Chapter 3701-44 Ryan White Program

As used in this chapter:

(A) “Ryan White program” means the program established by Title II of the “Ryan White Comprehensive AIDS Resources Emergency Act” 42 U.S.C. 300ff, (as published in January 19, 2004), and administered by the director of health under division (D) of section 3701.241 of the Revised Code.

(B) “Director” means the director of health or his or her designee.

(C) “Department” means the Ohio department of health.

(D) “HIV” means human immunodeficiency virus.

(E) “Community-based HIV case manager” means an individual designated by the director to provide case management services for individuals and families affected by HIV infection, or the designee of a designated individual.

(F) “Family” means a group of individuals who are related by blood, marriage, or adoption.

(G) “Significant other” means an individual who is responsible for a significant portion of an HIV-infected individual’s care or who is dependent upon an HIV-infected individual.

(H) “Central based” means that the program is administered within the AIDS client resources section of the department of health.

(I) “Skilled nursing” means those services provided for a client that are covered under the Nursing Practice Act as being performed only by a registered nurse or a licensed practical nurse under the direct supervision of a registered nurse;

(J) “Assessment” means a complete evaluation of a home health situation including patient, environment, support and physician’s orders.

(K) “Homemaker” means an individual who is an employee of a home health agency that is medicare certified and who primarily performs housekeeping chores but may also run errands, do laundry and prepare meals.

(L) “Home health aide” means an individual who is employed by a certified home health agency as defined in this chapter and who is trained to do hands-on bathing or assisting with a tub bath or shower, assisting with dressing, ambulation and toileting, catheter care but not insertion, and meal preparation and feeding.

(M) “Respite care provider” means an individual who provides relief for a care giver and who will be in the home for a prolonged period of time to provide hands on care and homemaking while the care giver leaves the home. A person who functions strictly as a homemaker and performs no hands-on care is not a respite care provider.

Effective: 12/18/2006

R.C. 119.032 review dates: 10/03/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 9/23/1991, 12/22/91, 5/20/99, 7/20/2001

(A) The director shall designate HIV care consortia for purposes of the Ryan White program. The director shall establish geographic areas to be served by consortia and shall designate one consortium for each geographic area. The geographic areas may include one or more counties,

(B) To be designated as a HIV care consortium, an applicant shall submit an application to the director that contains documentation showing that the applicant meets all of the following criteria:

(1) The consortium will have no fewer than seven and no more than twenty members, unless the director determines that a larger number of members is needed to appropriately represent affected individuals and organizations in the geographic area. The membership of the consortium shall be approved by the director and shall include agencies and community-based organizations that meet both of the following criteria:

(a) The agencies or organizations have a record of service to populations and subpopulations with HIV disease requiring care in the community to be served; and

(b) The agencies or organizations are representative of populations and subpopulations reflecting the local incidence of HIV and that are located in areas in which the populations reside;

(2) The consortium will include at least one representative of a public health care provider, one representative of a private non-profit health care provider, and one representative from a local community-based organization. The director also may consider whether the consortium will include representatives of rural areas, affected subpopulations, an individual with HIV infection and a representative of a drug and alcohol treatment organization and others as deemed necessary and appropriate;

(3) The consortium will include a community-based HIV case manager;

(4) The applicant has carried out an assessment of service needs within the geographic area to be served and, after consultation with the entities described in paragraph (C) of this rule, has established a plan to ensure the delivery of services to meet the identified needs that shall include all of the following:

(a) Assurances that service needs will be addressed through the coordination and expansion of existing programs before new programs are created;

(b) Assurances that, in metropolitan areas, the geographic area to be served by the consortium will correspond to the geographic boundaries of local health and support services delivery systems to the extent practicable;

(c) Assurances that, in the case of services for individuals residing in rural areas, the applicant consortium shall deliver case management services that link available community support services to appropriate specialized medical services. Case management under this paragraph shall be provided through community-based HIV case managers; and

(d) Assurances that the assessment of service needs and the planning of the delivery of services will include participation by individuals with HIV disease; and

(e) Assurances that the full continuum of health and social services needed for individuals with HIV disease has been considered;

