Chapter 173-40 State-Funded PASSPORT Program

173-40-01 Introduction and definitions.

(A) Introduction: Chapter 173-40 of the Administrative Code regulates the state-funded component of the PASSPORT program, , and establishes the criteria for receivership of ODA's designee. (See Chapter 173-42 of the Administrative Code for rules on the medicaid-funded component of the PASSPORT program.)

(B) Definitions for Chapter 173-40 of the Administrative Code:

(1) "Authorized representative" means a person, eighteen years of age or older, who is chosen by, and acts on behalf of, an individual who is applying for, or receiving, medical assistance. In accordance with rule 5101:1-38-01.2 of the Administrative Code, the individual must provide a written statement naming the authorized representative and the duties that the named authorized representative may perform on the individual's behalf.

(2) "CDJFS" means "county department of job and family services."

(3) "Form JFS02399" means "form JFS02399 'Request for Medicaid Home and Community-Based Services (HCBS).'"

(4) "Form JFS07200" means "form JFS07200 'Request for Cash, Food and Medical Assistance.'"

(5) "Form ODA1115" means "form ODA1115 'Financial Assessment Worksheet.'" The form is readily available onhttp://www.aging.ohio.gov/information/rules/forms.aspx.

(6) "Form ODA1116" means "form ODA1116 'Enrollment Agreement.'" The form is readily available onhttp://www.aging.ohio.gov/information/rules/forms.aspx.

(7) "Nursing facility" has the same meaning as in section 5111.20 of the Revised Code.

(8) "ODA" means "the Ohio department of aging."

(9) "ODA's designee" has the same meaning as "PASSPORT administrative agency" in section 173.42 of the Revised Code. The current PASSPORT administrative agencies are the area agencies on aging listed in rule 173-2-04 of the Administrative Code plus"Catholic Social Services of the Miami Valley."

(10) "ODJFS" means "the Ohio department of job and family services."

(11) "Service plan" means written documentation of the specific tasks and activities to be carried out by a service provider, including, but not limited to, consumer-specific goals and objectives, detailed description of the interventions, frequency, and time frames for ongoing services.

Effective: 12/29/2011
R.C. 119.032 review dates: 07/13/2011 and 12/29/2016
Promulgated Under: 111.15
Statutory Authority: 173.01 , 173.02 , 173.40
Rule Amplifies: 173.40
Prior Effective Dates: 06/11/1991 (Emer.), 09/13/1991, 11/09/1998, 04/17/2003, 01/01/2008, 05/07/2009

173-40-02 Eligibility criteria for the state-funded PASSPORT program.

(A) Presumptive: Only an individual who meets all the following criteria is eligible for the state-funded component of the PASSPORT program on the basis of presumptive eligibility:

(1) First time only: The individual was not previously enrolled in the state-funded component of the PASSPORT program or the state-funded component of the assisted living program.

(2) Consultation: The individual has participated in a long-term care consultation under section 173.42 of the Revised Code and Chapter 173-43 of the Administrative Code .

(3) Financial criteria:

(a) The individual completed and submitted forms JFS07200 and JFS02399 to the CDJFS to apply for the medicaid-funded component of the PASSPORT program and the application is still pending because the CDJFS has not yet made a final determination on his or her financial eligibility. (If the the CDJFS had already determined that he or she was eligible to participate in the medicaid-funded component of the PASSPORT program, he or she would be enrolled in the medicaid-funded component of the PASSPORT program and no longer be eligible for the state-funded component of the PASSPORT program. If the CDJFS had already determined that he or she was not financially eligible to participate in the medicaid-funded component of the PASSPORT program, he or she would also not be eligible to participate in the state-funded component of the PASSPORT program .)

(b) The individual agreed that, if he or she is enrolled into the state-funded component of the PASSPORT program, then the CDJFS determines that the individual is financially eligible for the medicaid-funded component of the PASSPORT program, that he or she would immediately be transferred to the medicaid-funded component of the PASSPORT program.

(c) The individual is actively assisting the CDJFS in determining if he or she is financially eligible to participate in the medicaid-funded component of the PASSPORT program by expeditiously providing the CDJFS with copies of any financial records the CDJFS may need to make its financial eligibility determination.

