5101:1-38-01.6 Medicaid: application for home and community-based (HCB) services.

(A) This rule sets forth the process for determining whether an individual is eligible for medicaid payments for services under the HCB services waivers set out in division 5101:3 of the Administrative Code.

(B) Eligibility for HCB services. To receive HCB services, the individual shall:

(1) Be in receipt of medicaid, as described in Chapters 5101:1-37 to 5101:1-40 or rule 5101:1-41-30 of the Administrative Code;

(2) Be in need of HCB services under a waiver described in division 5101:3 of the Administrative Code; and

(3) Be enrolled in an HCB services waiver described in rule 5101:3-1-06 of the Administrative Code.

(C) Determination of eligibility for HCB services. The county department of job and family services (CDJFS) shall approve HCB services for an individual in receipt of medicaid only upon:

(1) Approval by the HCB services waiver operational agency; and

(2) If services under the waiver are available only to a specific number of individuals, notification that the individual may be enrolled in the waiver from the Ohio department of job and family services (ODJFS), its designee, or a waiver operating agency.

(D) Coverage period. The HCB services coverage period can have a different beginning date or ending date from the medicaid eligibility period. However, HCB services cannot begin before an individual's medicaid eligibility period or before an individual's retroactive medicaid eligibility period as determined under rule 5101:1-38-01.2 of the Administrative Code; HCB services cannot extend beyond the termination date of an individual's medicaid coverage; and HCB services cannot be provided during any period of medicaid ineligibility.

(1) Medicaid coverage of HCB services begins on the latest of the following dates:

(a) The process date for application for HCB services. The process date is:

(i) The date the CDJFS receives a signed application for HCB services from an individual; or

(ii) The signature date, if the CDJFS receives a signed and dated HCB services application from a waiver operational agency no more than five working days after the date of signature; or

(iii) The date the CDJFS receives the signed application for HCB services, if the application was received from a waiver operational agency more than five working days after the date of signature.

(b) The date the individual meets all criteria for coverage of an HCB services waiver described in rule 5101:3-1-06 of the Administrative Code.

(c) The date the individual is authorized, by the waiver operational agency, to receive HCB services.

(2) Medicaid coverage of HCB services terminates when either:

(a) The CDJFS determines the individual no longer meets medicaid conditions of eligibility as described in rule 5101:1-38-01.8 of the Administrative Code or the criteria for coverage of HCB services; or

(b) The waiver operational agency notifies the CDJFS that it no longer authorizes the individual to receive its HCB services.

(E) HCB services waiver operational agency responsibilities. HCB services waiver operational agencies shall:

(1) Submit a JFS 02399 "Request for Medicaid Home and Community-Based Services (HCBS)" (rev. 1/2006), signed by the individual, to the CDJFS within five days of the signature date, if assisting an individual with an application for HCB services.

(2) Determine, in accordance with this rule and division 5101:3 of the Administrative Code, whether the individual requesting medicaid coverage of HCB services meets the requirements of the applicable HCB services waiver program.

(3) Provide written notification of determinations to individuals, including to whom any patient liability must be paid, if applicable.

(4) Notify the CDJFS of determinations and subsequent changes regarding approval of HCB services.

(F) Administrative agency responsibilities. The CDJFS shall:

(1) Determine an individual's eligibility for HCB services in accordance with this rule and Chapters 5101:1-37, 5101:1-38, 5101:1-39, 5101:1-40, 5101:1-41, and 5101:1-42 of the Administrative Code.

(a) If an individual who applies for HCB services is currently in receipt of medicaid, the CDJFS shall process the individual's application for HCB services.

(b) If an individual who applies for HCB services is not currently in receipt of medicaid, the CDJFS shall begin the application process described in rule 5101:1-38-01.2 of the Administrative Code.

(c) If the CDJFS determines that an individual who applies for HCB services is not eligible for any category of medical assistance under Chapters 5101:1-37 to 5101:1-40 or rule 5101:1-41-30 of the Administrative Code, the agency shall deny both medical assistance and HCB services for that individual.

(2) Within five days of the receipt of a signed JFS 02399, notify the applicable waiver agency via the electronic eligibility system of the receipt of the application. If the waiver agency is not known or if multiple waiver agencies are indicated on the application, the CDJFS shall submit the JFS 02399 to the Ohio department of job and family services (ODJFS) bureau administering HCB waiver services.

(3) Notify the applicable HCB services waiver operational agency of changes in the individual's eligibility for medicaid coverage of HCB services.

Replaces: 5101:1-38- 01.6

Effective: 10/01/2009
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.01 , 5111.011 , 5111.871
Rule Amplifies: 5111.01 , 5111.011 , 5111.012 , 5111.87 , 5111.871 , 5111.91
Prior Effective Dates: 6/1/1988 (Emer.), 8/1/1988 (Emer.), 10/30/1988, 1/1/1990 (Emer.), 3/1/1990 (Emer.), 3/30/1990 (Emer.), 4/1/1990, 6/29/1990, 7/1/1990, 10/1/1990, 1/1/1991 (Emer.), 4/1/1991, 1/1/1992 (Emer.), 3/20/1992, 3/30/1992, 5/1/1992 (Emer.), 7/1/1992, 8/14/1992 (Emer.), 1/1/1992, 5/1/1993, 9/1/1993, 7/1/1994, 10/1/2002, 10/1/2004