Chapter 5101:3-33 Assisted living HCBS waiver program

(A) The purpose of this rule is to define the terms used in the assisted living HCBS waiver program.

As used in this chapter:

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

(C) “Assessment” means a face-to-face evaluation and interview that is conducted by the preadmission screening system providing options and resources today (PASSPORT) administrative agency (PAA) 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) “Assisted living HCBS waiver” means the medicaid program that serves individuals residing in certified residential care facilities and enrolled on the waiver who would otherwise receive services in a nursing facility if the waiver program were not available.

(E) “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.

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

(G) “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 that administers the medicaid program and approves home and community-based services (HCBS) waivers.

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

(I) “HCBS” or “home and community-based services” means services furnished under the provisions set forth in 42 CFR 441 Subpart G (October 1, 2005) that permit individuals to live in a home setting rather than a nursing facility (NF) or hospital. HCBS waiver services are approved by CMS for specific populations and are not otherwise available under the medicaid state plan.

(J) “Level of care” (LOC) means the designation describing an individual’s functional levels and nursing needs pursuant to the criteria set forth in rules 5101:3-3-05, 5105:3-3-06, 5101:3-3-07 and 5101:3-3-08 of the Administrative Code.

(K) “NF” means a nursing facility as defined in section 5111.20 of the Revised Code.

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

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

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

(O) “PAA” means PASSPORT administrative agency.

(P) “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 consumer and case manager.

Effective: 07/01/2006

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

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

(A) The purpose of this rule is to outline the criteria that must be met for an individual to be eligible to enroll in the assisted living home and community based services (HCBS) waiver.

(B) To be eligible for the assisted living program, an individual must meet all of the following requirements:

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

(2) If the individual requires skilled nursing care beyond supervision of special diets, application of dressings, or administration of medication, it must only be required on a part-time, intermittent basis for not more than a total of one hundred twenty days in any twelve month period. A part-time, intermittent basis means that skilled nursing care is needed for less than eight hours a day or less than forty hours a week.

(3) At the time the individual applies for the assisted living program, be one of the following:

(a) A nursing facility resident who is seeking to move to a residential care facility and would remain in the nursing facility for long term care if not for the assisted living HCBS waiver; or

(b) A participant who is currently enrolled in any of the following medicaid waivers who would move to a nursing facility if not for the assisted living HCBS waiver:

(i) The preadmission screening system providing options and resources today (PASSPORT) HCBS waiver as set forth in Chapter 5101:3-31 of the Administrative Code that the Ohio department of aging administers; or

(ii) The choices HCBS waiver as set forth in Chapter 5101:3-32 of the Administrative Code that the Ohio department of aging administers; or

(iii) The Ohio home care HCBS waiver as set forth in Chapter 5101:3-12 of the Administrative Code that the Ohio department of job and family services administers; or

(iv) The transitions carve out waiver as set forth in Chapter 5101:3-50 of the Administrative Code that the Ohio department of job and family services administers.

(c) A resident of a residential care facility (RCF) who has resided in the RCF for at least six months immediately before the date the individual applies for the assisted living HCBS waiver.

(4) At the time of enrollment, and while receiving assisted living HCBS services, the individual must reside in a residential care facility certified by ODA, including:

(a) A residential care facility that is owned or operated by a metropolitan housing authority that has a contract with the United States department of housing and urban development to receive an operating subsidy or rental assistance for the residents of the facility;

(b) A county or district home licensed as a residential care facility.

(5) 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.

(6) The cost of the twelve-month service plan does not exceed the cost cap in effect for the program that is based on the maximum per-diem rate for assisted living services plus the maximum amount authorized for community transition services.

(7) The individual must have the ability to make room and board payments calculated at the current supplemental security income (SSI) federal benefit level minus fifty dollars.

(8) The individual is age twenty-one or older at the time of enrollment.

(9) The assisted living HCBS waiver has not reached the centers for medicare and medicaid services (CMS) authorized limit of participants for the current year.

(10) The individual’s health related needs, as determined by the PASSPORT administrative agency, can be safely met in a, an RCF as described in paragraph (B)(4) of this rule.

(C) Providers shall not charge or collect from consumers for room and board any amount in excess of the room and board payment calculated in paragraph (B)(7) of this rule.

(D) 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 the assisted living HCBS waiver. 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.

(E) An individual who has been enrolled in the assisted living HCBS waiver may subsequently be enrolled in hospice, however, an individual who is first enrolled in hospice and is not currently enrolled in a HCBS waiver specified in paragraph (A)(2)(b) of this rule is not subsequently eligible for assisted living HCBS enrollment.

Effective: 09/19/2009

R.C. 119.032 review dates: 03/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

Prior Effective Dates: 07/01/2006, 03/22/08

(A) In order to be enrolled in the assisted living HCBS waiver, individuals must be receiving medical assistance either in a nursing facility or be enrolled in the preadmission screening system providing options and resources today (PASSPORT) HCBS waiver or the choices HCBS waiver or the Ohio home care HCBS waiver or the “Transitions Carve Out” HCBS waiver or be a resident of a residential care facility (RCF), who has resided in an RCF for at least six months immediately before the date the individual applies for the assisted living HCBS waiver.

