Chapter 5101:3-51 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program. The following definitions are applicable to Chapter 5101:3-51 of the Administrative Code:

(A) “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.

(B) “Agency provider” is an agency that is eligible to participate in the HOME choice demonstration program.

(C) “All service plan” is the ODJFS-administered waiver 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 service 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 service plan is not the same as the physician’s plan of care.

(D) “Authorized representative”

(1) For a HOME choice demonstration program participant enrolled on an ODJFS-administered waiver, authorized representative has the same meaning as set forth in rule 5101:3-45-01 of the Administrative Code;

(2) For a HOME choice demonstration program participant enrolled on the ODA-administered choices waiver, authorized representative has the same meaning as set forth in rule 173-37-01 of the Administrative Code;

(3) For a HOME choice demonstration program participant enrolled on the ODA-administered PASSPORT waiver, authorized representative has the same meaning as set forth in rule 173-42-01 of the Administrative Code;

(4) For a HOME choice demonstration program participant enrolled on an ODMR/DD-administered waiver, authorized representative has the same meaning as set forth in rule 5101:1-2-01 of the Administrative Code; and

(5) For a HOME choice demonstration program participant who is not enrolled on an HCBS waiver, authorized representative has the same meaning as set forth in rule 5101:3-45-01 of the Administrative Code.

(E) “Case management agency” or “CMA” is the entity under contract with ODJFS that provides case management services to consumers enrolled on an ODJFS-administered waiver.

(F) “Case manager” or “CM” is the CMA or PAA employee who provides a variety of case management services and care coordination activities for individuals enrolled on an ODJFS- or ODA-administered waiver.

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

(H) “Choices waiver program” or “choices” is the CMS-approved HCBS waiver program administered by ODA in accordance with Chapters 5101:3-31 and 173-37 of the Administrative Code.

(I) “Classroom rate” is the amount that HOME choice independent living skills training service providers are reimbursed when the service is provided in a classroom setting. The rate is equivalent to fifty per cent of the reimbursement rate set forth in rule 5101:3-51-06 of the Administrative Code that is paid to a provider for furnishing HOME choice independent living skills training services to a single individual.

(J) “Classroom setting” is a situation in which a HOME choice independent living skills training service provider furnishes the same type of services to four or more individuals at the same address, during the same visit. The services provided in the classroom setting can be either the same type of HOME choice independent living skills training service, or a combination of HOME choice independent living skills training services and similar independent living skills training services.

(K) “County board” means a county board of mental retardation and developmental disabilities established under Chapter 5126. of the Revised Code, or a person or government entity, including a council of governments, with which a county board has contracted for assistance with its local medicaid administrative authority pursuant to division (E) of section 5126.055 of the Revised Code. The county board provides case management services to consumers enrolled on an ODMR/DD-administered waiver.

(L) “Demonstration services” are services available to the HOME choice demonstration program participant for up to three hundred sixty-five days beginning on the day a participant moves from an institutional setting into the community. Demonstration services include independent living skills training, community support coaching, social work/counseling, nutritional consultation services and HOME choice nursing services. Ohio is entitled to enhanced federal financial participation (FFP) from CMS for demonstration services.

(M) “Financial management services” or “FMS” are federally-mandated administrative services that an ODJFS-designated governmental entity and/or another ODJFS-designated third-party entity perform on behalf of the HOME choice demonstration program participant.

(N) “Group rate” is the amount that HOME choice demonstration program nursing service providers, or HOME choice independent living skills training service providers are reimbursed when the service is provided in a group setting. The rate is equivalent to seventy-five per cent of the reimbursement rate set forth in rule 5101:3-51-06 of the Administrative Code that is paid to a provider for delivering the HOME choice nursing services or HOME choice independent living skills training services to a single individual.

(O) “Group setting” is a situation in which a HOME choice demonstration nursing service provider, or the HOME choice independent living skills training service provider furnishes the same type of services to two or three individuals at the same address, during the same visit. The services provided in the group setting can be either the same type of HOME choice nursing service or HOME choice independent living skills training service, or a combination of HOME choice nursing services and similar nursing services, or HOME choice independent living skills training services and similar independent living skills training services.

(P) “Home and community-based services” or “HCBS” means medicaid-funded home and community-based services as set forth in Chapter 5111. of the Revised Code.

(Q) “HOME choice demonstration program” means “Helping Ohioans Move, Expanding Choice.”

(R) “HOME choice demonstration program application” is a formal request for a determination of HOME choice demonstration program eligibility that is made by an individual who is relocating from an institutional setting into the community. The ODJFS-approved application must be signed by the individual or the individual’s authorized representative.

(S) “HOME choice demonstration program participant” is a person receiving HOME choice demonstration program services who may or may not be enrolled on a CMS-approved HCBS waiver.

(T) “HOME choice demonstration program period” is the three hundred sixty-five day period that begins the day an individual moves from an institutional setting into the community, and during which the HOME choice demonstration program participant is eligible for HOME choice demonstration program services.

(U) “HOME choice demonstration program services” are pre-transition, demonstration, qualified, and supplemental services available through the HOME choice demonstration program.

(V) “ICF-MR” is an intermediate care facility for persons with mental retardation.

(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 options waiver” or “IO waiver” is a CMS-approved HCBS waiver administered by the Ohio department of mental retardation and developmental disabilities (ODMR/DD) in accordance with Chapters 5101:3-40, 5123:2-9 and 5123:2-13 of the Administrative Code.

(Y) “Individual service plan” or “ISP” is a written description of the services, supports and activities to be provided to a consumer enrolled on an ODMR/DD-administered waiver. The ISP is not the same as the physician’s plan of care.

(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 hospital, nursing facility (NF) or ICF-MR. Hospitals include institutions for mental diseases (IMD) only to the extent that medical assistance is available under the medicaid state plan for services provided by such institutions.

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

(DD) “Level one waiver” is a CMS-approved HCBS waiver administered by ODMR/DD in accordance with Chapters 5101:3-42, 5123:2-8 and 5123:2-9 of the Administrative Code.

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

(FF) “Non-agency provider” is an independent provider who is not employed by an agency, and who is eligible to participate in the HOME choice demonstration program.

(GG) “Non-waiver HOME choice demonstration program service plan” is the service coordination and payment authorization document that identifies the services, supports and activities to be provided to a HOME choice demonstration program participant who is not enrolled on an HCBS waiver. The non-waiver HOME choice demonstration program service plan is not the same as the physician’s plan of care.

(HH) “ODA” is the Ohio department of aging.

(II) “ODA-administered waiver” is a CMS-approved HCBS waiver administered by the Ohio department of aging in accordance with Chapters 5101:3-31, 5101:3-32, 173-37 and 173-42 of the Administrative Code.

(JJ) “ODJFS-administered waiver program” is the Ohio home care program benefit package that consists of CMS-approved HCBS waivers administered by ODJFS in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code and Chapters 5101:3-45, 5101:3-46, 5101:3-47 and 5101:3-50 of the Administrative Code.

(KK) “ODJFS HOME choice demonstration program care coordinator” is a person employed by ODJFS for the purpose of providing case management and care coordination services to HOME choice demonstration program participants who are not enrolled on an HCBS waiver.

(LL) “ODMR/DD” is the Ohio department of mental retardation and developmental disabilities.

(MM) “ODMR/DD-administered waiver” is a CMS-approved HCBS waiver administered by ODMR/DD in accordance with section 5111.871 of the Revised Code and Chapters 5101:3-40, 5101:3-42, 5123:2-8, 5123:2-9 and 5123:2-13 of the Administrative Code.

(NN) “Ohio home care waiver” is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code, and Chapters 5101:3-45 and 5101:3-46 of the Administrative Code.