(5) The applicant demonstrates that adequate planning has occurred to meet the special needs of families with HIV disease, including family centered care. As used in this paragraph “family centered care” means the system of services described in paragraph (B) of rule 3701-44-03 of the Administrative Code that is targeted specifically to the special needs of infants, children, women, and families. Family centered care shall be based on a partnership between parents, professionals, and the community designed to ensure an integrated, coordinated, culturally sensitive, and community-based continuum of care for children, women, and families with HIV disease;

(6) The applicant demonstrates that an independent committee has created a mechanism to periodically evaluate the success of the consortium in responding to identified needs and the cost effectiveness of the mechanisms employed by the consortium to deliver comprehensive care. The consortium shall provide for this evaluation by establishing an independent committee consisting of at least three but no more than six individuals who are not members of the consortium but who have experience in quality assurance review. The committee shall meet at least every twelve months to review services provided to individuals affected by HIV disease with special attention to quality based on availability, appropriateness, timeliness, and access;

(7) The applicant demonstrates that the consortium will report to the director the results of the evaluations described in paragraph (B)(6) of this rule. The consortium shall make this report by authorizing the independent committee established under that paragraph to provide the results of its evaluations directly to the director. The consortium also shall make available to the director or the secretary of the United States department of human services, on request, such data and information on the program methodology that may be required to perform an independent evaluation; and

(8) The consortium provides the following assurances:

(a) Within any locality in which the consortium is to operate, the populations and subpopulations of individuals and families with HIV disease have been identified by the consortium;

(b) The service plan established under paragraph (B)(4) of this rule by the consortium addresses the special needs of the populations and subpopulations identified under paragraph (B)(8)(a) of this rule; and

(c) The consortium will be a single coordinating entity that will integrate the delivery of services among the populations and subpopulations identified under paragraph (B)(8)(a) of this rule.

If more than one applicant seeks designation as an HIV care consortium, the director shall determine which applicant appears to be most capable of effectively serving the needs of individuals and families in the area who are affected by HIV disease.

(C) In establishing the plan required under paragraph (B)(4) of this rule, the consortium shall consult with either an agency described in paragraph (C)(1)(a) of this rule or an agency described in paragraph (C)(1)(b) of this rule.

(1) The consortium shall consult with either of the following:

(a) The public health agency that provides or supports ambulatory and outpatient HIV-related health care services within the geographic area to be served; or

(b) In the case of a public health agency that does not directly provide HIV-related health care services, the agency shall consult with an entity or entities that directly provide ambulatory and outpatient HIV-related health care services within the geographic area to be served.

(D) The director may request any additional information necessary to determine whether the applicant meets the requirements for designation established by this rule. The applicant shall provide the requested information within the time and in the manner specified by the director.

(E) The director shall provide written notification of his or her decision whether or not to designate an applicant as an HIV care consortium under this rule. If the director does not designate the applicant, the notice shall state the reasons for the decision and inform the applicant of the reconsideration process under paragraph (G) of this rule.

(F) The director may revoke the designation of an HIV care consortium upon a determination that the consortium is not adequately discharging its responsibilities under this chapter. The director shall provide written notice of the revocation which shall state the reasons for the decision and inform the consortium of the reconsideration process under paragraph (G) of this rule.

(G) If the director denies or revokes a consortium’s designation under paragraph (E) or (F) of this rule, the consortium may request reconsideration of the decision by submitting a written request for reconsideration. The request shall be filed with the director within fifteen days after the date of mailing of the denial or revocation of designation. The request shall be accompanied by any written information that the consortium wishes to have considered. The director shall render a written decision on reconsideration which shall be final.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999

(A) An HIV care consortium designated under rule 3701-44-02 of the Administrative Code shall not use any money allocated by the director for provision of emergency financial assistance services to individuals and families in the consortium’s geographic area to pay for the consortium’s personnel or administrative costs.

(B) The consortium shall list which of the services specified in this paragraph may be authorized for payment under the Ryan White program. The list shall apply to services requested by eligible individuals, or families that include eligible individuals, who reside in the area served by the consortium. The consortium may list any or all of the following services, and may revise the list when it considers revision to be appropriate:

(1) Home health services such as durable medical equipment, home health aide and homemaker services, home intravenous therapy, day treatment, and routine diagnostic tests, and hospice services, such as social work and counseling, nursing services, and home health aide services;

(2) Transportation by cab, bus, or contracted transportation service or by private vehicle but not including ambulance or airplane transportation. Gasoline used by an individual or family may be reimbursed via a gift certificate issued by a gasoline company which can only be redeemed for gasoline;

