Chapter 5101:3-32 Choices Program

Definitions as used in this chapter:

(A) “ADL” means activities of daily living including bathing; grooming; toileting; dressing; eating; and mobility that refers to bed mobility, transfer, and locomotion as these are defined in Chapter 5101:3-3 of the Administrative Code.

(B) “Agency Provider” means an established business who employs staff to provide choices program services, has a signed medicaid provider agreement with the Ohio department of job and family services (ODJFS) to provide choices program services, and meets the choices conditions of participation set forth in rule 5101:3-32-04 of the Administrative Code.

(C) “Assessment” means a face-to-face evaluation and interview that is conducted to collect in-depth information about an individual’s current situation and ability to function. It is comprehensive and identifies the individual’s strengths, problems, and care needs in the major functional areas: physical health, medical care utilization, activities of daily living, instrumental activities of daily living, mental and social functioning, financial resources, physical environment, and utilization of services and support.

(D) “Authorized representative” means a person, eighteen years of age or older, acting on behalf of an individual who is applying for or receiving medical assistance. An authorized representative may be a family member, attorney, hospital social worker, or any other person chosen to act on the individual’s behalf. In accordance with rule 5101:1-38-01.2 of the Administrative Code, the individual must provide a written statement naming the authorized representative and the duties that the named authorized representative may perform on the individual’s behalf.

(E) “Caregivers” mean relatives, friends, and/or significant others who voluntarily provide assistance to the consumer and are responsible for the consumer’s care on a continuing basis.

(F) “Case management” is a consumer-centered activity provided by the PASSPORT administrative agency (PAA).

(G) “CDJFS” means a county department of job and family services.

(H) “Choices home and community based services (HCBS) waiver program” means the Ohio waiver program which provides home and community-based services and the opportunity to direct their own care to individuals age sixty and over; have the level of care required for placement in a nursing facility if the waiver program were not available; and meet the choices program eligibility and enrollment criteria as described in Chapter 5101:3-32 of the Administrative Code.

(I) “CMS” means the centers for medicare and medicaid services, a federal agency that is part of the United States department of health and human services, and which administers the medicaid program and approves home and community-based services (HCBS) waivers.

(J) “Consumer” means the program participant and the representative that assists in directing the consumer’s care.

(K) “Consumers who are at high-risk” means consumers who live alone, or who are alone for significant parts of the day, and have no regular caregiver for extended periods of time.

(L) “Direct service worker” means the paid agency provider staff or individual provider who has in-person contact with the choices consumer while providing choices services.

(M) “IADL” means instrumental activities of daily living including shopping; meal preparation; laundry; community access activities that include telephoning, transportation, legal or financial; and environmental maintenance activities that are house cleaning, heavy chores, and yard work or maintenance, as these are defined in rule 5101:3-3-08 of the Administrative Code.

(N) “Individual provider” means a person with a signed medicaid provider agreement with ODJFS to provide choices services, and who meets the choices HCBS waiver program conditions of participation set forth in rule 5101:3-32-04 of the Administrative Code and who is not the spouse, parent, stepparent, and/or legal guardian of the consumer.

(O) “ODA” means the Ohio department of aging.

(P) “ODJFS” means the Ohio department of job and family services.

(Q) “Plan of care” means the written outline of the consumer’s HCBS waiver services, other medicaid services and any other services necessary to prevent institutionalization as developed by the choices consumer and case manager according to the provisions of rule 5101:3-32-03 of the Administrative Code.

(R) “PAA” means the local PASSPORT administrative agency.

(S) “PASSPORT” means the preadmission screening system providing options and resources today.

(T) “Payroll agent” means the entity operating under contract with the PAA to facilitate payment of individual providers on behalf of the consumer for the provision of choices services. The payroll agent shall withhold from claims payment, all required federal, state, and local payroll taxes, including workers’ compensation, and shall forward payments to relevant entities in compliance with applicable federal, state and local laws and regulations. The payroll agent shall collect all necessary paperwork related to paying the individual provider, and shall provide billing information to the PAA.

Effective: 07/01/2006

R.C. 119.032 review dates: 06/13/2006

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 8/30/01, 7/1/05

The following criteria must be met in order for a consumer to be eligible for enrollment:

(A) The consumer must be age sixty or older at time of enrollment.

(B) The consumer must have an intermediate or skilled level of care in accordance with rule 5101:3-3-05 or rule 5101:3-3-06 of the Administrative Code.

(C) The consumer must meet medicaid financial eligibility as determined by the county department of job and family services (CDJFS) in accordance with Chapters 5101:1-37 and 5101:1-39 of the Administrative Code.

(D) Prior to enrollment in the choices program the consumer must be a current preadmission screening systems providing options and resources today (PASSPORT) program participant.

(E) The needed services are not readily available through another source at the level required to allow the individual to live in the community.

(F) The individual’s health related needs can be safely met in a home setting as determined by the passport administrative agency (PAA).