(OO) “PAA” means the local PASSPORT administrative agency that provides case management services to consumers enrolled on an ODA-administered waiver.

(PP) “PASSPORT waiver program” means the CMS-approved PASSPORT HCBS waiver program administered by ODA in accordance with Chapters 5101:31 and 173-42 of the Administrative Code.

(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 by the treating physician prior to when a provider requests reimbursement for a service. The plan of care is not the same as the all services plan, service plan or ISP, if the participant is enrolled on an ODJFS- , ODA- or ODMR/DD-administered waiver, respectively, or the non-waiver HOME choice demonstration program service plan if the HOME choice demonstration program participant is not enrolled on an HCBS waiver.

(RR) “Pre-transition services” are administrative activities and supplemental services that can be provided to a HOME choice demonstration program participant up to one hundred eighty days before the participant moves from a NF, ICF-MR or hospital into the community. Pre-transitional services and activities include transition coordination services and community transitions services.

(SS) “Qualified residence” is:

(1) A home owned or leased by the HOME choice demonstration program participant or the HOME choice demonstration program participant’s family member;

(2) An apartment with an individual lease, that has lockable access and egress, and which includes living, sleeping, bathing and cooking areas over which the HOME choice demonstration program participant or the HOME choice demonstration program participant’s family has domain and control. An apartment includes only the following:

(a) A private apartment,

(b) A public housing unit, or

(c) Residential care facility units designated for assisted living that meet the requirements of paragraph (SS)(2) of this rule; or

(3) A residence in a community-based residential setting in which no more than four unrelated individuals reside. A community-based residential setting only includes the following:

(a) Adult foster homes,

(b) Adult family homes,

(c) HCBS adult foster care certified by ODMR/DD,

(d) Supported living arrangements for individuals with MR/DD who receive services through an ODMR/DD-administered waiver,

(e) Non-ICF-MR residential facilities licensed by ODMR/DD,

(f) Type 1 residential facilities licensed by the Ohio department of mental health (ODMH),

(g) Type 2 residential facilities licensed by ODMH,

(h) Foster homes for children that are certified by ODJFS,

(i) Medically fragile foster homes for children that are certified by ODJFS, or

(j) Group homes for children that are licensed or certified by ODJFS.

(TT) “Qualified home and community-based program” or “qualified HCB program” is the medicaid service package that shall be made available to a HOME choice demonstration program participant when the participant moves from an institutional setting into the community, and which will remain in effect at the conclusion of the HOME choice demonstration program. Qualified HCB programs include: HCBS waivers and the medicaid state plan.

(UU) “Qualified services” are existing waiver services, as well as the medicaid state plan services that have been determined by ODJFS to be non-acute, long term support services. They do not include demonstration and supplemental services.

(VV) “Service and support administrator” or “SSA” is a county board of MR/DD employee who provides a variety of coordination activities for individuals enrolled on an ODMR/DD-administered waiver in accordance with section 5126.15 of the Revised Code.

(WW) “Service plan” is the written outline of an ODA-administered waiver consumer’s services, including certified long term care services and all other services regardless of funding source. The service plan is not the same as the physician’s plan of care.

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

(YY) “Supplemental services” are HOME choice demonstration program services that are available to the HOME choice demonstration program participant during the three hundred sixty-five day demonstration period after a participant moves from an institution to the community that are not entitled to enhanced FFP. Supplemental services include:

(1) Communication aid services as set forth in paragraph (F) of rule 5101:3-51-04 of the Administrative Code; and

(2) Service animal services as set forth in paragraph (G) of rule 5101:3-51-04 of the Administrative Code.

(ZZ) “Transitions Carve-Out Waiver” is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code, and Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(AAA) “Transitions MR/DD Waiver” is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with rules 5101:3-12-28 to 5101:3-12-30 of the Administrative Code, and Chapters 5101:3-45 and 5101:3-47 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

The HOME choice demonstration program is a multi-system demonstration funded through a CMS money follows the person (MFP) demonstration grant. The HOME choice demonstration program transitions qualifying individuals currently residing in nursing facilities, ICFs-MR and hospitals to a community setting. The HOME choice demonstration program provides additional services to enhance existing medicaid state plan and home and community-based services (HCBS) that will enable qualified consumers to safely and successfully integrate into community life. The HOME choice demonstration program shall begin when ODJFS receives approval of the HOME choice demonstration program from CMS, or on the effective date of this rule, whichever is later, and open enrollment shall end on September 30, 2011. Any participant who qualifies prior to September 30, 2011 shall be entitled to receive HOME choice demonstration program services for three hundred sixty-five days beginning on the day the participant moves from an institutional setting into the community.

(A) To be eligible for the HOME choice demonstration program, an individual:

(1) Must continuously reside in a NF, ICF-MR and/or hospital, or a combination thereof, for a period of at least six months. If the hospital is an institution for mental diseases, the individual must be under age twenty-one or over age sixty-five.

(2) Must be receiving medicaid benefits for inpatient services furnished by the institutional setting for at least thirty days prior to discharge from the NF, ICF-MR or hospital.

(3) Must have an institutional level of care as defined in rule 5101:3-51-01 of the Administrative Code.

(4) Must be determined eligible for Ohio medicaid in accordance with rule 5101:1-38-01.6 of the Administrative Code.

(5) May be enrolled on an ODJFS- , ODA- or ODMR/DD-administered HCBS waiver.

(6) Must have available housing in a qualified residence in the community prior to leaving the institutional setting.

(7) Must agree to participate in the HOME choice demonstration program by signing an ODJFS-approved HOME choice demonstration program informed consent form.

(8) Must participate in the development of an all service plan, service plan or individual service plan (ISP) if the individual is enrolled on an ODJFS- ODAor ODMR/DD-administered HCBS waiver, respectively, or a non-waiver HOME choice service plan if the individual is not enrolled on an HCBS waiver.

(9) Must accept the all service plan, service plan, ISP or non-waiver HOME choice service plan, as appropriate, by signing and dating the plan.

(10) Must agree to participate in quality management and evaluation activities during the individual’s tenure in the HOME choice demonstration program, and for up to one year after completion of the HOME choice demonstration period.

(B) If an individual fails to meet any of the required eligibility criteria set forth in paragraph (A) of this rule, the individual shall be denied enrollment on the HOME choice demonstration program. In such instances, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(C) Except for pre-transition services, an individual enrolled on the HOME choice demonstration program shall be eligible for qualified, demonstration and supplemental HOME choice demonstration program services for three hundred sixty-five days beginning on the day the individual moves from the institutional setting into the community.

(D) If, at any time, an individual enrolled on the HOME choice demonstration program ceases to meet any of the required eligibility criteria set forth in paragraph (A) of this rule, the individual shall be disenrolled from the HOME choice demonstration program. In such instances, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(E) If, at any time, an individual enrolled on the HOME choice demonstration program fails to meet the criteria for any HOME choice demonstration program service(s) established on his or her all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, and as those services are defined in rule 5101:3-51-04 of the Administrative Code, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(F) If an individual is enrolled on an HCBS waiver and fails to meet the criteria for HCBS waiver services and/or medicaid state plan services as established on his or her all services plan, service plan, or ISP, as appropriate, the individual shall be afforded notice and hearing rights in accordance with the procedures set forth by the state agency administering the specific HCBS waiver.

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

This rule sets forth the conditions of participation for providers furnishing demonstration, supplemental and qualified services to HOME choice demonstration program participants.

(A) Demonstration and supplemental services.

(1) All providers of demonstration and supplemental services to participants enrolled on the HOME choice demonstration program shall:

(a) Meet all requirements in the applicable provider service specifications set forth in rule 5101:3-51-04 of the Administrative Code, and provider enrollment criteria set forth in rule 5101:3-51-05 of the Administrative Code.