(3) Child welfare and family services such as legal services (excluding litigation), individual and family mental health counseling, child care, short-term foster care, and emergency supplies;

(4) Physician’s services, including gynecological examinations;

(5) Diagnostics and monitoring, such as CD4 counts and viral load measurements;

(6) Housing referral and placement, such as rental deposits, and one month’s current rent on an emergency basis (limited to once per twelve months), moving expenses limited to travel within the state (limited to once per twelve months), and utility bills. No delinquent utility charges or delinquent rental payments are authorized for payment;

(7) Nutrition services, such as food vouchers, oral nutritional supplements, one-time nutritional consultations, baby formula, and food for an infected child. Gift certificates that specify the name of the client and contain prohibitions on alcohol, tobacco, lottery tickets and cash back may be used. Gift certificates may be used for food, health and hygiene products. Gift certificates must include an expiration date. Federal restrictions on product purchases with Ryan White funds supersede store authorization;

(8) Dental services, such as office visits and cleanings (limited to twice per year); and

(9) Rehabilitation services, such as physical therapy, speech therapy, and adaptive equipment.

All services set forth above are contingent upon United States department of health and human services, health resources and services administration policy and approval. Inpatient hospital and nursing home services are not covered under the Ryan White program.

(C) Each consortium shall establish and may revise dollar limitations or other limitations on each category of services, as specified in paragraph (B) of this rule, that it lists for purposes of payment by the Ryan White program. Alternatively, a consortium may establish a dollar limitation on total services for which payment may be authorized for each individual or family. The director may establish additional limitations on services for which payment may be authorized because of program fiscal constraints.

(D) The consortium shall provide copies of the list prepared under paragraph (B) of this rule and any revisions to the director and the community-based HIV case manager serving the area.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701-44-03

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999

(A) The director shall make payments for services under the Ryan White program in accordance with the requirements specified in this rule.

(B) The director shall allocate specific amounts of the money available for the consortia portion of the Ryan White program to pay for services to individuals and families residing in each of the geographic areas served by HIV care consortia. The director may revise these allocations as he or she considers appropriate. The director shall ensure that at least fifteen percent of the money available for the consortia portion of the Ryan White program is expended for services to infants, children, women, and families with HIV disease.

(C) The director may contract with a third-party administrator to make payments under this rule. The administrator shall pay the usual, customary, and reasonable charges in the area for the services at issue. If there is no usual, customary, and reasonable charge for a given service, the administrator shall pay an amount specified for the service by the HIV care consortium serving the geographic area where the services are provided. If there is no consortium serving the area, the administrator shall pay an amount specified by the director.

(D) The administrator shall make payments only for services for which payments are authorized by the appropriate community-based HIV case manager or the director. Upon request of an eligible individual, the case manager shall determine whether or not to authorize payment of the requested services in accordance with paragraph (E) of this rule. Authorization may be given orally or in writing.

(E) The community-based HIV case manager shall authorize payment for services only after making all of the following determinations:

(1) That the individual receiving services or a member of the service recipient’s family is eligible under rule 3701-44-05 of the Administrative Code;

(2) That the provider is eligible under rule 3701-44-06 of the Administrative Code;

(3) That all such services are HIV-related and enhance the health or prevent deterioration of the recipient’s health;

(4) That the HIV care consortium designated by the director to serve the area where the individual or family receiving services resides or the director, as applicable, has included the service in the list of covered services established under paragraph (B) or (D) of rule 3701-44-03 of the Administrative Code;

(5) That the service does not exceed any of the limitations established under paragraph (C) of rule 3701-44-03 of the Administrative Code. A case manager may authorize services in excess of those limitations if he or she obtains prior approval from the director, and

(6) That the recipient of services is not covered by any third-party payment source, including the medicaid program established by Chapter 5111. of the Revised Code, for the service at issue. A recipient shall be considered to be covered by a third-party payment source if such a source will provide any payment for the service, even if the payment does not cover the provider’s charges fully.

(F) If a community-based case manager denies authorization of payment for a requested service, he or she shall provide written notification of the denial to the person requesting authorization. The notice shall state the reasons for the denial and inform the person of the reconsideration process under rule 3701-44-07 of the Administrative Code.