(d) ODA (or ODA's designee) completed form ODA1115 and determined that the CDJFS will most likely determine that the individual meets the financial eligibility criteria for the medicaid-funded component of the PASSPORT program listed in rules 5101:1-38-01.6 and 5101:1-38-01.8 of the Administrative Code, and ODA (or ODA's designee) has no reason to doubt that determination.

(4) Non-financial criteria:

(a) ODA (or ODA's designee) and the individual completed form ODA1116, and the form indicated that the individual chose to enroll in the state-funded component of the PASSPORT program, named the individual's representative (if any), and indicated that the individual authorized ODA (or ODA's designee) to release information .

(b) ODA (or ODA's designee) determined that the individual meets the non-financial eligibility criteria for the medicaid-funded component of the PASSPORT program , which are listed in rule 5101:3-31-03 of the Administrative Code .

(5) Patient liability: ODA (or ODA's designee) assessed the individual's income and resources using the methodology described in paragraphs (C)(2) and (C)(3) of rule 5101:1-39-24 of the Administrative Code to determine if the individual should pay any patient liability and the individual agreed to make, and does make, any patient liability payment as it becomes due.

(B) Loss of medicaid financial eligibility: Only an individual who meets all the following criteria is eligible for the state-funded component of the PASSPORT program on the basis of losing medicaid financial eligibility:

(1) Financial criteria:

(a) The individual has had his or her enrollment in the medicaid-funded component of the PASSPORT program terminated due to the loss of medicaid financial eligibility, as determined by the CDJFS .

(b) ODA (or ODA's designee) has determined that the individual still needs the home and community-based services he or she received under the medicaid-funded component of the PASSPORT program because it is temporarily necessary to protect the individual's health and safety until the individual transfers to other community-based long-term care services or to a nursing facility .

(2) Patient liability: ODA (or ODA's designee) assessed the individual's income and resources using the methodology described in paragraphs (C)(2) and (C)(3) of rule 5101:1-39-24 of the Administrative Code to determine if the individual should pay any patient liability and the individual agreed to make, and does make, any patient liability payment as it becomes due.

(C) Grandparented: Only an individual who meets all the following criteria is eligible for the state-funded component of the PASSPORT program on the basis of a grandparented status:

(1) The individual has been enrolled in the state-funded component of the PASSPORT program since September 1, 1991. (For the individual enrolled in the state-funded component of the PASSPORT program on this basis, the program was formerly known as the "PASSPORT state home care program" and the "PASSPORT grandparented home care program .")

(2) Before the individual's initial enrollment in the state-funded component of the PASSPORT program, and at least once every twelve months of enrollment thereafter, the individual has applied for and was denied eligibility for either the medicaid-funded component of the PASSPORT program or the Ohio home care waiver program described in Chapter 5101:3-12 of the Administrative Code, and also one of the following:

(a) If the individual is at least sixty years of age, the individual has fully complied with the application and enrollment procedures for the medicaid-funded component of the PASSPORT program and was determined to be ineligible for the medicaid-funded component of the PASSPORT program. ODA (or ODA's designee) shall disenroll any such individual from the state-funded component of the PASSPORT program who is found to be eligible for enrollment in the medicaid-funded component of the PASSPORT program. An individual's failure or refusal to cooperate in providing either ODA (or ODA's designee) or a CDJFS with the information and documentation necessary to establish the individual's eligibility for the medicaid-funded component of the PASSPORT program constitutes a failure to meet this eligibility criterion; or,

(b) If the individual is no older than fifty-nine years of age, the individual has fully complied with the application and enrollment procedures for Ohio home care waiver program and was determined to be ineligible for the Ohio home care waiver program. ODA (or ODA's designee) shall disenroll any individual from the state-funded component of the PASSPORT program who is found to be eligible for the Ohio home care waiver program. An individual's failure or refusal to cooperate in providing ODJFS or a CDJFS with the information and the documentation necessary to establish the individual's eligibility for the Ohio home care waiver program constitutes a failure to meet this eligibility criterion.

