Chapter 173-51 State-Funded Assisted Living Program

173-51-01 Assisted living program (state-funded component): introduction and definitions.

(A) Introduction: Chapter 173-51 of the Administrative Code regulates the state-funded component of the assisted living program created under section 173.543 of the Revised Code. (See Chapter 173-38 of the Administrative Code for rules on the medicaid-funded component of the assisted living program.)

(B) Definitions for this chapter:

"Assisted living program" (program) means the state-funded component of the assisted living program. ODA created the component under the authority of section 173.543 of the Revised Code to temporarily provide eligible individuals 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.

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

"Form ODA1115" means "form ODA1115 'Financial Assessment Worksheet' (rev. November 1, 2018)." ODA publishes the form on www.aging.ohio.gov. It is available to the general public at no cost.

"Form ODA1116" means "form ODA1116 'Enrollment Agreement' (September, 2011)." ODA publishes the form on www.aging.ohio.gov. It is available to the general public at no cost.

"Form ODA1117 means "form ODA1117 'Notice of Proposed Action and Opportunity for Hearing' (rev. April, 2012)." ODA publishes the form on www.aging.ohio.gov. It is available to the general public at no cost.

"Nursing facility" has the same meaning as in section 5165.01 of the Revised 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: 173-51-01

Effective: 11/1/2018
Five Year Review (FYR) Dates: 11/01/2023
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 173.543
Rule Amplifies: 173.543
Prior Effective Dates: 12/29/2011, 07/01/2016, 02/01/2017, 04/01/2018

173-51-02 Assisted living program (state-funded component): eligibility requirements.

(A) Only an individual meeting all of the following requirements is eligible for the state-funded component of the assisted living program:

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

(2) Consultation: The individual 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 requirements:

(a) The individual contacted either ODA's designee or ODM's administrative agency to apply for the medicaid-funded component of the assisted living program, but the application is still pending because ODM's administrative agency has not yet made a final determination on the individual's financial eligibility. (If ODM's administrative agency already determined the individual was eligible to participate in the medicaid-funded component of the assisted living program, the individual would be enrolled in the medicaid-funded component of the assisted living program. If ODM's administrative agency already determined the individual was not financially eligible to participate in the medicaid-funded component of the assisted living program, the individual would also not be eligible to participate in the state-funded component of the assisted living program.)

(b) The individual agreed if he or she is enrolled into the state-funded component of the assisted living program, then ODM's administrative agency determines the individual is financially eligible for the medicaid-funded component of the assisted-living program, he or she would immediately be transferred to the medicaid-funded component of the assisted living program.

(c) The individual is actively assisting ODM's administrative agency in determining if he or she is financially eligible to participate in the medicaid-funded component of the assisted living program by timely providing ODM's administrative agency with information and copies of any records ODM's administrative agency needs to make its financial eligibility determination.

(d) ODA or its designee completed form ODA1115 and determined that ODM's administrative agency would most likely determine the individual meets all financial eligibility requirements for the medicaid-funded component of the assisted living program listed in rules 5160:1-2-03 and 5160:1-2-10 of the Administrative Code, and ODA or its designee has no reason to doubt that determination.

(4) Non-financial requirements:

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

(b) ODA or its designee determined the individual meets all non-financial eligibility requirements for the medicaid-funded component of the assisted living program in rule 5160-33-03 of the Administrative Code.

(c) The individual agreed to reside in a certified living unit of an Ohio licensed RCF that is authorized by a valid provider agreement to participate in the medicaid-funded component of the assisted living program while receiving assisted living services under the state-funded component of the assisted living program.

(5) Post-eligibility treatment of income (PETI) (i.e., patient liability or share of cost): After ODA or its designee assessed the individual's income and resources using the methodology described in rule 5160:1-6-07.1 of the Administrative Code to determine if the individual should pay any share of cost and the individual agreed to pay, and does pay, any share of cost as it becomes due.

(B) If, at any time, an individual enrolled in the state-funded component of the assisted living program no longer meets all the requirements under paragraph (A) of this rule, unless the only requirement the individual no longer meets is the PETI requirement in paragraph (A)(5) of this rule, the individual is no longer eligible for the state-funded component of the assisted living program.

(C) An individual who is eligible for the state-funded component of the assisted living program shall not participate in the state-funded component of the assisted living program for more than ninety days.

