(A) Before an individual can be eligible for enrollment in the pre-admission screening system providing options and resources today (PASSPORT) home and community based services (HCBS) waiver program, all of the following criteria must be met:
(1) A county department of job and family services (CDJFS) must have determined the individual to be eligible for medicaid in accordance with rules 5101:1-38-01.8 and 5101:1-38- 01.6 of the Administrative Code.
(2) The waiver service cost of the twelve-month service plan does not exceed the individual cost limit. The individual cost limit is calculated by the Ohio department of aging (ODA) at least biennially . The cost limit is a dollar amount equal to sixty per cent of the total medicaid cost for nursing facility (NF) services. The total medicaid cost for NF services is obtained by multiplying the average annual medicaid NF per diem rate by the number of days in the most recent state fiscal year in which data is available.
(a) If the PASSPORT administrative agency (PAA) determines that the applicant's needs cannot be met within the cost limit, the individual shall not be enrolled. However, if a consumer who has been enrolled and is receiving PASSPORT services experiences a change in his or her condition that causes the cost of care to exceed the cost limit, the consumer may remain on the waiver at a higher cost not to exceed one hundred per cent of the total medicaid cost for NF services to avoid service disruption to the consumer if the PAA grants approval to do so.
(b) If the consumer's needs exceed one hundred per cent of the total medicaid cost for NF services, the consumer shall be disenrolled from the waiver.
(3) The needed services are not readily available through another source at the level required to allow the individual to live in the community.
(4) The individual agrees to participate in PASSPORT and shall not be simultaneously enrolled in another HCBS medicaid waiver, the residential state supplement (RSS) program, or the program of all inclusive care for the elderly (PACE) while enrolled in PASSPORT.
(5) The individual's health related needs can be safely met in a home setting as determined by the PAA.
(6) Prior to PASSPORT enrollment, the attending physician must approve that the services are appropriate to meet the individual's needs. The physician's approval may be either verbal or written. If the approval is verbal, written approval must be obtained within thirty days of the enrollment date. The PAA shall be responsible for obtaining the physician's approval.
(7) While receiving PASSPORT, the consumer must not be a resident of a "Keys Amendment facility" as defined in rule 5101:3-31-02 of the Administrative Code; and must not reside in a hospital or NF as defined in rule 5101:3-31-02 of the Administrative Code. For purposes of this rule a resident of a"Keys Amendment facility" is an individual who receives services from the facility and is not a family member of the owner or operator of the facility.
(8) The individual is age sixty or older at the time of enrollment.
(9) The individual must be determined to meet the criteria for an intermediate or skilled level of care in accordance with rule 5101:3-3-05 or 5101:3-3-06 of the Administrative Code and, in the absence of PASSPORT, would require NF services as defined in 42 C.F.R. 440.40 and 42 C.F.R. 440.150 (dated October 1, 2007).
(10) PASSPORT has not reached the centers for medicare and medicaid services (CMS)-authorized limit of consumers for the current year.
(11) A consumer who has been enrolled in and is receiving PASSPORT services may subsequently be enrolled in and receive hospice services under medicaid or medicare. A person who is enrolled in hospice under medicaid or medicare is not eligible to enroll in PASSPORT if that hospice enrollment occurred prior to PASSPORT enrollment.
(12) The individual must require the provision of at least one waiver service on a monthly basis as documented in the consumer's approved service plan.
(B) If, at any time, the individual or consumer fails or ceases to meet any of the eligibility criteria identified in this rule, the individual or consumer shall be denied or disenrolled from PASSPORT. In such instances, the individual or consumer shall be notified by the CDJFS and entitled to hearing rights in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.
R.C. 119.032 review dates: 11/18/2010 and 03/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 12/22/86 (Emer.), 3/23/87, 1/14/96, 2/22/01, 1/31/05, 7/1/08