(3) ODA (or ODA's designee) and a physician have determined that the individual needs an intermediate level of care, as defined in rule 5101:3-3-06 of the Administrative Code, or a skilled level of care, as defined in rule 5101:3-3-05 of the Administrative Code .

(4) The individual is financially eligible for the state-funded component of the PASSPORT program based upon a documented inability of the individual to pay for nursing facility care without assistance from the medicaid program. ODA (or ODA's designee) shall only consider the individual's income and assets when determining the individual's financial eligibility for the state-funded component of the PASSPORT program. Countable income and assets are determined pursuant to rules 5101:1-38-01.6 and 5101:1-38-01.8 of the Administrative Code and the medicaid eligibility manual. ODA (or ODA's designee) shall calculate the inability to pay for nursing facility care in accordance with one of the following:

(a) If the most recent period of continuous enrollment in the state-funded component of the PASSPORT program for the individual began before April 1, 1988, the individual shall document that the individual lacks eleven thousand, seven hundred, and nine dollars in income and assets available within a ninety-day period to pay for nursing facility care without assistance from the medicaid program; or,

(b) If the most recent period of continuous enrollment in the state-funded component of the PASSPORT program for the individual began on or after April 1, 1988, the individual shall document that the individual lacks five thousand, eight hundred, fifty-four dollars, and fifty cents in income and assets available within a forty-five day period to pay for nursing facility care without assistance from the medicaid program.

(5) ODA (or ODA's designee) that serves the county of the individual's residence has approved a service plan for the individual that is signed by the individual's physician .

(6) The individual's approved service plan indicates that the total projected cost of services counted in the service plan cost cap calculation is less than six thousand dollars for a six-month period .

(7) The individual agrees to receive home and community-based services only from ODA-certified providers, and agrees to cooperate with ODA (or ODA's designee) in establishing and re-establishing eligibility for the medicaid-funded component of the PASSPORT program, the Ohio home care program, and/or the state-funded component of the PASSPORT program, when requested by ODA's designee,.

(8) The participation of the individual in the state-funded component of the PASSPORT program, as an alternative to admission to a nursing facility, does not present, in the professional judgment of ODA (or ODA's designee), a threat to the health and safety of the individual.

(D) If, at any time, a consumer enrolled in the state-funded component of the PASSPORT program on the basis of presumptive eligibility no longer meets all the criteria under paragraph (A) of this rule, unless the only criterion the consumer no longer meets is the patient-liability criterion listed in paragraph (A)(5) of the rule, the consumer is no longer eligible for the state-funded component of the PASSPORT program.

(E) If, at any time, a consumer enrolled in the state-funded component of the PASSPORT program on the basis of losing medicaid financial eligibility no longer meets all the criteria under paragraph (B) of this rule, unless the only criterion the consumer no longer meets is the patient-liability criterion listed in paragraph (B)(2) of this rule, the consumer is no longer eligible for the state-funded component of the PASSPORT program.

(F) An individual who is eligible for the state-funded component of the PASSPORT program because the individual meets all the criteria under paragraph (A) of this rule may not participate in the state-funded component of the PASSPORT program for more than ninety days.

(G) An individual who is eligible for the state-funded component of the PASSPORT program because the individual meets all the criteria under paragraph (B) of this rule may not participate in the state-funded component of the PASSPORT program for more than thirty days.

Effective: 09/10/2012
R.C. 119.032 review dates: 06/11/2012 and 09/10/2017
Promulgated Under: 111.15
Statutory Authority: 173.01 , 173.02 , 173.40
Rule Amplifies: 173.40
Prior Effective Dates: 06/11/1991 (Emer.), 09/13/1991, 11/09/1998, 04/17/2003, 01/01/2008, 09/29/2011 (Emer.), 12/29/2011

173-40-03 Disenrollment and other adverse actions regarding the state-funded PASSPORT program.

(A) Presumptive: For each consumer who is enrolled in the state-funded component of the PASSPORT program on the basis of paragraph (A) of rule 173-40-02 of the Administrative Code:

(1) Disenrollment: ODA (or ODA's designee) shall disenroll any consumer who no longer meets all the criteria under paragraph (A) of rule 173-40-02 of the Administrative Code unless the only criterion the consumer no longer meets is the patient-liability criterion listed in paragraph (A)(5) of the rule.