(B) Individuals who wish to enroll in the assisted living HCBS waiver must have an eligibility determination made by the county department of job and family services (CDJFS) and an assessment of assisted living HCBS waiver eligibility made by the PASSPORT administering agency (PAA). The individual may contact either the CDJFS or the PAA to start the enrollment process, and the two agencies shall coordinate processing the request for enrollment into the assisted living services HCBS waiver program:

(1) Individuals initially contacting the CDJFS will complete the JFS 07200 “Request for Cash, Food Stamps, and Medical Assistance” (rev. 10/06) and the JFS 02399 “Request for Medicaid Home and Community Based Services” (rev. 6/04) in accordance with rule 5101:1-38-01.2 of the Administrative Code. The CDJFS will notify the PAA of the individual’s application for waiver services. The PAA will initiate contact with the individual to complete the enrollment process.

(2) Individuals initially contacting the PAA will receive an in-person assessment to determine eligibility for the assisted living HCBS waiver program. If the individual has not already initiated an application for medicaid or waiver eligibility as described in paragraph (C)(1) of this rule, the PAA may assist the individual.

(C) Using the procedures outlined in rule 173-38-03 of the Administrative Code, the PAA shall offer enrollment to the individual if the individual has been determined eligible and a waiver slot is available. If a waiting list is employed, waiver slots shall be made available in accordance with rule 173-38-03 of the Administrative Code.

(D) The PAA shall make the determination of assisted living HCBS waiver eligibility for the individual using the criteria set forth in rule 5101:3-33-03 of the Administrative Code. The PAA shall notify the CDJFS of the results of the assisted living HCBS waiver eligibility determination.

(E) Pursuant to rule 5101:1-38-01.6 of the Administrative Code, if a consumer is determined eligible for medicaid by the CDJFS, the consumer shall not enroll in the assisted living HCBS waiver program until the PAA establishes a waiver program enrollment date and authorizes the provision of waiver services by an ODA certified RCF. The assisted living services HCBS waiver program enrollment date cannot be made retroactive, nor can the enrollment date be established to authorize assisted living waiver program services retroactively. The waiver program enrollment date shall in no way restrict retroactive eligibility for non-assisted living waiver services available to consumers through the medicaid state plan.

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

Effective: 09/19/2009

R.C. 119.032 review dates: 03/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

Prior Effective Dates: 7/01/2006, 03/22/08

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

(B) In order to obtain a medicaid provider agreement to be an assisted living services provider, the provider must be certified by the Ohio department of aging (ODA) or its designee in accordance with the provisions of rule 173-39-02 of the Administrative Code.

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

Effective: 07/01/2006

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

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

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

(B) The assisted living HCBS waiver benefit package is limited to the following services:

(1) Assisted living services as defined in rule 173-39-02.16 of the Administrative Code, and

(2) Community transition services as defined in rule 173-39-02.17 of the Administrative Code.

(C) Services will be delivered consistent with the consumer plan of care as documented in the preadmission screening system providing options and resources today (PASSPORT) information management system (PIMS).

Effective: 07/01/2006

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

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

(A) The purpose of this rule is to describe the methods used to determine provider rates for the assisted living home and community based services (HCBS) waiver as set forth in rule 5101:3-1-06 of the Administrative Code for the following categories:

(1) Per job bid rate or deposit made.

(2) Unit rate.

(B) A per job bid rate or deposit made shall be determined on a per job basis for the community transition service as set forth in rule 173-39-02.17 of the Administrative Code.

(1) The cost per job shall be reimbursed at a per job bid rate that is negotiated and approved by Ohio department of aging’s (ODA) designee and accepted by the consumer. The per job bid rate includes the cost of the purchase, delivery, and set-up of items. Deposits made include set-up fees or deposits for utility on service access.

(C) A unit rate shall be based on a three-tiered model as expressed in appendix A to rule 5101:3-1-06.5 of the Administrative Code. These rates will be used for assisted living services as set forth in rule 173-39-02.16 of the Administrative Code.

(1) Each consumer’s rate shall be determined by the preadmission screening system providing options and resources today (PASSPORT) administrative agency through an assessment of the consumer’s service needs in four areas:

(a) Cognitive impairments,

(b) Medication administration,

(c) Nursing services, and

(d) Functional impairments.

(2) The provider must agree to provide the services in the consumer’s plan of care at the rate determined by the assessment.

(D) ODA certified assisted living providers shall only be reimbursed for assisted living services authorized by the PASSPORT administrative agency (PAA) and reflected on the consumer’s care plan.

(E) Assisted living service payment constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider’s charge. The provider may not bill the consumer of assisted living HCBS waiver program services for any difference between the medicaid payment and the provider’s charge or request that the consumer share in the cost through a co-payment or other similar charge.

(F) The assisted living service payment is for assisted living services as defined in rule 173-39-02.16 of the Administrative Code and does not include payment for room and board as calculated pursuant to rule 5101:3-33-03 of the Administrative Code, which is the responsibility of the consumer.

Effective: 09/19/2009

R.C. 119.032 review dates: 03/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.85, 5111.89

Rule Amplifies: 5111.85, 5111.89

Prior Effective Dates: 7/01/06, 03/22/08