(G) The individual may not be enrolled in another home and community based medicaid waiver, residential state supplement (RSS), or program of all inclusive care for the elderly (PACE )while enrolled in choices.

(H) While receiving choices program services, the consumer must reside in the service area defined in the approved 1915(c) waiver for the choices program. The consumer shall not reside in any of the following living arrangements while enrolled in the choices program:

(1) Adult foster home certified under section 173.36 of the Revised Code;

(2) Adult family homes or adult group homes as defined in section 3722.01 of the Revised Code that is licensed as an adult care facility under section 3722.04 of the Revised Code;

(3) Residential care facility as defined in section 3721.02 of the Revised Code;

(4) Community alternative home as defined in section 3724.01 of the Revised Code that is licensed under section 3724.03 of the Revised Code;

(5) Residential facility of the type defined in division (A)(1)(d)(ii) of section 5119.22 of the Revised Code that is licensed by the Ohio department of mental health;

(6) An apartment or room that is used to provide community mental health housing services, is certified by the Ohio department of mental health under division (M) of section 5119.61 of the Revised Code, and is approved by a board of alcohol, drug addiction, and mental health services in accordance with division (A)(13) of section 340.03 of the Revised Code;

(7) Hospital or nursing facility (NF) as defined in rule 5101:3-31-02 of the Administrative Code;

(8) “Keys amendment facility” as defined in section 1616(e) of the Social Security Act; or

(9) Any other facility that is licensed and/or certified by any state or local government.

(I) The consumer or the consumer’s authorized representative must be willing and capable of directing provider activities. Capability must be demonstrated through a consumer certification process conducted by the (PAA). To obtain certification, the consumer or his or her designee must meet all of the following:

(1) Attend all required training;

(2) Demonstrate all skills necessary to supervise direct service workers, including but not limited to:

(a) An understanding of what service activities are covered and the corresponding provider requirements, including criminal records check requirements; and

(b) Methods for selecting and dismissing providers; and

(c) Methods for entering into written agreements with providers for specific activities and corresponding payment rates; and

(d) Methods for training providers to meet the consumer’s specific needs; and

(e) Methods for supervising and monitoring providers’ performance of specific activities, including written approval of provider time sheets and billing invoices; and

(f) Development of a reliable service delivery back-up plan for situations in which a provider is unable to deliver the agreed-upon service(s); and

(g) Methods for lodging complaints, including use of the regional and state long term care ombudsman, and familiarity with the state’s Ohio department of aging (ODA) ombudsman long term care complaint line; and

(h) Familiarity with state appeal and fair hearing request procedures; and

(i) Record keeping and ability to manage service delivery.

(3) Agree to actively participate with the case manager in the development, monitoring and revision of the service plan.

(4) Agree to inform the case manager of negotiated rates prior to delivery of choices services. ODA and/or PAA retains the authority to approve negotiated rates.

(5) The consumer must use a payroll agent under contract with the PAA to process all individual service provider claims.

(J) 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 choices. In such instances, the individual or consumer shall be notified by the CDJFS and entitled to hearing rights in accordance with rules contained in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(K) The choices program has not reached the center for medicaid and medicare services (CMS) authorized limit of participants for the current year.

(L) The cost of the twelve-month service plan does not exceed the cost cap. The “cost cap” is a dollar amount adjusted for inflation equal to sixty per cent of the total medicaid cost including consumer copayment for nursing facility services for the most recent state fiscal year for which data is available as set forth in rule 5101:3-31-03 of the Administrative Code.

(M) Prior to choices enrollment the individual’s attending physician must approve that the services contained in the individual’s service plan are appropriate to meet the individual’s needs. The approval may be given either verbal or written; however if the approval is verbal, written approval of the service plan must be obtained within thirty days of the enrollment date. If the written approval is not obtained, the individual shall be deemed to have not met the eligibility criteria set forth in this rule and disenrolled in accordance with paragraph (J) of this rule.

Effective: 10/01/2007

R.C. 119.032 review dates: 07/16/2007 and 10/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 8/30/01, 7/1/05, 7/1/06

(A) The purpose of this rule is to establish the conditions of participation under which providers are able to participate in the choices home and community based services (HCBS) waiver program.

(B) In order to obtain a medicaid provider agreement to be a choices provider, the provider must be certified by the Ohio department of aging (ODA) or its designee in accordance with the provisions of Chapter 173-39 of the Administrative Code .

(1) The provider may be certified as either:

(a) An ODA certified long-term care agency providers in accordance with the provisions of rule 173-39-02 of the Administrative Code, or

(b) An ODA certified long-term care non-agency provider in accordance with the provisions of rule 173-39-02 of the Administrative Code, or

(c) An ODA certified consumer-directed individual provider in accordance with the provisions of rule 173-39-02 of the Administrative Code.

(C) Individuals enrolled in the choices HCBS waiver shall be given a free choice of qualified providers in accordance with Chapter 5101:3-41 of the Administrative Code.