(2) No appeals: ODA (or ODA's designee) shall not provide the consumer with an opportunity for a hearing in accordance with Chapter 119. of the Revised Code if ODA (or ODA's designee) disenrolls a consumer for any of the following reasons:

(a) The consumer has been enrolled in the state-funded component of the PASSPORT program under the criteria of paragraph (A) of rule 173-40-02 of the Administrative Code for the maximum enrollment period of ninety days; or,

(b) The consumer voluntarily disenrolled from the state-funded component of the PASSPORT program under the criteria of paragraph (A) of rule 173-40-02 of the Administrative Code before reaching the maximum enrollment period of ninety days.

(3) Post-disenrollment prohibitions:

(a) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently re-enroll the consumer back into the state-funded component of the PASSPORT program on the basis of presumptive eligibility.

(b) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently enroll the consumer into the medicaid-funded component of the PASSPORT program until the CDJFS determines that the consumer meets the medicaid financial eligibility criteria and ODA (or ODA's designee) determines that the consumer meets the non-financial eligibility criteria under rule 5101:3-31-03 of the Administrative Code.

(c) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently enroll the consumer into the state-funded component of the assisted living program.

(4) Appeals:

(a) ODA (or ODA's designee) shall provide form ODA1117 to an individual as a notice of a proposed adverse action against the individual, if ODA (or ODA's designee) proposes any of the following:

(i) To deny the individual's enrollment into the state-funded component of the PASSPORT program under the criteria of paragraph (A) of rule 173-40-02 of the Administrative Code;

(ii) To require the consumer to pay a specified patient-liability amount each month;

(iii) To change the services the consumer receives through the program; or,

(iv) To disenroll the consumer from the program before the consumer reaches the maximum enrollment period of ninety days, unless the consumer voluntarily disenrolls from the program.

(b) On form ODA1117, ODA (or ODA's designee) shall provide notice of an individual's opportunity to appeal the proposed adverse action by requesting a hearing in accordance with Chapter 119. of the Revised Code. ODA (or ODA's designee) shall also print a mailing date on the form.

(c) If an individual wishes to appeal ODA's (or ODA's designee's) proposed adverse action, the individual shall request a hearing. To request a hearing, the individual shall sign form ODA1117 and mail the signed form to ODA, addressed as follows:

"Director

Ohio Dept. of Aging

50 W. Broad St., 9th Floor

Columbus, OH 43215"

(d) In order for ODA to accept the request for a hearing, ODA must receive the original signed form ODA1117 in its office before five p.m. on or before the thirtieth day after ODA (or ODA's designee) mailed form ODA1117 to the individual. If ODA does not receive the original signed form on or before the thirtieth day, ODA will proceed with a final order that contains findings.

(B) Loss of medicaid financial eligibility: For each consumer who is enrolled in the state-funded component of the PASSPORT program on the basis of paragraph (B) of rule 173-40-02 of the Administrative Code:

(1) Disenrollment: ODA (or ODA's designee) shall disenroll any consumer who no longer meets all the criteria under paragraph (B) of rule 173-40-02 of the Administrative Code unless the only criterion the consumer no longer meets is the patient-liability criterion listed in paragraph (B)(3) of the rule.

(2) No appeals: ODA (or ODA's designee) shall not provide the consumer with an opportunity for a hearing in accordance with Chapter 119. of the Revised Code if ODA (or ODA's designee) disenrolls a consumer for any of the following reasons:

(a) The consumer has been enrolled in the state-funded component of the PASSPORT program under the criteria of paragraph (B) of rule 173-40-02 of the Administrative Code for the maximum enrollment period of ninety days; or,

(b) The consumer voluntarily disenrolled from the state-funded component of the PASSPORT program under the criteria of paragraph (B) of rule 173-40-02 of the Administrative Code before reaching the maximum enrollment period of ninety days.

(3) Post-disenrollment prohibitions:

(a) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently re-enroll the consumer back into the state-funded component of the PASSPORT program on the basis of presumptive eligibility.

(b) After (ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently enroll the consumer into the state-funded component of the assisted living program.