(G) After providing authorized services, the provider shall bill the recipient of the services and send a copy of the bill to the community-based case manager within forty-five days after the services were provided. The case manager, after verifying that the services were authorized, shall forward the bill to the third-party administrator for payment.

(H) In addition to the requirements of paragraph (D) of this rule, the third-party administrator shall make payments under this rule for authorized services only if both of the following conditions are met:

(1) The amount to be paid does not cause the total payments for the geographic area where the service recipient lives to exceed the amount that the director has allocated to provide services in that area under paragraph (B) of this rule unless the director has indicated a need to do so:

(2) The bill identifies the individual or family for whom the services were provided and itemizes the charges for all services for which payment is requested.

(I) The third-party administrator shall send the director biweekly written reports that identify, by number, the recipients of services for which payments were made during the preceding period, the providers to whom the payments were made, the amounts of the payments, the types of services for which the payments were made, and the geographical areas involved. The administrator also shall provide any other information required by the director.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999

(A) To be eligible for benefits under the Ryan White program, an individual shall meet all of the following requirements:

(1) The individual shall be an Ohio resident;

(2) The individual shall have a verified HIV infection ; and

(3) The individual’s or family’s monthly gross income, excluding taxes and any mandatory retirement deduction, does not exceed three hundred percent of the currently applicable supplemental security income payment under Title XVI of the “Social Security Act,” 49 Stat. 620 (1935), 42 U.S.C. 301, as amended. The director may adjust this eligibility standard if he or she determines that it is necessary due to program fiscal considerations.

(B) The community-based HIV case manager for the area where the applicant for program eligibility resides shall determine whether the applicant meets the requirements specified in paragraph (A) of this rule. Upon determining that the applicant is eligible, the case manager shall assign the applicant an identification number and shall report the applicant’s number to the third-party administrator responsible for making payments under rule 3701-44-04 of the Administrative Code. The case manager also shall report the applicant’s identification number and date of birth to the director.

(C) The community-based case manager may give the applicant for program eligibility written notification of the decision on eligibility. If eligibility is denied, the case manager shall state in the notice the reasons for denial and the process for reconsideration under rule 3701-44-07 of the Administrative Code.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999

(A) An individual or entity that wishes to receive payments for services under the Ryan White program shall meet the eligibility criteria specified in this rule.

(B) The provider shall possess any license or other regulatory approval required by law to practice in Ohio.

(C) If the provider is not required to have a license or other regulatory approval to practice in Ohio, the provider shall have a current federal tax identification number, except as otherwise provided in this paragraph. A community-based HIV case manager may authorize payment for services provided by an individual or entity In such a case, the agency that employs the community-based HIV case manager shall pay the individual or entity. That agency shall enter into a provider agreement with the director under paragraph (D) of this rule and shall bill the third-party administrator for reimbursement, under rule 3701-44-04 of the Administrative Code, for payments made under this paragraph.

(D) The provider shall execute an agreement with the consortium which includes, but is not limited to, the following provisions:

(1) A requirement that the provider accept as payment in full for the service the following applicable payment, as determined under paragraph (C) of rule 3701-44-04 of the Administrative Code;

(a) Usual, customary, and reasonable charges, as determined by the thirdparty administrator for the service in question; or

(b) The payment rate established by the applicable HIV care consortium or the director for the service.

The provider shall not bill the recipient of services or any other person for any services for which payment is made under the Ryan White program and for which an outstanding balance remains. Ryan White program funds constitute payment in full; and

(2) A requirement that the provider comply with all applicable provisions of state and federal law regarding confidentiality of information about individuals with HIV infection.

(E) The consortium serving the geographic area where the provider provides services shall determine the provider’s eligibility. Once a provider has been determined to be eligible, the provider shall be eligible to provide services to individuals and families residing in any geographic area in the state unless the director has terminated the provider’s eligibility under paragraph (F) of this rule.

(F) The director may terminate a provider’s eligibility upon determining that the provider no longer meets the eligibility requirements specified by this rule or has violated the provider agreement required by paragraph (D) of this rule.