Effective: 07/01/2007

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 08/30/01, 07/01/05, 07/01/06

(A) The purpose of this rule is to establish services covered by the choices home and community based services (HCBS) waiver program.

(B) The Ohio department of aging (ODA) is responsible for the daily administration of the choices HCBS waiver. ODA will administer this waiver pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS), in accordance with sections 5111.91 and 5111.851 of the Revised Code.

(C) The choices HCBS waiver program benefit package is limited to the following services:

(1) Home care attendant services as set forth in rule 173-39-02.4 of the Administrative Code;

(2) Minor home modification, maintenance and repair services as set forth in rule 173-39-02.9 of the Administrative Code;

(3) Alternative meal services as set forth in rule 173-39-02.2 of the Administrative Code;

(4) Home delivered meal services as set forth in rule 173-39-02.14 of the Administrative Code;

(5) Emergency response systems services as set forth in rule 173-39-02.6 of the Administrative Code;

(6) Home medical equipment and supplies services as set forth in rule 173-39-02.7 of the Administrative Code;

(7) Adult day services as set forth in rule 173-39-02.1 of the Administrative Code; and

(8) Pest control services as set forth in rule 173-39-02.3 of the Administrative Code.

(D) Services will be delivered consistent with the consumer service plan as documented in the PASSPORT information management system (PIMS).

Replaces: 5101:3-32-05

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 8/30/01, 7/1/05

(A) The purpose of this rule is to establish the standards and procedures for enrollment in the choices home and community based services (HCBS) waiver program.

(B) An individual must be currently enrolled in the PASSPORT HCBS waiver program as described rule 173-42-01 of the Administrative Code to begin the choices waiver program enrollment process. The individual, a family member or case manager may initiate the contact to the choices HCBS waiver program staff to request enrollment.

(C) An individual who requests enrollment into the choices HCBS waiver program must meet the program eligibility requirements as described in rule 5101:3-32-03 of the Administrative Code prior to enrollment.

(D) Any applicant for choices HCBS waiver program services is entitled to notice and hearing rights as set forth in section 5101.35 of the Revised Code and division-level designation 5101:6 of the Administrative Code.

(1) The PAA must notify the individual and authorized representative, if any, of the approval for enrollment for an individual determined to meet all choices HCBS waiver program eligibility criteria.

(2) If the PAA determines that the individual does not meet the criteria for enrollment into the choices HCBS waiver program, the PAA must notify the CDJFS of the results, and the CDJFS must send notice of the denial of the waiver application to the individual and authorized representative, if any.

(3) If the CDJFS determines the individual does not meet the financial eligibility criteria, the CDJFS must send notice of denial of the waiver application to the individual and authorized representative, if any, and notify the PAA.

(E) If an individual meets all the eligibility criteria, but a slot is not available for enrollment in the choices waiver program, the individual must be placed on a waiting list according to the date the individual was determined to meet eligibility for choices as described in paragraphs (A) to (E) of rule 5101:3-32-03 of the Administrative Code.

(F) The PAA must remove each individual from the waiting list be enrolled in the choices waiver program according to the chronological order of the date the individual was placed on the waiting list.

Replaces: 5101:3-32-06

Effective: 07/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 8/30/01, 7/1/05

(A) Subject to the limits set forth in rule 5101:3-1-06.4 of the Administrative Code, consumers negotiate rates with providers whereby expenditures may not exceed the authorized amounts identified in the service plan.

(B) Consumers shall negotiate rates for choices HCBS waiver program covered services as specified in rule 5101:3-32-05 of the Administrative Code, except for the enhanced level and the intensive level of adult day services, as defined in rule 173-39-02.1 of the Administrative Code as these are set forth in appendix A to rule 5101:3-1-06.4 of the Administrative Code.

(C) The consumer shall contract for the services specified in the service plan with providers who have a signed medicaid provider agreement with ODJFS to provide choices HCBS waiver program covered services, who meet the requirements set forth in rules 5101:3-32-02 and 501:3-32-04 of the Administrative Code to provide the specified service in the region for which the rate will be negotiated.

(1) The consumer shall:

(a) Specify the time period for which the rates shall be in effect;

(b) Base rates on the units of service as set forth in rule 173-39-02 of the Administrative Code.

(2) The rates shall not exceed the cost cap as specified in paragraph (H) of rule 5101:3-32-03 of the Administrative Code nor the maximum allowed per service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code.

(D) Payment for choices HCBS wavier covered services constitutes payment in-full and may not be construed as a partial payment when the payment amount is less than the provider’s usual and customary charge. The provider may not bill the consumer for any difference between the medicaid payment and the provider’s charge or request the recipient to share in the cost through a co-payment or other similar charge. The provider shall accept medicaid payment as payment in full.

Replaces: 5101:3-32-08

Effective: 07/01/2007

R.C. 119.032 review dates: 07/01/2012

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.85

Prior Effective Dates: 08/30/01, 7/1/05

Rescinded eff 7-1-07