173-38-03 Assisted living program (medicaid-funded component): enrollment process for individuals.

(A) Initial contact: To determine if an individual who applies for the medicaid-funded component of the assisted living program meets the eligibility criteria for the program under rule 5160-33-03 of the Administrative Code, the CDJFS shall determine if the individual meets the medicaid financial eligibility criteria required by that rule and ODA's designee shall determine if the individual meets the non-financial eligibility required by that rule. An individual may initially contact either the CDJFS 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) CDJFS: The individual who makes initial contact with the CDJFS shall complete forms JFS07200 and JFS02399. The CDJFS shall determine if the individual meets the program's financial eligibility criteria and shall notify ODA's designee of the individual's application. In response, ODA's designee shall initiate contact with the individual to perform an in-person assessment to determine if the individual meets the non-financial eligibility criteria.

(2) ODA's designee:

(a) The individual who makes initial contact with ODA's designee shall complete forms JFS07200 and JFS02399 and submit the forms to the CDJFS. ODA's designee may help the individual complete the forms and may forward the completed forms to the CDJFS on behalf of the individual. ODA's designee shall perform an in-person assessment to determine if the individual meets the non-financial eligibility criteria.

(b) Once ODA (or ODA's designee) receives the individual's application for the medicaid-funded component of the assisted living program, ODA (or ODA's designee) shall notify the applicant 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 the enrollment in the state-funded component of the program.

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

(1) CDJFS: If the CDJFS determines that the individual does not meet the financial eligibility criteria, it shall notify ODA's designee and send to 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 to the individual.

(2) ODA's designee: If ODA's designee determines that the individual does not meet the non-financial eligibility criteria, it shall notify the CDJFS and, in turn, the CDJFS shall send to 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:

(1) Medicaid waiver program enrollment date:

(a) According to paragraph (D)(1)(c) of rule 5160:1-2-01.6 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 conditions are met:

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

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

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

(iv) The date that the individual has a service plan that is approved by ODA's designee and that includes at least one medicaid waiver service; and,

(v) The date that the individual resides in an ODA-certified residential care facility 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 in accordance with paragraph (C)(1)(b) of the rule.

(d) The individual's medicaid wavier 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 may enroll the individual 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 the terms of 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:

(i) ODA's designee shall enroll an eligible individual who qualifies for the home first component of the medicaid-funded component of the assisted living program before any eligible individual on the unified waiting list.

(ii) An eligible individual qualifies for the home first component of the medicaid-funded component of the assisted living program if the eligible individual meets both of the following sets of criteria:

(a) ODA's designee has determined that the individual meets all the eligibility criteria in rule 5160-33-03 of the Administrative Code; and,

(b) The individual meets at least one of the following three sets of criteria:

(i) The individual resides in a nursing facility.

(ii) A physician has determined and documented in writing that the individual has a medical condition that, unless ODA's designee enrolls the individual in a home and community-based program such as the medicaid-funded component of the assisted living program, the individual will require admission to a nursing facility in fewer than thirty days after the physician's determination.

(iii) Both of the following apply:

(A) The individual is the subject of a report made under section 5101.61 of the Revised Code regarding abuse, neglect, or exploitation or such a report referred to the CDJFS under section 5126.31 of the Revised Code; or has made a request for adult protective services, as defined in section 5101.60 of the Revised Code.

(B) A CDJFS and ODA's designee have jointly documented in writing that, unless CDJFS and ODA's designee enroll the individual into a home and community-based services program such as the medicaid-funded component of the assisted living program, the individual should be admitted to a nursing facility.

(D) An authorized representative may represent an individual in the enrollment process.

(E) Definitions for this rule:

(1) "Basic medicaid effective date" means the date that an individual is eligible to receive services under the medicaid state plan. Rules 5160:1-2-01.6 and 5160:1-2- 01.8 of the Administrative Code establish the basic medicaid effective date.

(2) "Form JFS02399" (rev. 05/2013) means "form JFS02399 'Request for Medicaid Home and Community-Based Services (HCBS).'" The form is readily available on http://www.odjfs.state.oh.us/forms/

(3) "Form JFS07200" (rev. 12/2012) means "form JFS07200 'Request for Cash, Food, and Medical Assistance.'" The form is readily available on http://www.odjfs.state.oh.us/forms/

Effective: 03/01/2014
R.C. 119.032 review dates: 11/29/2013 and 03/01/2019
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.54
Rule Amplifies: 173.54 , 173.542 , 173.55
Prior Effective Dates: 07/16/2006, 09/18/2009, 03/12/2011, 09/29/2011, 09/10/2012