(b) As applicable, comply with the criminal records check requirements set forth in:

(i) Rules 5101:3-45-07 and 5101:3-45-08 of the Administrative Code if the provider is approved by ODJFS;

(ii) Rule 173-41-01 of the Administrative Code if the provider is certified by the Ohio department of aging (ODA);

(iii) Rule 5123:2-1-05 or 5123:2-1-05.1 of the Administrative Code, as applicable, if the provider is certified by the Ohio department of mental retardation and developmental disabilities (ODMR/DD); or

(iv) Rules 5122-30-03 and 5122-30-04 of the Administrative Code, or rule 5122-26-06 of the Administrative Code, as applicable, if the provider is certified by the Ohio department of mental health (ODMH).

(c) Attend ODJFS-sponsored HOME choice demonstration program provider training sessions.

(d) Assure participants receive HOME choice demonstration program services in accordance with their all service plan, service plan, individual service plan (ISP) or non-waiver HOME choice demonstration service plan, as appropriate.

(e) Upon request and within the timeframe prescribed in the request, provide all information to the state agency administering the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or ODJFS if the HOME choice demonstration program participant is not enrolled on an HCBS waiver, and to CMS and the entity under contract with ODJFS to provide HOME choice financial management services (FMS).

(f) Comply with all federal and state privacy laws, including the health insurance portability and accountability act (HIPAA) regulations set forth in 45 C.F.R. parts 160, 162 and 164 (as in effect on the effective date of this rule), and the medicaid confidentiality regulations as set forth in 42 C.F.R. 421.300 to 306 (as in effect on the effective date of this rule), and sections 5101.26 to 5101.28 of the Revised Code.

(g) Maintain and retain all required documentation. For each unit of service furnished, the provider shall clearly document what service was provided and obtain the signature of the participant on the dated document.

(h) Retain all records of service delivery and billing for a period of six years after the date of receipt of the payment based upon those records or until any initiated audit is completed, whichever is longer.

(i) Cooperate with ODJFS and the FMS provider under contract with ODJFS during any quality assurance activities to monitor the provider’s performance, including providing space for and being able to answer questions during onsite reviews, and making all requested information available promptly.

(j) Notify the case manager (CM), the service and support administrator (SSA) or ODJFS HOME choice demonstration program care coordinator, as appropriate, within twenty-four hours and provide written documentation within five calendar days when the provider is aware of significant changes that may affect the service needs of the participant. Significant changes that may affect the service needs of the participant include, but are not limited to:

(i) The participant consistently declines services.

(ii) The participant moves to another residential setting.

(iii) Changes in the physical, mental and/or emotional status of the participant, changes in environmental conditions, and/or other health and welfare issues.

(iv) Abuse or neglect of the participant is suspected.

(k) Submit written notification to the participant and the FMS provider under contract with ODJFS, and the CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, at least fourteen calendar days prior to the anticipated last date of the service if the provider is terminating the provision of HOME choice demonstration program services to the participant. Exceptions to this requirement include:

(i) Fourteen-day advanced notification is not required when the participant has been hospitalized, placed in a long term care facility, or has expired.

(ii) The fourteen-day advanced notification may be waived for the provider by the CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, on a case-by-case basis.

(iii) Advanced notification of service termination is not required if the participant is terminating the services of the provider.

(2) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODA-administered waiver, providers shall comply with the consumer incident reporting requirements set forth in rule 173-39-02 of the Administrative Code.

(3) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODMR/DD-administered waiver, or who are not enrolled on an HCBS waiver but are eligible for services through a county board of mental retardation and developmental disabilities (CBMR/DD), providers shall comply with the major unusual incident requirements set forth in rule 5123:2-17-02 of the Administrative Code.

(4) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODJFS-administered waiver, providers shall comply with the consumer incident reporting requirements set forth in rule 5101:3-12-29 of the Administrative Code.

(5) Providers furnishing HOME choice demonstration program services to participants who are not enrolled on an HCBS waiver, or who are not eligible for services through a CBMR/DD, providers shall comply with the consumer incident reporting requirements set forth in rule 5101:3-12-29 of the Administrative Code

(6) Agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements.

(7) Non-agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. On an annual basis, non-agency providers must also submit an ODJFS-approved affidavit stating that they paid the applicable federal, state and local income and employment taxes.

(8) All providers shall deliver services professionally, respectfully, and legally, and during the provision of authorized services, shall not engage in unprofessional, disrespectful or illegal behavior that includes, but is not limited to, the following:

(a) Consuming the participant’s food and/or drink, or using the participant’s personal property without the participant’s offer and consent.

(b) Bringing children, pets, friends, relatives or anyone else to the participant’s place of residence.

(c) Taking the participant to the provider’s place of residence.

(d) Consuming alcohol, medicine, drugs or other chemical substances not in accordance with the legal, valid, prescribed use and/or in any way that impairs the provider in the delivery of services to the participant.

(e) Discussing religion or politics with the participant and others present in the care setting.

(f) Discussing providers’ personal issues with the participant and others in the care setting.

(g) Accepting, obtaining or attempting to obtain money or anything of value, including gifts or tips from the participant, household members and family members of the participant.

(h) Engaging with the participant in sexual conduct, or in conduct that may reasonably be interpreted as sexual in nature, regardless of whether or not the contact is consensual.

(i) Leaving the home for a purpose not related to the provision of services without notifying the agency supervisor, the participant’s emergency contact person, identified caregiver and/or CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate.

(j) Using the participant’s motor vehicle, unless used solely for the benefit of the participant.

(k) Engaging in activities that may distract from service delivery including, but not limited to:

(i) Watching television or playing computer or video games.

(ii) Making or receiving personal calls.

(iii) Engaging in non-care-related socialization with individuals other than the participant.

(iv) Providing care to individuals other than the participant.

(v) Smoking without the consent of the participant.

(vi) Sleeping.

(9) HOME choice demonstration program providers shall not:

(a) Engage in behavior that causes or may cause physical, verbal, mental or emotional distress or abuse to the participant.

(b) Engage in behavior that may reasonably be interpreted as inappropriate involvement in the participant’s personal relationships.

(c) Be designated to serve or make decisions for the participant in any capacity involving a declaration for mental health treatment, durable power of attorney, financial power of attorney, or guardianship pursuant to court order.

(d) Sell to or purchase from the participant products or personal items. The only exception to this would be family members when not delivering services.

(e) Engage in behavior that constitutes a conflict of interest or takes advantage of or manipulates the HOME choice demonstration program rules set forth in Chapter 5101:3-51 of the Administrative Code, resulting in an unintended advantage for personal gain; or that has detrimental results for the participant, the family, caregiver and/or another provider.

(B) Qualified services.

(1) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODMR/DD shall meet the assurances set forth in rules 5123:2-9-08 and 5123:2-9-09 of the Administrative Code.

(2) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODA shall meet the conditions of participation established for ODA-administered waivers set forth in rule 173-39-02 of the Administrative Code.

(3) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODJFS shall meet the conditions of participation established for ODJFS-administered waivers as set forth in rule 5101:3-45-10 of the Administrative Code.

(4) Providers furnishing qualified services to HOME choice demonstration program participants who are not enrolled on an HCBS waiver shall meet the same conditions of participation set forth for ODJFS-administered waiver service providers as described in rule 5101:3-45-10 of the Administrative Code.

(C) Failure to meet the requirements set forth in this rule may result in termination of the HOME choice demonstration program provider’s provider agreement in accordance with rule 5101:3-1-17.6 of the Administrative Code. The provider shall be entitled to a hearing under Chapter 119. of the Revised Code in accordance with Chapter 5101:6-50 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

This rule sets forth the definitions of the covered services and some program service limitations available to a HOME choice demonstration program participant. This rule also sets forth the provider requirements and specifications for the delivery of HOME choice demonstration program services. The HOME choice demonstration program participant shall have choice and control over the selection of his or her provider of services, and the direction over the provision of the services. HOME choice demonstration program services are reimbursed in accordance with rule 5101:3-51-06 of the Administrative Code.

