5101:3-45-01 ODJFS-administered waiver program: definitions.

(A) “Accreditation commission for health care (ACHC)” is a national organization that evaluates and accredits home health agencies seeking to participate in the medicare and medicaid programs.

(B) “Activities of daily living” are personal or self-care skills performed on a regular basis, with or without the use of adaptive and assistive devices that enable a consumer to meet basic life needs for food, hygiene and appearance as defined in rule 5101:3-3-06 of the Administrative Code.

(C) “Agency-consumer agreement” means the ODJFS-approved agreement signed by the consumer and/or authorized representative and the case manager (CM) that assures that the consumer is voluntarily enrolling in an ODJFS-administered waiver as an alternative to receiving services in a facility or hospital. It identifies the conditions and responsibilities a waiver consumer must agree to as a condition of enrollment.

(D) “Agency provider” is a provider that is eligible to participate in the medicaid program upon execution of a medicaid provider agreement in accordance with rule 5101:3-1- 17.2 of the Administrative Code.

(E) “All services plan” is the service coordination and payment authorization document that identifies specific goals, objectives and measurable outcomes for consumer health and functioning expected as a result of services provided by both formal and informal caregivers, and that addresses the physical and medical conditions of the consumer.

(1) At a minimum, the all services plan shall include:

(a) Essential information needed to provide care to the consumer that assures the consumer’s health and welfare;

(b) Billing authorization; and

(c) Signatures indicating the consumer’s acceptance or rejection of the all services plan.

(2) The all services plan is not the same as the physician’s plan of care.

(F) “Applicant” is a person who completes a JFS 02399 “Request for Medicaid Home and Community-Based Services” (rev. 1/2006) and submits it to the county department of job and family services (CDJFS) requesting an eligibility determination for an ODJFS-administered waiver.

(G) “Assessment” is a comprehensive face-to-face evaluation conducted as part of the ODJFS-administered waiver program eligibility determination/redetermination process. It is an evaluation of a person’s living arrangements/ household composition, medical and acute/long term care history, medical interventions and treatment regimens, medication profile, functional ability, psycho-social status, safety and cognition status, environmental situation, usage of adaptive and assistive equipment, informal supports and caregiver involvement, and formal supports, and results in a level of care recommendation.

(H) “Authorized representative” is a person the waiver applicant or consumer identifies in writing to ODJFS or its designee as a person who will act on his or her behalf for specifically identified purposes. The authorized representative shall not be the consumer’s ODJFS-administered waiver service provider.

(I) “Case management agency (CMA)” is the entity designated by ODJFS to provide case management services to consumers enrolled on an ODJFS-administered waiver.

(J) “Case management services” are the administrative activities that link, coordinate and monitor the services and resources provided to a consumer enrolled on an ODJFS-administered waiver. ODJFS may designate other entities to perform one or more of these functions.

(K) “Case manager” is a registered nurse (RN), licensed social worker (LSW) or licensed independent social worker (LISW) employed by the CMA who provides case management services to consumers enrolled on an ODJFS-administered waiver.

(L) “CDJFS” is a county department of job and family services.

(M) “Clinical record” is a record containing written documentation that must be maintained by each ODJFS-administered waiver service provider.

(N) “CMS” is the federal centers for medicare and medicaid services.

(O) “Community health accreditation program (CHAP)” is a national organization that evaluates and accredits home health agencies seeking to participate in the medicare and medicaid programs. For the purpose of providing services to ODJFS-administered waiver consumers, CHAP-accredited agencies are “otherwise-accredited agencies” that may provide the same ODJFS-administered waiver services that ACHC-accredited and joint commission-accredited agencies provide.

(P) “Consumer” is an applicant determined financially eligible for medicaid and program-eligible for an ODJFS-administered waiver who is enrolled on an ODJFS-administered waiver.

(Q) “Consumer acknowledgement of risk agreement” is the document created between ODJFS or its designee and the consumer identifying and setting forth the interventions recommended by the case manager to remedy risks to the consumer’s health and welfare.