(G) The consortium or the director, as applicable, shall provide written notification of any decision regarding eligibility of a provider. If the consortium or director denies or terminates eligibility, he or she shall state in the notice the reasons for denial or termination and the process for reconsideration under rule 3701-44-07 of the Administrative Code.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999

(A) The following persons may seek reconsideration of the specified decisions pertaining to the Ryan White program:

(1) An individual who has applied for eligibility for benefits and whose application has been denied by the community-based HIV case manager;

(2) An individual or entity that has applied for eligibility as a provider and whose application has been denied by the community-based HIV case manager;

(3) An individual or entity whose eligibility as a recipient or provider has been terminated by the community based HIV case manager or the director, as applicable; and

(4) An individual or entity that has sought authorization of payment for services from the community-based HIV case manager and whose request has been denied.

(B) A person seeking reconsideration shall file a written request for reconsideration With the case management agency. A further appeal to the HIV care consortium may be made within thirty days after the date of mailing the case management agency’s decision. A final appeal to the director may be made within fifteen days after the date of mailing the HIV care consortium’s decision. The final appeal shall be submitted to the aids client resources section of the Ohio department of health. The request shall be accompanied by any written material that the person making the request wishes to present. The director shall provide the person with written notice of his or her decision on reconsideration, which decision shall be final.

R.C. 119.032 review dates: 04/30/2004 and 04/30/2009

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 5/20/1999

(A) In order to be eligible for the Ohio HIV drug assistance program an individual shall meet the following requirements:

(1) The individual shall be an Ohio resident and shall have a verified HIV positive infection;

(2) The individual shall submit a complete, accurate, and truthful Ohio HIV drug assistance program application in accordance with this rule and include a copy of any health insurance policy held by the applicant;

(3) The individual shall be enrolled in a community based HIV case management program approved by the department;

(4) The individual shall submit documentation of CD4 and viral load results that are not more than six months prior to the date of application;

(5) The individual shall submit satisfactory documentation that he or she has applied for medicaid or deemed to be unlikely eligible for medicaid by an HIV case manager approved by the department. An applicant who has been determined eligible for the medicaid program under the spend down provision set forth in rule 5101:1-39-10 of the Administrative Code may be eligible for the Ohio HIV drug assistance program until such time as he or she reaches their monthly spenddown amount;

(6) The individual shall meet the financial eligibility requirements of paragraph (B) of this rule;

(7) The individual shall cooperate with the department in investigating and applying for any potential third party payments. Refusal to cooperate in obtaining any third party payment shall result in ineligibility for the Ohio HIV drug assistance program.

(B) Financial eligibility for the Ohio HIV drug assistance program is determined by comparing the individual or family income to the following income standard based on an individual’s circumstances. This criteria may be adjusted upward or downward based on federal and state funding as determined by the director.

(1) For an individual eighteen years of age or older, or a minor not residing with a parent or guardian, the income standard is three hundred per cent of the currently applicable federal poverty level.

(2) For an individual under eighteen years of age residing with a parent or guardian or for individuals over eighteen years of age with dependents, the income standard is the sum of the following:

(a) Three hundred per cent of the currently applicable federal poverty level, and

(b) An amount for each dependent equal to the currently applicable federal poverty level.

(3) An individual applying for the Ohio HIV drug assistance program shall submit income verification that demonstrates to the director’s satisfaction that he or she meets the eligibility criteria. This documentation may include, but is not limited to, current and prior state and federal income tax returns. For purposes of this paragraph, “family” means the biological and adoptive parents and all children and stepchildren of such parents under eighteen years of age living in the home. A childless married couple is considered a family.

(C) When an individual resides in the same household with his or her spouse, or a child under age eighteen resides in the same household with his or her parent(s), the individual’s income and the income of such spouse and/or parent(s) shall be included in determining the applicant’s eligibility.

(D) Individuals denied medicaid or general assistance and individuals who have been determined eligible for the medicaid program under the spenddown provisions of rule 5101:1-39-10 of the Administrative Code shall be approved for a period not to exceed twelve months from the date of application approval.

(E) Individuals shall be referred to their county department of job and family services to make application for those programs and shall be eligible for the Ohio HIV drug assistance program for ninety days which may be extended as follows:

(1) If the applicant is approved for medicaid under the spenddown provisions pursuant to rule 5101:1-39-10 of the Administrative Code, the program eligibility period shall be extended for a period not to exceed twelve months from initial application approval;

(2) If the applicant otherwise meets the eligibility requirements for the Ohio HIV drug assistance program and his or her medicaid application has been denied, the program eligibility period shall be extended for a period not to exceed twelve months from initial application approval;

(3) If the applicant is approved for medicaid either without a spendown, or with a spendown the applicant can afford, his or her Ohio HIV drug assistance program eligibility shall be terminated.