(A) “Independent living skills training” is information and educational supports and resources provided to a HOME choice demonstration program participant or group of HOME choice demonstration program participants for the purpose of developing or increasing skills, knowledge or abilities needed to live more independently. Independent living skills training services can be furnished individually, or in a group setting or classroom setting as those terms are defined in rule 5101:3-51-01 of the Administrative Code.

(1) Training focuses on:

(a) Financial management skills including, but not limited to:

(i) Finding a bank and establishing an account,

(ii) How to pay bills and taxes,

(iii) Personal budgeting,

(iv) How to manage entitlements and insurance,

(v) How to use a bank machine,

(vi) Understanding credit, and

(vii) Understanding contracts;

(b) Social skills development including, but not limited to:

(i) Communication skill building,

(ii) How to be a good neighbor/roommate,

(iii) How to work with providers, and

(iv) How to know when and how to ask for help;

(c) Health management skills including, but not limited to:

(i) How to efficiently manage nutrition and diet,

(ii) How to talk to the doctor,

(iii) Training service providers,

(iv) Managing and accessing medical supplies,

(v) Crisis care/recovery services,

(vi) Linking to medical/dental services,

(vii) Assessing the need for, and accessing, adaptive and assistive devices,

(viii) Continuing therapies,

(ix) Emergency preparedness, and

(x) Medication management;

(d) Home management skills including, but not limited to:

(i) Personal shopping,

(ii) Housekeeping and laundry,

(iii) Grocery shopping, cooking and meal planning,

(iv) How to request and/or complete simple repairs,

(v) Safety skills at home, and

(vi) Operating simple technology;

(e) Personal skills including, but not limited to:

(i) Daily functions such as hygiene, dressing and undressing,

(ii) Scheduling, and

(iii) Utilization of leisure/education/physical/emotional activities; and

(f) Community living skills including, but not limited to:

(i) Travel training,

(ii) How to negotiate transportation systems and arrange transportation,

(iii) Identifying and accessing existing community resources,

(iv) Job training and seeking employment opportunities,

(v) Linking to legal resources, and

(vi) Safety skills in the community.

(2) Independent living skills training shall not duplicate community support coaching services available through the HOME choice demonstration program. In addition, independent living skills training shall not duplicate similar waiver or administrative services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled.

(3) If the HOME choice demonstration program participant is enrolled on an ODMR/DD-administered waiver, the HOME choice demonstration program participant must access homemaker/personal care in lieu of independent living skills training.

(4) The independent living skills training provider shall, as a function of the service, provide the entity responsible for assisting the HOME choice demonstration program participant with the development of his or her all service plan, service plan or non-waiver HOME choice demonstration program service plan, as appropriate, with written status reports during the HOME choice demonstration program participant’s transition, as prescribed by the plan.

(5) In order to submit a claim for reimbursement of independent living skills training, the independent living skills training provider delivering the service:

(a) Must be either a community mental health center certified by the Ohio department of mental health (ODMH) in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or a non-profit agency provider,

(i) Whose staff with direct participant contact:

(a) May have either:

(i) A disability and lived in an institution and successfully transitioned to the community, and/or

(ii) Experience transitioning individuals from an institution to the community, and

(b) Must have knowledge and experience about:

(i) Local community resources,

(ii) Applicable disability laws and regulations, and

(c) Are age eighteen or older; and

(ii) Whose staff that provide transportation:

(a) Possess a valid Ohio driver’s license, and

(b) Possess valid automobile liability insurance;

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code;

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable;

(d) Must be identified as the provider, and have specified on the participant’s all service plan, service plan or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish independent living skills training services to the participant; and

(e) Must be providing the service to one individual, or to two or three individuals in a group setting, or four or more individuals in a classroom setting, during the same face-to-face visit.

(B) “Community support coaching” is a service provided for the purpose of guiding, educating and empowering the HOME choice demonstration program participant, authorized representative and family members during the HOME choice demonstration program participant’s transition from an institution into the community.

(1) The community support coach shall:

(a) Communicate with and educate the HOME choice demonstration program participant in vital aspects of the transition process;

(b) Assist the HOME choice demonstration program participant in:

(i) Making informed and independent choices,

(ii) Setting and achieving short and long-term goals,

(iii) Managing multiple tasks, and

(iv) Identifying options and problem solving;

(c) Provide one-on-one coaching;

(d) Provide follow-up coaching during and after the transition;

(e) Inform and advise the HOME choice demonstration program participant in such a manner that empowers, but protects, the participant from being taken advantage of in the community;

(f) Assist with the identification of community resources and linkages to be used by the HOME choice demonstration program participant; and

(g) Provide the entity responsible for assisting the HOME choice demonstration program participant with the development of his or her all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, with written status reports during the HOME choice demonstration program participant’s transition, as prescribed by the all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan.

(2) Community support coaching shall include assistance after normal business hours when the HOME choice demonstration program participant is not enrolled on an HCBS waiver and is only receiving medicaid state plan services.

(3) Community support coaching shall not duplicate independent living skills training available through the HOME choice demonstration program. In addition, community support coaching shall not duplicate similar waiver or administrative services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled.

(4) In order to submit a claim for reimbursement of community support coaching, the community support coach provider delivering the service:

(a) Must be:

(i) A non-agency provider who:

(a) May have either:

(i) A disability and lived in an institution and successfully transitioned to the community, and/or

(ii) Experience transitioning individuals from an institution to the community; and

(b) Is age eighteen or older, and

(c) Possesses a valid Ohio driver’s license, and

(d) Possesses valid automobile liability insurance, and

(e) Is not the participant’s legally responsible family member as that term is defined in rule 5101:3-51-01 of the Administrative Code, and

(f) Is not the participant’s case manager (CM), service and support administrator (SSA), or HOME choice demonstration program care coordinator, as those terms are defined in rule 5101:3-51-01 of the Administrative Code; or

(ii) Either a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or a non-profit agency provider,

(a) Whose staff with direct participant contact:

(i) May have either:

(A) A disability and lived in an institution and successfully transitioned to the community; and/or

(B) Experience transitioning individuals from an institution to the community; and

(ii) Are age eighteen or older, and

(b) Whose staff that provide transportation:

(i) Possess a valid Ohio driver’s license, and

(ii) Possess valid automobile liability insurance;

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code;

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable; and

(d) Must be identified as the provider, and have specified on, the participant’s all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish community support coaching services to the participant.

(C) “HOME choice nursing services” are intermittent services provided to HOME choice demonstration program participants that require the skills of a registered nurse (RN) or licensed practical nurse (LPN) at the direction of an RN. All nurses providing HOME choice nursing services shall provide services within the nurse’s scope of practice as set forth in Chapter 4723. of the Revised Code and rules of the Administrative Code adopted thereunder, and shall possess a current, valid and unrestricted license with the Ohio board of nursing.

(1) HOME choice nursing services do not include:

(a) Services delegated in accordance with Chapter 4723. of the Revised Code and rules of the Administrative Code adopted thereunder and to be performed by individuals who are not licensed nurses in accordance with Chapter 4723. of the Revised Code;

(b) Services that require the skills of a psychiatric nurse; or

(c) Services performed in excess of the number of hours approved pursuant to the HOME choice demonstration program participant’s service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(2) HOME choice nursing services shall not duplicate similar waiver or administrative services available on the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or medicaid state plan home health nursing and/or private duty nursing services.