(R) “Event-based assessment” is a face-to-face comprehensive evaluation of an ODJFS-administered waiver consumer as warranted by a significant change experienced by that consumer.

(S) “Formal services” are paid services provided to a consumer regardless of funding source. Formal services include, but are not limited to, medicare, private insurance, third party insurance, and community-funded services such as those funded by county boards of mental retardation and developmental disabilities (CBMR/DD).

(T) “Group rate” is the amount that certain waiver service providers are reimbursed when the service is provided in a group setting. When providing services in a group setting, the provider must bill using the HQ modifier as described in rule 5101:3-46-06, 5101:3-47-06 or 5101:3-50-06 of the Administrative Code, as applicable.

(U) “Group setting” is a situation in which certain service providers furnish the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODJFS-administered waiver service, or a combination of ODJFS-administered waiver services and similar non-ODJFS-administered waiver services.

(V) “Health and welfare” is a requirement imposed by CMS whereby ODJFS must assure that necessary safeguards are taken to protect the health and welfare of ODJFS-administered waiver consumers. CMS will not grant an ODJFS-administered waiver, and may terminate an existing ODJFS-administered waiver, if ODJFS fails to assure compliance with this requirement. ODJFS meets this requirement, at a minimum, by implementing policies and procedures regarding the following:

(1) Consumer risk and safety planning and evaluations;

(2) Consumer critical incident management;

(3) Housing and environmental safety evaluations;

(4) Consumer behavioral interventions;

(5) Consumer medication management; and

(6) Natural disaster and public emergency response planning.

(W) “ICF-MR level of care” is the institutional level of care set forth in rule 5101:3-3-07 of the Administrative Code.

(X) “Individual cost cap” is the monthly cost of services that is approved by ODJFS for a consumer enrolled in the “Ohio Home Care Waiver,” “Transitions DD Waiver” or “Transitions Carve-Out Waiver.” ODJFS or its designee oversees that the cost of covered services does not exceed the individual cost cap, determines when an increase or decrease in the cap is required, and makes a recommendation with justification to ODJFS for approval for increasing or decreasing the individual cost cap.

(Y) “Informal services” are unpaid services provided to a consumer.

(Z) “Institutional level of care” is any of the levels of care set forth in rules 5101:3-3-05, 5101:3-3-06 and 5101:3-3-07 of the Administrative Code.

(AA) “Institutional setting” is any nursing facility (NF), intermediate care facility for the mentally retarded/developmentally disabled (ICF-MR) or hospital.

(BB) “Instrumental activity of daily living” is a community living skill performed on a regular basis, with or without the use of adaptive and assistive devices, that enables a consumer to independently manage his or her living arrangement as defined in rule 5101:3-3-08 of the Administrative Code.

(CC) “Intermediate level of care (ILOC)” is the institutional level of care set forth in rule 5101:3-3-06 of the Administrative Code.

(DD) “Joint commission” is a national organization that evaluates and accredits home health agencies that seek to participate in the medicare and medicaid programs. For the purpose of providing services to ODJFS-administered waiver consumers, joint commission-accredited agencies are “otherwise-accredited agencies” that may provide the same ODJFS-administered waiver services that ACHC-accredited and CHAP-accredited agencies provide.

(EE) “Legally responsible family member,” as that term is used in the Ohio home care waiver set forth in Chapter 5101:3-46 of the Administrative Code, the transitions DD waiver set forth in Chapter 5101:3-47 of the Administrative Code, and the transitions carve-out waiver set forth in Chapter 5101:3-50 of the Administrative Code, is a consumer’s spouse, or in the case of a minor, the consumer’s birth or adoptive parent, or foster caregiver.

(FF) “Medical necessity” and “medically necessary” have the same meaning as set forth in rule 5101:3-1-01 of the Administrative Code.

(GG) “Medicare-certified home health agency” is any entity, agency or organization that has and maintains medicare certification as a home health agency, and is eligible to participate in the medicaid program upon execution of a medicaid provider agreement in accordance with rule 5101:3-1- 17.2 of the Administrative Code.