(F) Prior to the end of the approved Ohio HIV drug assistance program eligibility period, the individual must complete a reapplication process to enter into a new Ohio HIV drug assistance program eligibility period.

(G) An individual who has been determined to be ineligible for the Ohio HIV drug assistance program, or has been notified that he or she is being terminated from the program, may request reconsideration of that determination by filing a written request for reconsideration with the director within thirty days after the date of mailing of the notice of the determination or termination of eligibility. The request shall be accompanied by any written material that the individual wishes to present. The director shall provide the person with a written decision regarding the request for reconsideration. The director’s decision shall be final and non-appealable.

Effective: 12/18/2006

R.C. 119.032 review dates: 10/03/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 7/20/2001

(A) The home health program shall list which of the services specified in this paragraph may be authorized for payment under the home health program. The list shall apply to services requested by eligible individuals or families that include eligible individuals who reside in the state. The program may list any or all of the following services and may revise the list when it considers revision to be appropriate. Appropriate services include home health care provided by registered nurses and licensed practical nurses licensed pursuant to Chapter 4723. Of the Revised Code, social work and counseling as provided by individuals licensed pursuant to Chapter 4757. Of the Revised Code, home health aide, homemaker services, home intravenous therapy, respite care and hospice services.

All services set forth above are contingent upon United States department of health and human services, health resources and services administration, policy and approval. Inpatient hospital and nursing home services are not covered under the home health program.

(B) The home health program shall establish and may revise dollar limitations or other limitations on each category of services as specified in paragraph (A) of this rule that it lists for purposes of payment by the home health program. The director may establish additional limitations on services for which payment may be authorized because of program fiscal constraints.

(C) The home health program shall provide copies of the list prepared under paragraph (B) of this rule and any revisions to the director and the community-based HIV case managers serving the area.

R.C. 119.032 review dates: 06/29/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 7/20/2001

(A) The director shall make payments for services under the Ryan White program in accordance with the requirements specified in this rule.

(B) The director shall allocate specific amounts of the money available for the central based home health program within the Ryan White program to pay for services to individuals and families residing in Ohio. The director may revise these allocations as the director considers appropriate.

(C) The director may contract with a third-party administrator to make payments under this rule. The third-party administrator shall pay the usual, customary, and reasonable charges in the area for the services at issue. If there is no usual, customary, and reasonable charge for a given service, the administrator shall pay an amount specified for the service by the Ohio department of health Ryan White home health coordinator.

(D) The third-party administrator shall make payments only for services for which payments are authorized by the registered nurse coordinator or the director. Upon request of an eligible individual the registered nurse coordinator shall determine whether or not to authorize payment of the requested services in accordance with paragraph (E) of this rule. Authorization may be given orally or in writing.

(E) The Ohio department of health Ryan White home health coordinator shall authorize payment for services only after making all of the following determinations:

(1) That the individual receiving services is eligible under rule 3701-44-11 of the Administrative Code;

(2) That the provider is eligible under rule 3701-44-12 of the Administrative Code;

(3) That the service is needed as a the result of the service recipient’s HIV disease or is needed because of the HIV disease of a member of the recipient’s family and;

(4) That the recipient of services is not fully covered by any third-party payment source, including the medicaid program established by Chapter 5111. of the Revised Code, for the service at issue. The Ryan White home health program may supplement medicaid or another third party payor.

(F) If the program coordinator denies authorization of payment for a requested service, he or she shall provide written notification of the denial to the person requesting authorization. The notice shall state the reasons for the denial and inform the person of the reconsideration process under rule 3701-44-07 of the Administrative Code.

(G) After providing authorized services, the provider shall bill the recipient of the services and send a copy of the bill to the registered nurse coordinator within sixty days after the services were provided. The coordinator shall forward the bill to the third-party administrator for payment after verifying that the services were authorized.

(H) In addition to the requirements of paragraph (D) of this rule, the third-party administrator shall make payments under this rule for authorized services only if both of the following conditions are met:

(1) The amount to be paid does not cause the total payments for the program to exceed the amount that the director has allocated to provide services under paragraph (B) of this rule;

(2) The bill identifies the individual or family for whom the services were provided and itemizes the charges for all the services for which payment is requested.