(3) In order to submit a claim for reimbursement of HOME choice nursing services, the RN, or LPN at the direction of an RN, delivering the service:

(a) Must be employed by a medicare-certified, or otherwise-accredited home health agency, or be a non-agency home care nurse provider;

(b) Must not be the participant’s spouse, or in the case of a minor, the participant’s birth or adoptive parent, unless the family member is employed by a medicare-certified, or otherwise-accredited home health agency;

(c) Must not be the foster caregiver of the HOME choice demonstration program participant;

(d) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code;

(e) Must meet the provider enrollment criteria set forth in paragraph (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable;

(f) Must be identified as the provider, and have specified on, the participant’s service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish HOME choice nursing services to the participant;

(g) Must be performing HOME choice nursing services pursuant to the participant’s plan of care, as that term is defined in rule 5101:3-51-01 of the Administrative Code; and

(h) Must be providing the service for one individual during a face-to-face visit, or for two or three individuals in a group setting during the same face-to-face visit.

(4) Non-agency LPNs, at the direction of an RN, must:

(a) Conduct a face-to-face visit with the directing RN at least every sixty days after the initial visit to evaluate the provision of HOME choice nursing services and LPN performance, and to assure that HOME choice nursing services are being provided in accordance with the approved plan of care; and

(b) Conduct a face-to-face visit with the participant and the directing RN no less than once every one hundred twenty days for the purpose of evaluating the provision of HOME choice nursing services, the participant’s satisfaction with care delivery, and LPN performance, and to assure that HOME choice nursing services are being provided in accordance with the approved plan of care.

(5) All HOME choice nursing service providers must maintain a clinical record for each participant served in a manner that protects the confidentiality of these records. Medicare-certified, or otherwise-accredited home health agencies, must maintain the clinical records at their place of business. Non-agency HOME choice nursing service providers must maintain the clinical records at their place of business, and maintain a copy in the participant’s residence. For the purposes of this rule, the place of business must be a location other than the participant’s residence. The clinical record must contain the information listed in paragraphs (C)(5)(a) to (C)(5)(l) of this rule.

(a) Participant identifying information, including but not limited to: name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers.

(b) Participant medical history.

(c) Name of participant’s treating physician.

(d) A copy of the initial and all subsequent service plans, ISPs or non-waiver HOME choice demonstration program service plans, as appropriate.

(e) A copy of the initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the HOME choice nursing services being performed. When services are performed by an LPN at the direction of an RN, the clinical record shall include documentation that the RN has reviewed the plan of care with the LPN. The plan of care must be recertified by the treating physician every sixty days, or more frequently if there is a significant change in the participant’s condition.

(f) In all instances when the treating physician gives verbal orders to the nurse, the nurse must document, in writing, the physician’s orders, the date and time the orders were given, and sign the entry in the clinical record. The nurse must subsequently secure documentation of the verbal orders, signed and dated by the treating physician.

(g) In all instances when a non-agency LPN is providing HOME choice nursing services, the LPN must provide clinical notes, signed and dated by the LPN, documenting face-to-face visits between the LPN and the directing RN, and documenting the face-to-face visits between the LPN, the participant and the directing RN. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(h) Documentation of drug allergies and interactions, and dietary restrictions.

(i) A copy of any advanced directives including, but not limited to, “do not resuscitate order” or medical power of attorney, if they exist.

(j) Clinical notes, signed and dated by the nurse, documenting the services performed during, and outcomes resulting from, each nursing visit. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(k) Clinical notes, signed and dated by the nurse, documenting all communications between the treating physician and other members of the multidisciplinary team.

(l) A discharge summary, signed and dated by the departing nurse, at the point the nurse is no longer going to provide services to the participant, or when the participant no longer needs HOME choice nursing services.

(D) “Social work/counseling services” are transitional services provided to the HOME choice demonstration program participant, authorized representative, caregiver and/or family member on a short-term basis to promote the participant’s physical, social and emotional well-being. Social work/counseling services promote the development and maintenance of a stable and supportive environment for the HOME choice demonstration program participant.

(1) Social work/counseling services can include crisis interventions, grief counseling and/or other social service interventions that support the HOME choice demonstration program participant’s health and welfare.

(2) Social work/counseling services shall not:

(a) Take the place of case management services, nor do they include social services provided to the HOME choice demonstration program participant’s authorized representative, family member(s) and/or caregiver(s) who are unrelated to the HOME choice demonstration program participant;

(b) Duplicate similar services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled; or

(c) Include services provided in excess of what is approved on the participant’s all service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(3) In order to submit a claim for reimbursement of social work/counseling services, the social work/counseling service provider delivering the service:

(a) Must be either:

(i) A non-agency provider who shall:

(a) Be a licensed professional clinical counselor (LPCC), licensed psychologist, licensed independent social worker (LISW) or RN who holds a certificate of authority from the Ohio board of nursing in psych-mental health nursing specialty, and

(b) Maintain documentation of licensure by the applicable Ohio licensure board and have at least one year of social work/counseling experience, or

(ii) An agency provider who shall:

(a) Assure that direct care staff include LPCCs, licensed professional counselors (LPC), licensed psychologists, LISWs, or licensed social workers (LSW),

(b) Assure that LSWs and LPCs are supervised by an LSW with a master’s degree in social work, LISW, LPCC, licensed psychologist, psychiatrist, licensed physician, or an RN who holds a certificate of authority from the Ohio board of nursing in a psych-mental health nursing specialty, and that the supervisor of an LSW or LPC co-signs all initial assessments and social work/counseling intervention plans prepared by the LSW or LPC, and

(c) Maintain documentation that all direct care social work/counseling staff are licensed by the applicable Ohio licensure board, and have at least one year of social work/counseling experience; and

(b) Must conduct an individual assessment to evaluate the HOME choice demonstration program participant’s psycho-social, financial and environmental status;

(c) Must develop and revise, as necessary, with the assistance of the participant, and/or the participant’s authorized representative, caregiver(s) and the CM or SSA, as appropriate, a treatment plan that includes the recommended method of treatment and the recommended number of counseling sessions;

(d) Must assure the treatment plan is implemented;

(e) Must furnish the CM or SSA, as appropriate, the participant and/or the participant’s authorized representative with a copy of the individual assessment report and the treatment plan no later than seven working days after completion of the individual assessment;

(f) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code; and

(g) Must meet the provider enrollment criteria set forth in paragraph (B), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable; and

(h) Must be identified as the provider, and have specified on the participant’s all service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish social work/counseling services to the participant.

(4) Providers of social work/counseling services must maintain a clinical record for each participant served. The clinical record must contain the information listed in paragraphs (D)(4)(a) to (D)(4)(j) of this rule.

(a) Participant identifying information, including but not limited to name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification information.

(b) Participant medical history.

(c) Name of participant’s treating physician.

(d) A copy of the initial and all subsequent all service plans, ISPs or non-waiver HOME choice demonstration program service plans, as appropriate.

(e) A copy of the initial and all subsequent individual assessments.

(f) A copy of the initial and all revised treatment plans.

(g) A copy of any advanced directives including, but not limited to, “do not resuscitate order” or medical power of attorney, if they exist.

(h) Documentation of drug allergies and interactions, and dietary restrictions.

(i) Documentation that clearly shows the date of social work/counseling service delivery. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(j) A discharge summary, signed and dated by the departing social work/counseling service provider, at the point the service provider is no longer going to provide social work/counseling services to the participant, or when the participant no longer needs social work/counseling services. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups and/or referrals.

(E) “Nutritional consultation services” are services providing guidance to a HOME choice demonstration program participant with special dietary needs, taking into consideration the participant’s cultural and ethnic background and dietary preferences and/or restrictions.