Replaces: 173-51-02

Effective: 11/1/2018
Five Year Review (FYR) Dates: 11/01/2023
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 173.543
Rule Amplifies: 173.543
Prior Effective Dates: 09/29/2011 (Emer.), 12/29/2011, 09/10/2012

173-51-03 Assisted living program (state-funded component): Disenrollment and other adverse actions.

(A) Disenrollment: ODA or its designee shall disenroll an individual enrolled in the state-funded component of the assisted living program under any one or more of the following situations:

(1) The individual no longer meets all requirements under rule 173-51-02 of the Administrative Code, unless the only requirement the individual no longer meets is the PETI requirement listed in paragraph (A)(5) of that rule.

(2) ODM's administrative agency determined the individual meets all medicaid financial eligibility requirements under rules 5160:1-2-03 and 5160:1-2-10 of the Administrative Code. (If an individual meets all requirements for the medicaid-funded component of the assisted living program, the individual would be enrolled into the medicaid-funded component of the program and no longer remain in the state-funded component.)

(3) ODM's administrative agency determined the individual does not meet all financial eligibility requirements under rules 5160:1-2-03 and 5160:1-2-10 of the Administrative Code.

(4) The individual has been enrolled in the state-funded component of the assisted living program for the maximum enrollment period of ninety days.

(5) The individual voluntarily disenrolls from the state-funded component of the assisted living program before reaching the maximum enrollment period of ninety days.

(B) No appeals: ODA or its designee shall not provide the individual an opportunity for a hearing in accordance with Chapter 119. of the Revised Code if ODA or its designee disenrolls an individual for either of the following reasons:

(1) The individual has been enrolled in the state-funded component of the assisted living program for the maximum enrollment period of ninety days.

(2) The individual voluntarily disenrolled from the state-funded component of the assisted living program.

(C) Post-disenrollment prohibitions:

(1) After ODA or its designee disenrolls an individual from the state-funded component of the assisted living program, ODA or its designee shall not subsequently re-enroll the individual back into the state-funded component of the assisted living program.

(2) After ODA (or its designee) disenrolls an individual from the state-funded component of the assisted living program, ODA or its designee shall not subsequently enroll the individual into the medicaid-funded component of the assisted living program until ODM's administrative agency determines the individual meets all medicaid financial eligibility requirements and ODA or its designee determines the individual meets all non-financial eligibility requirements in rule 5160-33-03 of the Administrative Code.

(3) After ODA or its designee disenrolls an individual from the state-funded component of the assisted living program, ODA or its designee shall not subsequently enroll the individual into the state-funded component of the PASSPORT program.

(D) Appeals:

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

(a) To deny the individual's enrollment into the state-funded component of the assisted living program;

(b) To require the individual to pay a specified PETI each month;

(c) To change the services the individual receives through the program; or,

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

(2) On form ODA1117, ODA (or its designee) shall provide notice of an individual's opportunity to appeal the proposed adverse action by requesting a hearing according to Chapter 119. of the Revised Code.

(3) If an individual wishes to appeal ODA's or its 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

246 N. High St., 1st Floor

Columbus, OH 43215

(4) In order for ODA to accept the request for a hearing, ODA must receive the original signed form ODA1117 in fewer than thirty days after the mailing date listed on the notice. If ODA does not receive the original signed form in fewer than thirty days after the mailing date listed on the notice, ODA shall issue a final order of adjudication adopting the allegations contained in the original notice.

Replaces: 173-51-03

Effective: 11/1/2018
Five Year Review (FYR) Dates: 11/01/2023
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 173.543
Rule Amplifies: 173.543
Prior Effective Dates: 09/29/2011, 09/10/2012

173-51-04 Assisted living program (state-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: 173-51-04

Effective: 4/1/2018
Five Year Review (FYR) Dates: 04/01/2023
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 173.391, 173.543
Rule Amplifies: 173.39 , 173.543
Prior Effective Dates: 09/29/2011

173-51-05 Assisted living program (state-funded): covered services.

An individual's service plan may not authorize 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: 173-51-05

Effective: 4/1/2018
Five Year Review (FYR) Dates: 04/01/2023
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 173.543
Rule Amplifies: 173.543
Prior Effective Dates: 09/29/2011