(HH) “Non-agency waiver service provider” is an independent provider who is not employed by an agency, and who is eligible to participate in the medicaid program upon execution of a medicaid provider agreement in accordance with rule 5101:3-1- 17.2 of the Administrative Code.

(II) “Noninstitutional setting” is any setting that is not a NF, ICF-MR or hospital.

(JJ) “Non-legally responsible family member,” as that term is used in the Ohio home care waiver set forth in Chapter 5101:3-46 of the Administrative Code, the transitions DD waiver set forth in Chapter 5101:3-47 of the Administrative Code, and the transitions carve-out waiver set forth in Chapter 5101:3-50 of the Administrative Code, is a member of the consumer’s family, excluding the consumer’s spouse, or in the case of a minor, the consumer’s birth or adoptive parent, or foster caregiver.

(KK) “ODJFS” is the Ohio department of job and family services.

(LL) “ODJFS-administered waiver program” is the Ohio home care program benefit package that consists of home and community-based service waivers administered by ODJFS in accordance with Chapter 5101:3-45 of the Administrative Code, and Chapter 5101:3-46, 5101:3-47 and/or 5101:3-50 of the Administrative Code, as applicable.

(MM) “ODJFS-administered waiver provider” is an agency or non-agency provider eligible to provide ODJFS-administered waiver services upon execution of a medicaid provider agreement in accordance with rule 5101:3-1- 17.2 of the Administrative Code.

(NN) “Ohio Home Care Waiver” is a CMS-approved home and community-based services waiver administered by ODJFS that serves consumers in accordance with Chapters 5101:3-45 and 5101:3-46 of the Administrative Code.

(OO) “Otherwise-accredited agency” is an agency that has and maintains accreditation by a national accreditation organization for the provision of home health services, private duty nursing, personal care services and support services upon execution of a medicaid provider agreement in accordance with rule 5101:3-1- 17.2 of the Administrative Code. The national accreditation organization shall be approved by CMS, and shall include, but not be limited to: ACHC, CHAP and the joint commission.

(PP) “Program eligibility assessment tool (PEAT)” is the ODJFS-developed tool used during a face-to-face interview with an applicant or consumer as part of the ODJFS-administered waiver program eligibility determination/redetermination process.

(QQ) “Plan of care” is the medical treatment plan that is established, approved and signed by the treating physician. The plan of care must be signed and dated by the treating physician prior to requesting reimbursement for a service. The plan of care is not the same as the all services plan.

(RR) “Request for Medicaid Home and Community-Based Services” and “JFS 02399 Request for Medicaid Home and Community-Based Services” mean the form an applicant must complete and submit to the CDJFS requesting an eligibility determination for enrollment in an ODJFS-administered waiver

(SS) “Residential address” is any physical dwelling with a unique mailing address where an ODJFS-administered waiver consumer lives. A residential address shall include, but is not limited to an apartment within an apartment complex. It shall not include the entire apartment building or complex.

(TT) “Significant change” is a change experienced by a consumer that warrants an event-based assessment. Significant changes include, but are not limited to, a change in health status, caregiver status, and location/residence; referral to or active involvement on the part of a protective service agency; institutionalization; and when the consumer has not received waiver services for ninety calendar days.

(UU) “Skilled level of care (SLOC)” is the institutional level of care set forth in rule 5101:3-3-05 of the Administrative Code.

(VV) “Transitions Carve-Out Waiver” is a CMS-approved home and community-based services waiver administered by ODJFS that serves consumers in accordance with Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(WW) “Transitions DD Waiver” is a CMS-approved home and community-based services waiver administered by ODJFS that serves consumers in accordance with Chapters 5101:3-45 and 5101:3-47 of the Administrative Code.

Effective: 10/25/2010

R.C. 119.032 review dates: 10/01/2014

Promulgated Under: 119.03

Statutory Authority: 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85

Prior Effective Dates: 5/1/98, 9/29/00, 3/1/02 (Emer), 5/30/02, 7/1/06, 2/15/07, 10/26/09, 7/1/10