(1) Nutritional consultation services shall not:

(a) Duplicate similar services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled; or

(b) Include services provided in excess of what is approved on the participant’s all service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(2) In order to submit a claim for reimbursement of nutritional consultation services, the nutritional consultation service provider delivering the service:

(a) Must be a dietitian registered by the commission on dietetic registration and licensed by the Ohio board of dietetics;

(b) Must be providing services pursuant to a plan of care for nutritional consultation services that is signed and dated by the treating physician. The plan of care must be recertified by the treating physician every sixty days, or more frequently if there is a significant change in the participant’s condition;

(c) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code;

(d) Must meet the provider enrollment criteria set forth in paragraph (B), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable; and

(e) Must be identified as the provider, and have specified on the participant’s all service plan, ISP or non-waiver HOME choice demonstration program service plan, the number of hours for which the provider is authorized to furnish nutritional consultation services to the participant.

(3) All providers of nutritional consultation services must:

(a) Conduct an initial individual assessment of the participant’s nutritional needs, and subsequent assessments when necessary, using a tool that identifies whether the participant is at nutritional risk. The tool must include the following:

(i) An assessment of height and weight history;

(ii) An assessment of adequacy of nutrient intake;

(iii) A review of medications, diagnoses and diagnostic test results;

(iv) An assessment of verbal, physical and motor skills that could be attributable to, or affect, nutrient needs;

(v) An assessment of caregiver and participant interactions during feeding; and

(vi) An assessment of the need for additional adaptive equipment and/or other community resources and/or services.

(b) Develop, implement, evaluate and revise, as necessary, a nutrition intervention plan with the assistance of the participant and/or authorized representative, and when applicable, the treating physician and other relevant service providers. The plan must include any appropriate food and diet modifications, any specific nutrients that may be required or limited, feeding modality, nutrition education and counseling, and expected measurable outcomes.

(c) Furnish the CM or SSA, as appropriate, the participant and/or the participant’s authorized representative with a copy of the assessment and the nutrition intervention plan no later than seven working days after completion of the assessment.

(d) Furnish evidence, upon request, that the nutrition intervention plan was developed and services were delivered in accordance with professional licensure requirements.

(4) Providers of nutritional consultation services must maintain a clinical record for each HOME choice demonstration program participant served. The clinical record must contain the information listed in paragraphs (E)(4)(a) to (E)(4)(j) of this rule.

(a) Participant identifying information, including but not limited to name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification numbers.

(b) Participant medical history.

(c) Name of participant’s treating physician.

(d) Treating physician’s authorization for a nutritional assessment.

(e) A copy of the initial and all subsequent all service plans, ISPs or non-waiver HOME choice demonstration program service plans, as appropriate.

(f) A copy of the initial and all subsequent individual assessments of the participant’s nutritional needs.

(g) A copy of the initial and all subsequent plans of care specifying the type, frequency, scope and duration of the nutritional consultation services being performed.

(h) Documentation of drug and food interactions and allergies, and dietary restrictions.

(i) Documentation that clearly shows the date of nutritional consultation service delivery, including copies of all nutritional assessments conducted and all nutrition intervention plans developed and implemented. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(j) A discharge summary, signed and dated by the departing dietitian providing nutritional consultation services, at the point the dietitian is no longer going to provide services to the participant, or when the participant no longer needs nutritional consultation services.

(F) “Communication aids” are devices, systems or services necessary to assist the HOME choice demonstration program participant with hearing, speech or vision impairments to effectively communicate with service providers, family, friends and the general public.

(1) Communication aids include, but are not limited to:

(a) Augmentative communication devices or systems that transmit or produce a message or symbols in a manner that compensates for the HOME choice demonstration program participant’s communication impairment;

(b) Computers and computer equipment;

(c) Other mechanical and electronic devices;

(d) Cable and internet access; and

(e) The cost of installation, repair, maintenance and support of any covered communication aid.

(2) Communication aids may also include:

(a) Interpreter services that support the HOME choice demonstration program participant’s integration into the community. Interpreter services refer to the process by which the interpreter conveys one person’s message to another by incorporating both the message and the attitude of the communicator.

(b) New technologies and any other devices so long as the technologies and devices achieve the objective of the service.

(3) Reimbursement for communication aids shall not exceed a total of five thousand dollars within the three hundred sixty-five day HOME choice demonstration program eligibility period per participant. The CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, shall not approve the same type of communication aid equipment for the same HOME choice demonstration program participant more than once unless there is a documented need for ongoing communication aid services or a change in the HOME choice demonstration program participant’s medical and/or physical condition requiring the replacement.

(4) If the HOME choice demonstration program participant is enrolled on an HCBS waiver, then the participant must exhaust similar waiver services that are available to the participant before utilizing communication aid services. Communication aid service costs are not included in the cost of HCBS waiver services.

(5) In order to submit a claim for reimbursement of communication aid services, the communication aid service provider delivering the service:

(a) Must be an agency provider;

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code;

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable; and

(d) Must be identified as the provider, and have specified on the participant’s all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish communication aid services to the participant.

(G) “Service animals” are animals that are individually trained to perform tasks for HOME choice demonstration program participants that the participants are unable to perform for themselves. They also assist people with disabilities in their day-to-day activities.

(1) Tasks performed by service animals include, but are not limited to:

(a) Guiding people who are blind;

(b) Alerting people who are deaf;

(c) Pulling wheelchairs;

(d) Alerting and protecting participants who are having a seizure;

(e) Carrying and picking up things for participants with mobility impairments; and

(f) Assisting participants with mobility impairments with balance.

(2) Service animals may include, but are not limited to:

(a) Seeing eye dogs;

(b) Hearing dogs; and

(c) Service monkeys.

(3) Activities related to the use of service animals include, but are not limited to:

(a) First-year costs associated with the raising of the animal;

(b) Housing, feeding, upkeep and medical care of the animal during training;

(c) Actual training of the animal, student training and related transportation, room/board and administrative activities;

(d) Equipment and supplies;

(e) Home care, including cooking/food, housekeeping, laundry for students in training;

(f) Animal health insurance; and

(g) Transportation to the veterinarian.

(4) Reimbursement for service animals shall not exceed a total of eight thousand dollars within the three hundred sixty-five day HOME choice demonstration program eligibility period per participant. The CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, shall not approve the same type of service animal services for the same HOME choice demonstration program participant more than once unless there is a documented need for ongoing service animal services or a change in the HOME choice demonstration program participant’s medical and/or physical condition requiring the replacement.

(5) If the HOME choice demonstration program participant is enrolled on an ODMR/DD-administered waiver, then the participant must exhaust similar waiver services that are available to the participant before utilizing the service animal service. Service animal costs are not included in the cost of waiver services.

(6) In order to submit a claim for reimbursement of service animal services, the service animal service provider delivering the service:

(a) Must be an agency provider;

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code;

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable; and

(d) Must be identified as the provider, and have specified on, the participant’s all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish service animal services to the participant.

(H) “Community transition services” are services providing goods, services and support for the purpose of addressing an identified need in the HOME choice demonstration program participant’s all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, including improving and maintaining the HOME choice demonstration program participant’s opportunities for membership in the community.

(1) Community transition services are intended to meet the following criteria:

(a) The goods and services will decrease the need for formal support services and other medicaid services;

(b) The goods and services will take into consideration the appropriateness and availability of a lower cost alternative for comparable services that meet the HOME choice demonstration program participant’s needs;

(c) The goods and services will promote community inclusion and family involvement;

(d) The goods and services will increase the HOME choice demonstration program participant’s health and welfare in the home and/or community;

(e) The HOME choice demonstration program participant does not have the funds to purchase the goods and services, or the goods and services are not available through another source;

(f) The goods and services will assist the HOME choice demonstration program participant in developing and maintaining personal, social, physical or work-related skills; and

(g) The goods and services will assist the HOME choice demonstration program participant in living independently in the home and community.