(I) The third-party administrator shall sendto the department bi-weekly reports that identify, by number, the recipients of services for which payments were made during the preceding period, the providers to whom the payments were made, the amounts of the payments, the types of services for which the payments were made and the designated geographical areas involved. The administrator also shall provide any other information requested by the department.

R.C. 119.032 review dates: 06/29/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 7/20/2001

(A) To be eligible for benefits under the Ryan White home health program, an individual shall meet all of the following requirements:

(1) The individual shall be an Ohio resident;

(2) The individual or a member of an individual’s family shall have a verified HIV infection or the individual shall be a significant other of an individual who has a verified HIV infection; and

(3) The individual’s or family’s monthly gross income, excluding taxes and any mandatory retirement deduction does not exceed three hundred per cent of the currently applicable supplemental security income payment which is determined in accordance with 20 C.F.R. subpart D (as published on April 1, 2006). The director may raise or lower this eligibility standard if the director determines that it is necessary because of program fiscal changes.

(B) The community-based HIV case manager for the area where the applicant resides shall determine whether the applicant meets the requirements specified in paragraph (A) of this rule. Upon determining that the applicant is eligible, the case manager shall assign the applicant an identification number and shall report the applicant’s name and number to the third-party administrator responsible for making payments under rule 3701-44-04 of the Administrative Code. Upon request by the director the case manager also shall report the applicant’s identification number and date of birth to the director.

(C) The community-based HIV case manager shall give the applicant program eligibility notification of the decision of eligibility. If eligibility is denied, the case manager shall state in a written notice the reason(s) for denial and the process for reconsideration under rule 3701-44-07 of the Administrative Code.

Effective: 12/18/2006

R.C. 119.032 review dates: 10/03/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 7/20/2001

(A) An individual or entity that wishes to receive payments for services under the Ryan White program shall meet the eligibility criteria specified in this rule.

(B) The provider shall possess any license or other regulatory approval required to practice in Ohio.

(C) The provider shall execute an agreement with the director which includes, but is not limited to, the following provisions:

(1) A requirement that the provider accept as payment in full for the service the following applicable payment, as determined under paragraph (C) of rule 3701-44-04 of the Administrative Code:

(a) Usual, customary, and reasonable charges, as determined by the third-party administrator, for the service in question; or

(b) The payment rate established by the ohio department of health Ryan White home health coordinator or the director for the service;

(2) A requirement that the provider comply with all applicable provisions of state and federal law regarding confidentiality of information about individuals with HIV infection.

(D) The consortium or the consortia program coordinator serving the geographic area where the provider provides services shall determine the provider’s eligibility. Once a provider has been determined to be eligible, the provider shall be eligible to provide service to individuals and families residing in any geographic area in the state unless the director has terminated the provider’s eligibility pursuant to paragraph (C) of this rule.

(E) The director may terminate a provider’s eligibility upon determining that the provider no longer meets the eligibility requirements specified by this rule or has violated the provider agreement required by paragraph (C) of this rule.

(F) The community based HIV case manager or the director, as applicable, shall provide written notification of any decision regarding eligibility of a provider. If the case manager or director denies or terminates eligibility, he or she shall state in the notice the reason(s) for denial or termination and the process for reconsideration under rule 3701-44-24 of the Administrative Code.

R.C. 119.032 review dates: 06/29/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 7/20/2001

(A) The following persons may seek reconsideration of the specified decisions pertaining to the Ryan White home health program:

(1) An individual who has applied for eligibility for benefits and whose application has been denied by the community-based HIV case manager;

(2) An individual or entity that has applied for eligibility as a provider and whose application has been denied by the consortium or consortia program coordinator;

(3) An individual or entity whose eligibility as a recipient or provider has been terminated by the community-based HIV case manager or the director, as applicable; and

(4) An individual or entity that has sought authorization of payment for services from the director and whose request has been denied.

(B) A person seeking reconsideration shall file a written request for reconsideration with the program within thirty days of receipt of the decision. A final appeal to the director may be made within thirty days after the date of mailing the home health program’s decision. The final appeal shall be submitted to the AIDS client resources section of the Ohio department of health. The request shall be accompanied by any written material that the person making the request wishes to present. The director shall provide the person with written notice of his or her decision on reconsideration and the decision shall be final.

R.C. 119.032 review dates: 06/29/2006 and 06/29/2011

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 7/20/2001