(4) Appeals:

(a) ODA (or ODA's designee) shall provide form ODA1117 to an individual as a notice of a proposed adverse action against the individual, if ODA (or ODA's designee) proposes any of the following:

(i) To deny the individual's enrollment into the state-funded component of the PASSPORT program under the criteria of paragraph (B) of rule 173-40-02 of the Administrative Code;

(ii) To require the consumer to pay a specified patient-liability amount each month;

(iii) To change the services the consumer receives through the program; or,

(iv) To disenroll the consumer from the program before the consumer reaches the maximum enrollment period of ninety days, unless the consumer voluntarily disenrolls from the program.

(b) On form ODA1117, ODA (or ODA's designee) shall provide notice of an individual's opportunity to appeal the proposed adverse action by requesting a hearing in accordance with Chapter 119. of the Revised Code. ODA (or ODA's designee) shall also print a mailing date on the form.

(c) If an individual wishes to appeal ODA's (or ODA's designee's) proposed adverse action, the individual shall request a hearing. To request a hearing, the individual shall sign form ODA1117 and mail the signed form to ODA, addressed as follows:

"Director

Ohio Dept. of Aging

50 W. Broad St., 9th Floor

Columbus, OH 43215"

(d) In order for ODA to accept the request for a hearing, ODA must receive the original signed form ODA1117 in its office before five p.m. on or before the thirtieth day after ODA (or ODA's designee) mailed form ODA1117 to the individual. If ODA does not receive the original signed form on or before the thirtieth day, ODA will proceed with a final order that contains findings.

(C) Grandparented: For a consumer who is enrolled in the state-funded component of the PASSPORT program on the basis of paragraph (C) of rule 173-40-02 of the Administrative Code:

(1) Reassessment:

(a) Whenever ODA (or ODA's designee) reassesses the condition and service needs of a consumer, ODA (or ODA's designee) shall verify if the consumer continues to meet all eligibility criteria under paragraph (C) of rule 173-40-02 of the Administrative Code.

(b) ODA (or ODA's designee) shall reassess each consumer to assess the consumer's condition and service needs at least once every twelve months or at any time the consumer's condition or service needs change substantially.

(c) At least once every six months ODA (or ODA's designee) shall develop and implement a revised service plan for each consumer so long as the consumer continues to meet all the eligibility criteria under paragraph (C) of rule 173-40-02 of the Administrative Code.

(d) If a consumer does not continue to meet all the eligibility criteria under paragraph (C) of rule 173-40-02 of the Administrative Code, ODA (or ODA's designee) shall provide the consumer with a written notice of intent to disenroll the consumer from the state-funded component of the PASSPORT program.

(2) Disenrollment:

(a) ODA (or ODA's designee) may propose that any consumer in the state-funded component of the PASSPORT program be disenrolled based upon any of the following:

(i) The consumer does not continue to meet all the eligibility criteria under paragraph (C) of rule 173-40-02 of the Administrative Code;

(ii) The consumer's permanent relocation; or,

(iii) The consumer's death.

(b) When a consumer's services are suspended for any reason for sixty calendar days, ODA (or ODA's designee) shall provide the consumer (or the consumer's authorized representative, if any), with notice of disenrollment from the state-funded component of the PASSPORT program.

(c) Suspensions which ultimately result in disenrollment shall have a disenrollment date that is retroactive to the first day of the suspension of services.

(3) No appeals: ODA (or ODA's designee) shall not provide the consumer with an opportunity for a hearing in accordance with Chapter 119. of the Revised Code if ODA (or ODA's designee) disenrolls a consumer if the consumer voluntarily disenrolled from the state-funded component of the PASSPORT program under the criteria of paragraph (C) of rule 173-40-02 of the Administrative Code.

(4) Post-disenrollment prohibitions:

(a) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently re-enroll the consumer back into the state-funded component of the PASSPORT program on the basis of presumptive eligibility.

(b) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the PASSPORT program, ODA (or ODA's designee) shall not subsequently enroll the consumer into the state-funded component of the assisted living program.