(2) Allowable community transition service expenses include, but are not limited to:

(a) Security deposits that are required to obtain a lease on an apartment or home;

(b) Essential household furnishings, including furniture, window coverings, food preparation items, and bed/bath linens;

(c) Set-up fees or deposits for utility or service access, including telephone, electricity, heating and water;

(d) Services necessary for the participant’s health and welfare, such as pest control and one-time cleaning prior to moving in to the residence;

(e) Moving expenses;

(f) Necessary home accessibility adaptations; and

(g) Start-up groceries, i.e., food and household supplies.

(3) Community transition services do not include:

(a) Experimental or prohibited treatments;

(b) The ongoing cost of room and board;

(c) Regular utility charges;

(d) Ongoing grocery expenses;

(e) Cigarettes and alcohol;

(f) Uniforms and memberships;

(g) Electronics and other household appliances or items that are used for entertainment or recreational purposes; and

(h) Cable/internet access.

(4) Reimbursement for community transition services shall not exceed a cumulative maximum of two thousand dollars for the items purchased or deposits made during the participant’s period of eligibility for the HOME choice demonstration program. The CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, shall not approve the same type of community transition services for the same HOME choice demonstration program participant unless there is a documented need for ongoing community transition services or a change in the HOME choice demonstration program participant’s medical and/or physical condition requiring the replacement.

(5) Except as provided for in paragraph (H)(6) of this rule, community transition services shall not duplicate similar waiver or administrative services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled.

(6) When the HOME choice demonstration program participant is enrolling on an ODA-administered waiver, the participant may use HOME choice community transition services in lieu of, but not in addition to, the community transition service available through the ODA-administered waiver.

(7) In order for a provider to submit a claim for reimbursement of community transition services,

(a) The specific goods and services to be purchased shall be:

(i) Determined by the HOME choice demonstration program participant in conjunction with his or her CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate,

(ii) Based upon the HOME choice demonstration program participant’s established need, and

(iii) Specified on the participant’s all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, and

(b) During the HOME choice demonstration period, the purchase of community transition services shall be coordinated by the participant’s CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, in conjunction with the ODJFS-designated HOME choice financial management service (FMS) provider. Community transition services shall be reimbursed in accordance with rule 5101:3-51-06 of the Administrative Code, the requirements set forth in the FMS contract and established HOME choice demonstration program policies and procedures.

Effective: 06/01/2009

R.C. 119.032 review dates: 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A.

Prior Effective Dates: 07/01/2008

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or on the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

(A) All providers of HOME choice demonstration program services must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code, as appropriate, and the provider requirements and specifications set forth in rule 5101:3-51-04 of the Administrative Code prior to furnishing services to a consumer.

(B) A prospective provider intending to furnish HOME choice demonstration program services to a participant enrolled on a home and community-based services (HCBS) waiver administered by ODJFS must meet the requirements set forth in this paragraph. The provider must submit a signed statement affirming that the provider received and read all rules of the Administrative Code governing the HOME choice demonstration program and the ODJFS-administered waiver on which the participant is enrolled.

(1) For qualified services, the provider shall:

(a) Be a provider as approved by ODJFS in accordance with rule 5101:3-12-28 of the Administrative Code, and the ODJFS-administered waiver service provider specifications set forth in rule 5101:3-46-04, 5101:3-47-04 or 5101:3-50-04 of the Administrative Code, as appropriate, for the specific waiver service to be furnished.

(b) Be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a medicaid provider of nutritional consultation services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, or an ODA-certified long term care provider of nutritional consultation services in accordance with rule 173-39-02.10 of the Administrative Code, if the provider is furnishing nutritional consultation as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of social work counseling services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, or as certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or be an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39-02.12 of the Administrative Code, if the provider is furnishing social work counseling as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a provider of community support coaching as approved by ODJFS in accordance with rule 5101:3-12-28 of the Administrative Code, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(d) Be a provider of independent living skills training as approved by ODJFS in accordance with rule 5101:3-12-28 of the Administrative Code, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing independent living skills training as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall:

(a) Be a:

(i) Medicaid provider of supplementary adaptive and assistive device services as approved by ODJFS in accordance with rule 5101:3-12-28 of the Administrative Code, and rule 5101:3-46-04, 5101:3-47-04 or 5101:3-50-04 of the Administrative Code, as appropriate, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(ii) Provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of adaptive and assistive equipment services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(C) A prospective provider intending to furnish HOME choice demonstration program services to a participant enrolled on an HCBS waiver administered by ODA must meet the requirements set forth in this paragraph.

(1) For qualified services, the provider shall:

(a) Be an ODA-certified long term care provider in accordance with rule 173-39-02 of the Administrative Code.

(b) Be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a provider of HOME choice nursing services as approved by ODJFS in accordance with rule 5101:3-51-04 of the Administrative Code, if the provider is furnishing HOME choice nursing services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a provider of community support coaching as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a provider of independent living skills training as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing independent living skills training as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall:

(a) Be:

(i) An ODA-certified long term care provider of specialized medical equipment and supplies in accordance with rule 173-39-02.7 of the Administrative Code, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(ii) A provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of adaptive and assistive equipment services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(D) A prospective provider intending to furnish HOME choice demonstration program services to a participant enrolled on an HCBS waiver administered by ODMR/DD must meet the requirements set forth in this paragraph. The provider must submit a signed statement affirming that the provider received and read all rules of the Administrative Code governing the HOME choice demonstration program.

(1) For qualified services, the provider shall:

(a) Be a medicaid provider as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code for the specific waiver service to be furnished.

(b) Be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a medicaid provider of nutritional consultation services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, or an ODA-certified long term care provider of nutritional consultation services in accordance with rule 173-39-02.10 of the Administrative Code, if the provider is furnishing nutritional consultation as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of social work counseling services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, or as certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or be an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39-02.12 of the Administrative Code, if the provider is furnishing social work counseling as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a provider of HOME choice nursing services as approved by ODJFS in accordance with rule 5101:3-51-04 of the Administrative Code, if the provider is furnishing HOME choice nursing services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(d) Be a provider of community support coaching as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall be:

(a) A medicaid provider of adaptive and assistive equipment or specialized medical equipment as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(b) A provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; and

(c) Be a medicaid provider of adaptive and assistive equipment services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(E) A prospective provider intending to furnish HOME choice demonstration program services to a participant who is not enrolled on an HCBS waiver must meet the requirements set forth in this paragraph.

(1) For qualified medicaid state plan services, the provider shall be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a provider of HOME choice nursing services as approved by ODJFS in accordance with rule 5101:3-51-04 of the Administrative Code, if the provider is furnishing HOME choice nursing services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of nutritional consultation services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, or an ODA-certified long term care provider of nutritional consultation services in accordance with rule 173-39-02.10 of the Administrative Code, if the provider is furnishing nutritional consultation as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a medicaid provider of social work counseling services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, or as certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or be an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39-02.12 of the Administrative Code, if the provider is furnishing social work counseling as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(d) Be a provider of community support coaching as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(e) Be a provider of independent living skills training as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing independent living skills training as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall:

(a) Be:

(i) A medicaid provider of durable medical equipment as approved by ODJFS in accordance with rule 5101:3-10-01 of the Administrative Code, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(ii) A provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of adaptive and assistive equipment services as certified by ODMR/DD in accordance with rule 5123:2-9-09 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(F) ODJFS shall not process a service provider application packet for prospective providers of HOME choice nursing, community support coaching, independent living skills training, or communication aid services if the packet does not contain information necessary to complete the required verifications.

(1) ODJFS shall not process a service provider application packet for prospective providers of HOME choice nursing, community support coaching, independent living skills training or communication aid services if the provider does not submit the signed statement as required by paragraphs (B) and (D) of this rule.

