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 5160:1-1-55.1 of the Administrative Code.

"Form JFS07200" means "form JFS07200 'Request for Cash, Food, and Medical Assistance.' (rev. 9/2014)" The Ohio department of job and family services publishes the form onhttp://www.odjfs.state.oh.us/forms/." It is available to the general public at no cost.

"Form ODA1115" means "form ODA1115 'Financial Assessment Worksheet." (September, 2011). 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" (April, 2012). ODA publishes the form onwww.aging.ohio.gov. It is available to the general public at no cost.

"Form ODM02399" means "form JFS02399 'Request for Medicaid Home and Community-Based Services (HCBS)' (07/2014)." ODM publishes the form onhttp://medicaid.ohio.gov/RESOURCES/Publications/MedicaidForms.aspx. 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.

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

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

Replaces: 173-51-01

Effective: 7/1/2016
Five Year Review (FYR) Dates: 07/01/2021
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.543
Rule Amplifies: 173.543
Prior Effective Dates: 12/29/2011

173-51-02 Eligibility criteria for the state-funded assisted living program.

(A) Only an individual who meets all of the following criteria 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 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 completes and submits forms JFS07200 and JFS02399 to the CDJFS to apply for the medicaid-funded component of the assisted living 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 CDJFS had already determined that he or she was eligible to participate in the medicaid-funded component of the assisted living program, he or she would be enrolled in the medicaid-funded component of the assisted living program. If the CDJFS had already determined that he or she was not financially eligible to participate in the medicaid-funded component of the assisted living program, he or she would also not be eligible to participate in the state-funded component of the assisted living program.)

(b) The individual agreed that, if he or she is enrolled into the state-funded component of the assisted living program, then the CDJFS determines that the individual is financially eligible for the medicaid-funded component of the assisted-living program, that he or she would immediately be transferred to the medicaid-funded component of the assisted living 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 assisted living 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 assisted living 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 assisted living 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 assisted living program, which are listed in rule 5101:3-33-03 of the Administrative Code .

(c) The individual agreed to reside in an Ohio licensed residential care facility 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) Patient liability: After ODA (or ODA's designee) assessed the individual's income and resources using the methodology described in paragraph (C)(4) of rule 5101:1-39-24.1 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) If, at any time, a consumer enrolled in the state-funded component of the assisted living program 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 this rule, the consumer 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 may not participate in the state-funded component of the assisted living program for more than ninety 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, 5111.89
Rule Amplifies: 5111.89, 5111.892
Prior Effective Dates: 09/29/2011 (Emer.), 12/29/2011

173-51-03 Disenrollment and other adverse actions regarding the state-funded assisted living program.

(A) Disenrollment: ODA (or ODA's designee) shall disenroll a consumer who is enrolled in the state-funded component of the assisted living program if:

(1) The consumer no longer meets all the criteria under paragraph (A) of rule 173-51-02 of the Administrative Code, unless the only criterion the consumer no longer meets is the patient-liability criterion listed in paragraph (A)(5) of rule 173-51-02 of the Administrative Code;

(2) The CDJFS has determined that the consumer meets the medicaid financial eligibility criteria under rules 5101:1-38-01.6 and 5101:1-38-01.8 of the Administrative Code;

(3) The CDJFS has determined that the consumer does not meet the financial eligibility criteria under rules 5101:1-38-01.6 and 5101:1-38-01.8 of the Administrative Code;

(4) The consumer has been enrolled in the state-funded component of the assisted living program for the maximum enrollment period of ninety days; or,

(5) The consumer 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 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:

(1) The consumer has been enrolled in the state-funded component of the assisted living program for the maximum enrollment period of ninety days; or,

(2) The consumer voluntarily disenrolled from the state-funded component of the assisted living program before reaching the maximum enrollment period of ninety days.

(C) Post-disenrollment prohibitions:

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

(2) After ODA (or ODA's designee) disenrolls a consumer from the state-funded component of the assisted living program, ODA (or ODA's designee) shall not subsequently enroll the consumer into the medicaid-funded component of the assisted living 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 in rule 5101:3-33-03 of the Administrative Code.

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

(D) Appeals:

(1) 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:

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

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

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

(d) 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.

(2) 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.

(3) 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"

(4) 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, 5111.89
Rule Amplifies: 5111.89
Prior Effective Dates: 09/29/2011

173-51-04 Provider certification.

(A) A person or entity that seeks to become an ODA-certified assisted living provider may apply to become so under rule 173-39-03 of the Administrative Code.

(B) "Assisted living provider" means a residential care facility that is licensed by the department of health and that ODA certifies to provide services according to rules 173-39-02.16 and 173-39-02.17 of the Administrative Code.

R.C. 119.032 review dates: 03/25/2013 and 03/25/2018
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 5111.89
Rule Amplifies: 5111.89
Prior Effective Dates: 09/29/2011

173-51-05 Covered services.

(A) A consumer's service plan may authorize no more than these two services:

(1) The assisted living service under rule 173-39-02.16 of the Administrative Code; and,

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

(B) While a provider may provide a consumer who is enrolled in the state-funded component of the assisted-living program with a service that is not authorized in the consumer's services 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.

R.C. 119.032 review dates: 03/25/2013 and 03/25/2018
Promulgated Under: 111.15
Statutory Authority: 173.01, 173.02, 5111.89
Rule Amplifies: 5111.89
Prior Effective Dates: 09/29/2011