(5) Appeals:

(a) ODA (or ODA's designee) shall provide form ODA1117 to an individual as a notice of a proposed adverse action against the individual, if ODA (or ODA's designee) proposes any of the following:

(i) To deny the individual's enrollment into the state-funded component of the PASSPORT program under the criteria of paragraph (C) of rule 173-40-02 of the Administrative Code;

(ii) To require the consumer to pay a specified patient-liability amount each month; or,

(iii) To change the services the consumer receives through the program.

(b) On form ODA1117, ODA (or ODA's designee) shall provide notice of an individual's opportunity to appeal the proposed adverse action by requesting a hearing in accordance with Chapter 119. of the Revised Code. ODA (or ODA's designee) shall also print a mailing date on the form.

(c) If an individual wishes to appeal ODA's (or ODA's designee's) proposed adverse action, the individual shall request a hearing. To request a hearing, the individual shall sign form ODA1117 and mail the signed form to ODA, addressed as follows:

"Director

Ohio Dept. of Aging

50 W. Broad St., 9th Floor

Columbus, OH 43215"

(d) In order for ODA to accept the request for a hearing, ODA must receive the original signed form ODA1117 in its office before five p.m. on or before the thirtieth day after ODA (or ODA's designee) mailed form ODA1117 to the individual. If ODA does not receive the original signed form on or before the thirtieth day, ODA will proceed with a final order that contains findings.

Effective: 09/10/2012
R.C. 119.032 review dates: 06/11/2012 and 09/10/2017
Promulgated Under: 111.15
Statutory Authority: 173.01 , 173.02 , 173.40
Rule Amplifies: 173.40
Prior Effective Dates: 06/11/1991 (Emer.), 09/13/1991, 11/09/1998, 04/17/2003, 01/01/2008, 09/29/2011

173-40-04 Provider certification.

A person or entity that seeks to become an ODA-certified provider for the state-funded component of the PASSPORT program shall apply to become so under rule 173-39-03 of the Administrative Code.

Effective: 02/13/2012
R.C. 119.032 review dates: 02/13/2017
Promulgated Under: 111.15
Statutory Authority: 173.01 , 173.02 , 173.40
Rule Amplifies: 173.40

173-40-05 Covered services.

(A) The service plan for a consumer enrolled in the state-funded component of the PASSPORT program shall only authorize services allowed under rule 5101:3-31-05 of the Administrative Code for the medicaid-funded component of the PASSPORT program.

(B) While a provider may furnish a consumer who is enrolled in the state-funded component of the PASSPORT program with a service that is not authorized in the consumer's service plan, ODA (or ODA's designee) shall not reimburse a provider for any service that is not explicitly authorized in the consumer's service plan.

Effective: 02/13/2012
R.C. 119.032 review dates: 02/13/2017
Promulgated Under: 111.15
Statutory Authority: 173.01 , 173.02 , 173.40
Rule Amplifies: 173.40

173-40-06 Consumer choices and responsibilities.

(A) Choices:

(1) Any consumer who is enrolled in the state-funded component of the PASSPORT program may choose to obtain a service under the state-funded component of the PASSPORT program from any agency, non-agency, or consumer-directed personal care provider if:

(a) The provider agrees to furnish the service to the consumer;

(b) ODA certifies the provider to furnish the service;

(c) The case manager authorizes the service in the consumer's service plan;

(d) ODJFS enters into a medicaid provider agreement with the provider; and,

(e) If the consumer chooses a consumer-directed personal care provider, the case manager determines that the consumer is able to direct services under paragraph (B)(1)(b) of this rule.

(2) ODA's designee shall assure the health and welfare of each consumer while acknowledging that, according to this rule, every consumer has a right to make informed choices that may impact his or her life.

(B) Responsibilities related to developing a service plan:

(1) To help the case manager develop a service plan that best addresses the consumer's needs, the consumer shall do the following:

(a) The consumer and the case manager shall meet face-to-face to develop the consumer's service plan. The consumer shall decide if anyone other than the case manager shall participate in this meeting.