(2) ODJFS shall notify the service provider in writing of any missing information, and shall provide the applicant thirty calendar days to submit the required documentation. If the provider does not submit the required documentation within thirty calendar days, the service provider application process shall be terminated.

(3) ODJFS shall review all information and make a determination regarding the prospective service provider’s eligibility for enrollment. If ODJFS determines the provider is ineligible for enrollment as a provider of HOME choice demonstration program services, the provider shall be entitled to a hearing under Chapter 119. of the Revised Code in accordance with Chapter 5101:6-50 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A

The requirements set forth in this rule begin when the Ohio department of job and family services (ODJFS) receives approval of the HOME choice demonstration program from the centers for medicare and medicaid services (CMS), or upon the effective date of this rule, whichever is later. The requirements shall remain in effect through the duration of the HOME choice demonstration program.

(A) Definitions of terms used for billing and calculating rates.

(1) “Base rate,” as used in table A, column 3 of paragraph (B) of this rule, means the amount paid for up to the first four units of service delivered.

(2) “Billing unit,” as used in table B, column 3 of paragraph (B) of this rule, means a single fixed item or amount of time.

(3) “Classroom rate” is the amount that HOME choice independent living skills training service providers are reimbursed when the service is provided in a classroom setting. The rate is equivalent to fifty per cent of the reimbursement rate set forth in paragraph (B), table (B) of this rule that is paid to a provider for furnishing HOME choice independent living skills training services to a single individual.

(4) “Classroom setting” is a situation in which a HOME choice independent living skills training service provider furnishes the same type of services to four or more individuals at the same address, during the same visit. The services provided in the classroom setting can be either the same type of HOME choice independent living skills training service, or a combination of HOME choice independent living skills training services and similar independent living skills training services.

(5) “Group rate,” as used in paragraph (E)(1) of this rule, is the amount that HOME choice nursing providers, or HOME choice independent living skills training services are reimbursed when the service is provided in a group setting. The rate is equivalent to seventy-five per cent of the reimbursement rate set forth in paragraph (B), table (A) of this rule for HOME choice nursing services, and in paragraph (B), table (B) of this rule for HOME choice independent living skills training services that is paid to a provider for delivering the HOME choice nursing services or HOME choice independent living skills training services to a single individual.

(6) “Group setting” is a situation in which a HOME choice nursing, service provider, or a HOME choice independent living skills training service provider furnishes the same type of services to two or three individuals at the same address, during the same visit. The services provided in the group setting can be either the same type of HOME choice nursing service or HOME choice independent living skills training service, or a combination of HOME choice nursing services and similar nursing services, or HOME choice independent living skills training services and similar independent living skills training services.

(7) “Maximum usage amounts,” as used in table B, column 6 of paragraph (B) of this rule, means the maximum number of hours, or the maximum dollar amount that a HOME choice demonstration program service can be reimbursed, and as set forth on the HOME choice demonstration program participant’s all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(8) “Maximum hours per month,” as used in table A, column 5 of paragraph (B) of this rule, means the maximum number of hours that a HOME choice demonstration program service can be reimbursed per month, and as set forth on the HOME choice participant’s all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(9) “Maximum rate” means the maximum amount that will be paid for the HOME choice demonstration program service rendered.

(a) For the billing codes in table B of paragraph (B) of this rule, the HOME choice demonstration program maximum rate is set forth in column (4).

(b) For the billing codes in table A of paragraph (B) of this rule, the HOME choice demonstration program maximum rate is:

(i) The base rate as defined in paragraph (A)(1) of this rule, or

(ii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A)(10) of this rule for each additional unit of service delivered.

(10) “Unit rate,” as used in table A, column 4 of paragraph (B) of this rule, and in table B, column 5 of paragraph (B) of this rule, means the amount paid for each fifteen minute unit following the base rate paid for the first four units of service provided.

(B) Billing code tables.

Table A

Table B

See Tables at http://www.registerofohio.state.oh.us/pdfs/5101/3/51/5101$3-51-06_PH_FF_A_RU_20090511_1058.pdf

(C) In order for a provider to submit a claim for HOME choice demonstration program services, the services must be provided in accordance with Chapter 5101:3-51 of the Administrative Code.

(D) The amount of reimbursement for a service shall be the lesser of the provider’s billed charge or the HOME choice demonstration program maximum rate.

(E) Required modifiers.

(1) The “GS” modifier must be used when a provider submits a claim for HOME choice nursing services, or HOME choice independent living skills training services, if the service was delivered in a group setting. Reimbursement as a group rate shall be the lesser of the provider’s billed charge or seventy-five per cent of the HOME choice demonstration program maximum for the specific service.

(2) The “CS” modifier must be used when a provider submits a claim for HOME choice independent living skills training services if the service was delivered in a classroom setting. Reimbursement as a classroom rate shall be the lesser of the provider’s billed charge or fifty per cent of the HOME choice demonstration program maximum.

(3) The “N2” modifier must be used when the same provider submits a claim for HOME choice nursing services for a second visit to a participant for the same date of service.

(4) The “N3” modifier must be used when the same provider submits a claim for HOME choice nursing services for three or more visits to a participant for the same date of service.

(5) The “N4” modifier must be used when a provider submits a claim for HOME choice nursing services for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(F) Reimbursement will be provided in accordance with the following:

(1) Except as stated in paragraph (F)(2) of this rule, claims must be received by the financial management service provider (FMS) within ninety calendar days of the actual date the HOME choice demonstration service was provided.

(2) Reimbursement requests for community transition services must be received by the FMS within fourteen calendar days of the actual date goods and services were purchased. Reimbursement requests must be in the form of either an invoice, a receipt or a purchase order.

(3) The payment for a covered HOME choice demonstration program service constitutes payment-in-full and shall not be construed as a partial payment when the reimbursement amount is less than the provider’s charge. The provider may not collect and/or bill the participant for any difference between the HOME choice demonstration program payment and the provider’s charge, or request the participant to share in the cost through a deductible, coinsurance, co-payment or other similar charge.

(4) Except for as stated in paragraphs (F)(5) and (F)(6) of this rule, HOME choice demonstration program reimbursement is not available for non-covered services, or for similar waiver or administrative services available on the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or the medicaid state plan.

(5) When the HOME choice demonstration program participant is enrolled on an HCBS waiver, HOME choice demonstration program reimbursement is available for communication aid services only after the participant has received and exhausted same or similar waiver services.

(6) When the HOME choice demonstration program participant is enrolling on an ODA-administered waiver, the participant may use HOME choice community transition services in lieu of, but not in addition to, the community transition service available through the ODA-administered waiver.

(7) Reimbursement is made only for those HOME choice demonstration program services that are set forth in the participant’s all services plan, service plan, individual service plan or non-waiver HOME choice demonstration program service plan, as appropriate. The amount of payment is determined in accordance with federal and state laws and regulations. In establishing HOME choice demonstration program maximums, ODJFS must assure that the maximum reimbursement is consistent with efficiency, economy and quality of care.

(8) The state’s appropriation determines the total amount of funds that may be expended for HOME choice demonstration program services. The maximums used by ODJFS may be less than the maximums permitted under federal law for same or similar services, but may not be more. Providers are expected to bill the FMS provider their usual and customary charge (i.e., the amount the provider charges the general public). If the amount billed to the FMS exceeds the maximum set forth in this rule, the amount paid will automatically be reduced to the maximum permitted.

Effective: 06/01/2009

R.C. 119.032 review dates: 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.85

Rule Amplifies: 5111.01, 5111.02, 5111.85, Section 309.30.70 of Am. Sub. H.B. 119, 127th G.A.

Prior Effective Dates: 07/01/2008