODM's administrative agency or ODA's designee to begin the enrollment process. The two agencies shall coordinate processing the request for enrollment into the medicaid-funded component of the assisted living program:

(1) ODM's administrative agency: An individual who makes initial contact with ODM's administrative agency, shall apply for medicaid (unless already enrolled in medicaid) and for the medicaid-funded component of the assisted living program with the assistance of ODM's administrative agency. ODM's administrative agency shall determine if the individual meets all financial eligibility requirements and shall notify ODA's designee of the individual's application. In response, ODA's designee shall initiate contact with the individual to conduct an in-person assessment to determine if the individual meets all non-financial eligibility requirements.

(2) ODA's designee:

(a) An individual who makes initial contact with ODA's designee shall apply for medicaid (unless already enrolled in medicaid) and for the medicaid-funded component of the assisted living program with the assistance of ODA's designee. ODA's designee shall conduct an in-person assessment to determine if the individual meets all non-financial eligibility requirements.

(b) After the individual applies for the medicaid-funded component of the assisted living program, ODA or its designee shall notify the individual of the existence of the state-funded component of the assisted living program in Chapter 173-51 of the Administrative Code and offer the individual an opportunity to apply for enrollment in the state-funded component of the program.

(B) If determined ineligible: If ODM's administrative agency or ODA's designee determines the individual does not meet all eligibility requirements for the program under rule 5160-33-03 of the Administrative Code, ODA's designee shall not enroll the individual in the program.

(1) ODM's administrative agency: If ODM's administrative agency determines the individual does not meet all financial eligibility requirements, it shall notify ODA's designee and send the individual a notice of denial and hearing rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

(2) ODA's designee: If ODA's designee determines the individual does not meet all non-financial eligibility requirements, it shall notify ODM's administrative agency and, in turn, ODM's administrative agency shall send the individual a notice of denial and hearing rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

(C) If determined eligible: If ODM's administrative agency or ODA's designee determines the individual meets all eligibility requirements for the medicaid-funded component of the assisted living program under rule 5160-33-03 of the Administrative Code, ODA's designee shall calculate the individual's medicaid waiver program enrollment date according to paragraph (C)(1) of this rule and enroll the individual into the program according to paragraph (C)(2) or (C)(3) of this rule.

(1) Medicaid waiver program enrollment date:

(a) According to paragraph (D)(1)(c) of rule 5160:1-2-03 of the Administrative Code, ODA's designee shall establish the individual's medicaid waiver program enrollment date.

(b) ODA's designee shall establish the individual's medicaid waiver program enrollment date as the latest date that all the following requirements are met:

(i) The individual's basic medicaid effective date.

(ii) The date the individual meets all level of care requirements to participate in the medicaid waiver program.

(iii) The date the individual meets all medicaid waiver program requirements listed in rule 5160-33-03 of the Administrative Code.

(iv) The date ODA's designee approves the individual's person-centered services plan, which includes at least one medicaid waiver service.

(v) The date the individual resides in an ODA-certified RCF in an ODA-approved living unit.

(c) The medicaid-funded component of the assisted living program shall not pay for any service provided to an individual before ODA's designee establishes the medicaid waiver program enrollment date according to paragraph (C)(1)(b) of this rule.

(d) The individual's medicaid waiver program enrollment date for the medicaid-funded component of the assisted living program may differ from the basic medicaid effective date.

(2) Available slot: If a waiver slot in the medicaid-funded component of the assisted living program is available, and if ODA's designee has established the individual's medicaid waiver program enrollment date, ODA's designee shall enroll the individual into the program, if the individual continues to meet the eligibility requirements for the program and continues to want to enroll into the program. ODA's designee shall not place the individual on the unified waiting list.

(3) No available slot: If a waiver slot is not available in the medicaid-funded component of the assisted living program, ODA's designee may enroll the eligible individual when a waiver slot does become available by one of two means: the unified waiting list or the home-first component of the medicaid-funded component of the assisted living program:

(a) Unified waiting list: ODA's designee shall place the individual on the unified waiting list according to rule 173-44-04 of the Administrative Code, unless the individual qualifies for the home first component of the medicaid-funded component of the assisted living program, as addressed in paragraph (C)(3)(b) of this rule.

(b) Home first: If an individual meets all requirements for the home first component of the assisted living program in section 173.542 of the Revised Code, ODA's designee shall enroll the individual before enrolling any individual from the unified waiting list.

(D) Reassessment: ODA's designee shall reassess each individual enrolled into the medicaid-funded component of the assisted living program no less often than one time each year after the date the individual enrolled into the program. After ODA's designee conducts each reassessment, if the individual continues to qualify for the medicaid-funded component of the program, the individual shall decide if he or she wishes to remain in the program. If the individual wishes to remain, the individual shall sign form ODA1044 as a condition of continued enrollment.

(E) An authorized representative may represent an individual in the enrollment and reassessment processes.

(F) Definitions for this rule:

(1) "Basic medicaid effective date" means the date an individual becomes eligible to receive services under the medicaid state plan. Rule 5160:1-2-03 of the Administrative Code establishes the basic medicaid effective date.

(2) "Form ODA1044" means "form ODA1044 'Annual Enrollment Agreement' (March, 2014)." ODA publishes the form on www.aging.ohio.gov. It is available to the general public at no cost.

Replaces: 173-38-03

Effective: 11/1/2018
Five Year Review (FYR) Dates: 11/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.54
Rule Amplifies: 173.54 , 173.542, 173.55 ; 42 C.F.R 441.352
Prior Effective Dates: 07/16/2006, 09/18/2009, 03/12/2011, 09/29/2011, 09/10/2012, 03/01/2014

173-38-04 Assisted living program (medicaid-funded): provider certification.

An RCF seeking to become an assisted living provider certified by ODA to provide goods and services according to rules 173-39-02.16 and 173-39- 02.17 of the Administrative Code shall apply to become so according to rule 173-39-03 of the Administrative Code.

Replaces: 173-38-04

Effective: 4/1/2018
Five Year Review (FYR) Dates: 04/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.391, 173.54.
Rule Amplifies: 173.39 , 173.54; 42 C.F.R. 441.352.
Prior Effective Dates: 09/18/2009, 09/29/2011

173-38-05 Assisted living program (medicaid-funded): covered services.

An individual's service plan may authorize no more than the following two services:

(A) The assisted living service under rule 173-39-02.16 of the Administrative Code.

(B) The community transition service under rule 173-39-02.17 of the Administrative Code.

Replaces: 173-38-05

Effective: 4/1/2018
Five Year Review (FYR) Dates: 04/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.54.
Rule Amplifies: 173.54; 42 C.F.R. 441.352.
Prior Effective Dates: 09/18/2009, 09/29/2011