(b) If the consumer chooses to receive a service from a consumer-directed personal care provider, the case manager shall assess the consumer's strengths and weaknesses (and/or, if the consumer has an authorized representative, the authorized representative's strengths or weaknesses) related to his or her ability to direct a provider. The case manager shall retain records supporting the determination. The case manager shall allow the consumer to direct a provider if the case manager's assessment establishes that the consumer demonstrates an understanding of the elements of the service the provider shall furnish, an understanding of how to direct the provider, and an understanding of, and ability to, perform the responsibilities of an employer, including:

(i) Completing any consumer training that ODA (or ODA's designee) requires;

(ii) Understanding which service activities are covered according to rule 173-39-02.11 of the Administrative Code;

(iii) Understanding of the database reviews and criminal records check requirements under Chapter 173-9 of the Administrative Code;

(iv) Understanding of the methods for selecting and dismissing providers;

(v) Understanding of the methods for entering into written agreements with providers for specific activities;

(vi) Understanding of the methods for training providers to meet the consumer's specific needs;

(vii) Understanding of the methods for supervising and monitoring the provider's performance of specific activities, including written approval of the provider's time sheets;

(viii) Developing a back-up plan for furnishing services if a provider is unable to furnish the agreed-upon service;

(ix) Understanding of the methods for lodging complaints, including use of the regional and state long term care ombudsman, and familiarity with how to contact the state long-term care ombudsman;

(x) Familiarity with state appeal and fair hearing request procedures;

(xi) Understanding the record-retention requirements; and,

(xii) Managing the provider when the provider furnishes a service.

(c) If the case manager developed a service plan according to his or her determination that the consumer (and/or, the consumer's authorized representative) was able to direct a consumer-directed personal care provider according to paragraph (B)(1)(b) of this rule, but the case manager later determines that the consumer is no longer able to direct a provider, the case manager shall implement an alternative service plan utilizing an agency or non-agency provider in place of the consumer-directed personal care provider.

(d) The consumer shall notify the case manager if the consumer desires to change the type of provider from whom he or she receives a service. If the consumer who directs a consumer-directed personal care provider desires to receive a service from another provider type, ODA's designee shall identify and secure a provider of another type. If a consumer who does not direct a consumer-directed personal care provider desires to receive a service from a consumer-directed personal care provider, ODA's designee shall conduct the assessment under paragraph (B)(1)(b) of this rule.

(e) After the case manager has developed the service plan, the consumer shall notify the case manager of any significant change that may affect his or her service needs, including a change that may require more or fewer hours of service, and the case manager shall revise the service plan accordingly. Significant changes include:

(i) The consumer moves to another address; or,

(ii) The consumer's physical, mental, or emotional status changes; the consumer's environmental conditions change; or other health and safety issues.

(2) The consumer shall inform each provider of his or her personal preferences about how the provider will furnish the duties, tasks, or interventions that the case manager authorizes in the consumer's service plan.

(3) The consumer shall allow the case manager to exchange information with any of the consumer's service providers on a need-to-know basis.

(C) Consumer responsibilities related to the provider furnishing services:

(1) Agency provider: If the consumer chooses to receive a service from an agency provider:

(a) The consumer shall not aid the provider's staff in furnishing a service, nor request that the provider's staff furnish a service, in a manner that does not comply with any rule or law that regulates the provider, including rule 173-39-02 of the Administrative Code. The requirements of rule 173-39-02 of the Administrative Code include requiring the provider's staff to adhere to the provider's ethical standards and the provider's written policies.

(b) The consumer shall report any incident involving the provider's staff to the case manager.

(c) The consumer shall notify the provider if he or she is going to miss a scheduled service episode, unless the provider is already informed of the consumer's absence.

(d) The consumer shall notify the provider if the provider's staff misses a scheduled service episode.

(e) Immediately following the conclusion of each episode of service, the consumer shall provide the provider's staff with his or her signature to verify that the provider's staff furnished the service. The consumer shall never sign blank timesheets or timesheets that the provider's staff completes before furnishing services.

(f) ODA's designee shall act as a facilitator to resolve conflicts between the consumer and the provider.

(2) Non-agency provider: If the consumer chooses to receive a service from a non-agency provider:

(a) The consumer shall not aid the provider in furnishing a service in a manner that does not comply with any rule or law that regulates the provider, including rule 173-39-02 of the Administrative Code.

(b) The consumer shall report any incident involving the provider to the case manager.

(c) The consumer shall notify the provider if he or she is going to miss a scheduled service episode, unless the provider is already informed of the consumer's absence.

(d) Immediately following the conclusion of each episode of service, the consumer shall provide the provider with his or her signature to verify that the provider furnished the service. The consumer shall never sign blank timesheets or timesheets that the provider completes before furnishing services.

(e) ODA's designee shall act as a facilitator to resolve conflicts between the consumer and the provider.

(3) Consumer-directed personal care provider: If the consumer chooses to receive a service from a consumer-directed personal care provider:

(a) The consumer shall recruit, select, and dismiss his or her consumer-directed personal care provider and the case manager shall assist the consumer in these responsibilities.

(b) The case manager shall provide the consumer with a list of the consumer's rights and responsibilities listed in this rule, with the provider's requirements under rules 173-39-02 and 173-39-02.11 of the Administrative Code, and with other medicaid waiver information and materials. In doing so, ODA's designee shall use communication mechanisms that are most effective for the consumer. The case manager shall review these materials with the consumer and assist him or her to understand his or her specific responsibilities.

(c) The consumer shall not aid the provider in furnishing a service in a manner that does not comply with any rule or law that regulates the provider, including rules 173-39-02 and 173-39-02.11 of the Administrative Code.

(d) The consumer and the case manager shall work together to develop a back-up plan for furnishing the service if the provider cannot, or does not, meet his or her obligation to furnish services for the consumer.

(e) The consumer shall report any incident involving the provider to the case manager. In turn, the case manager shall investigate any reported incident and report any incident that may impact the health and welfare of the consumer to ODA.

(f) The case manager shall assist the consumer in resolving conflicts between the consumer and the provider.

(g) The consumer shall notify the provider if he or she is going to miss a scheduled service episode, unless the provider is already informed of the consumer's upcoming absence.

(h) The consumer shall work with the case manager and the provider to decide what, if any, additional orientation or training within the provider's scope of practice is necessary for the provider to meet the consumer's needs. The consumer and the case manager shall work with the provider to secure the educational opportunity.

(i) The consumer shall work with the case manager and the provider to decide what, if any, continuing education requirement within the provider's scope of practice is necessary to meet the consumer's expectations. The consumer and the case manager shall work with the provider to secure the educational opportunity. (The consumer may participate in the continuing education.)

(j) The case manager shall assist the consumer to retain records that identify the method by which the consumer will verify that the provider furnishes each episode of service according to the service plan.

(k) Immediately following the conclusion of each episode of service, the consumer shall provide the provider with his or her signature to verify that the provider furnished the service. The consumer shall never sign blank timesheets or timesheets that the provider completes before furnishing services.

(l) The consumer shall work with ODA's designated financial management service for consumers who direct consumer-directed personal care providers under the PASSPORT program.

(m) The consumer shall designate a location in his or her home in which the provider may safely store a copy of the consumer's activity plan in a manner that protects the consumer's confidentiality. (Having a copy of the activity plan in the consumer's home contributes to the provider's ability to adhere to the activity plan.)

(n) The consumer and ODA's designee shall work together to monitor the provider's performance.

(o) ODA's designee shall communicate with the consumer in a manner that protects the consumer's right to confidentiality.

(p) ODA's designee shall act as a facilitator to resolve conflicts between the consumer and the provider.

(D) Authorized representative: A consumer's authorized representative may represent the consumer for any purpose under this rule if the consumer authorizes the person to do so.

(E) Definitions for this rule:

(1) "Agency provider," "non-agency provider," and "consumer-directed personal care provider" have the same meaning as in rule 173-39-01 of the Administrative Code.

(2) "Incident" has the same meaning as in rule 173-39-01 of the Administrative Code.

(3) "Financial management service" has the same meaning as in rule 5101:3-31-02 of the Administrative Code.

(4) "Signature" has the same meaning as "consumer signature" in rule 173-39-01 of the Administrative Code.

Effective: 01/01/2013
R.C. 119.032 review dates: 03/17/2016
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02
Rule Amplifies: Section 1902(a)(23) of the Social Security Act; 42 C.F.R. 431.51
Prior Effective Dates: 2/13/12