5101:3-3-15.5 ICF-MR Level of care determination process for home and community based medicaid waivers administered by the Ohio department of mental retardation and developmental disabilities.

(A) The purpose of this rule is to describe the level of care review and determination process for all individuals applying for an ICF-MR home and community based medicaid waiver administered by the Ohio department of mental retardation and development disabilities and to describe the annual level of care redetermination process. An ICF-MR level of care determination is required for all individuals as a component of eligibility for ICF-MR home and community based services.

(B) Definitions

(1) "CBMRDD" means a county board of mental retardation and developmental disabilities that has local medicaid administrative authority under section 5126.055 of the Revised Code.

(2) "CDJFS" means a county department of job and family services.

(3) "ICF-MR" means intermediate care facility for the mentally retarded.

(4) "HCBS", as defined in section 5126.01 of the Revised Code means medicaid-funded home and community based services as an alternative to placement in an intermediate care facility for mental retardation provided under a medicaid component that the department of mental retardation and development disabilities administers pursuant to section 5111.871 of the Revised Code.

(5) "ICF-MR home and community based services" means the residential facility waiver, the individual options waiver and any new or amended hcbs waivers that are designed to provide services in lieu of an ICF-MR facility.

(6) "ICF-MR LOC determination" means a decision made by appropriately qualified personnel which establishes that an individual does or does not meet the criteria for an intermediate care facility for the mentally retarded level of care specified in rule 5101:3-3-07 of the Administrative Code.

(7) "Individual" means a medicaid recipient or person with pending medicaid eligibility who is making application for an ICF-MR home and community based waiver.

(8) "ODJFS" means the Ohio department of job and family services.

(9) "ODMRDD" means the Ohio department of mental retardation and developmental disabilities.

(10) "Significant change of condition" means that the individual has experienced a change in physical or mental condition, or functional abilities, or has reached the age of 6 or the age of 16, any of which may result in a change in the individual's level of care.

(C) The CBMRDD, shall, in accordance with section 5126.055 of the Revised Code, coordinate and/or perform evaluations and assessments of the individual and make a recommendation to ODJFS or designee as to whether the individual meets the criteria for an ICF-MR level of care as set forth in rule 5101:3-3-07 of the Administrative Code.

(1) The assessment shall include:

(a) Medical, psychiatric and developmental diagnoses, and dates of onset if the date of onset is significant in determining whether the individual has a developmental disability; and

(b) Review of current functional capacity. This review should be documented on a standard functional assessment form that is approved by the Ohio department of job and family services.

(2) The assessment documentation shall be kept in the official waiver file and made available for state and federal quality assurance and audit purposes.

(D) CBMRDD shall submit a recommendation and supporting documentation described in this section to ODJFS or designee for review and approval or denial of an ICF-MR LOC determination as set forth in rule 5101:3-3-07 of the Administrative Code.

(1) For an initial ICF-MR LOC determination, the cbmrdd shall submit to ODJFS or designee the following documentation supporting the individual's need for an ICF-MR LOC:

(a) A medical evaluation which includes etiology of the condition leading to a developmental disability, diagnoses, and dates of onset, completed by a doctor of medicine or osteopathy who is licensed by the state of Ohio medical board.

(b) A psychological evaluation completed by a psychologist who has been licensed by the Ohio board of psychology to practice psychology in the state of Ohio, or a psychiatric evaluation completed by a psychiatrist licensed to practice psychiatry by the state of Ohio medical board, which includes the most current diagnoses as specified in the most current diagnostic statistical manual of mental disorders, axes I, II and III.

(c) ICF-MR LOC eligibility determination form as approved by ODJFS.

(2) The CBMRDD shall submit an ICF-MR LOC redetermination to ODJFS or designee within twelve months of the initial LOC determination, and every year thereafter, and upon a significant change of the individual's condition, as defined in paragraph (B) (10) of this rule, which will establish one of the following:

(a) The individual has not had a significant change in condition. The cbmrdd shall submit the appropriate ICF-MR LOC redetermination form verifying that the individual's condition has not changed significantly since the initial loc determination and shall recommend continuation of the ICF-MR LOC; or

(b) The individual has experienced a significant change of condition from the time of the initial ICF-MR LOC determination. The CBMRDD shall reassess the individual's needs and submit new evaluations which verify the change in condition with the appropriate ICF-MR LOC redetermination form. This redetermination should be completed as soon as a significant change in condition has occurred.

(E) Following receipt by ODJFS or designee of the documentation specified in paragraph (D) (1)(c) of this rule, ODJFS or designee shall make a determination of whether the documentation is sufficiently complete for its personnel to perform the ICF-MR LOC review and make a determination based upon the criteria set forth in rule 5101:3-3-07 of the Administrative Code.

(1) If the documentation is not complete, ODJFS or designee shall notify the individual and the CBMRDD regarding the need for additional documentation. This notice shall specify the additional documentation that is required and shall indicate that the individual, or someone on their behalf, has twenty days from the date ODJFS or designee mails the notice to submit additional documentation or the authorized form will be denied for incompleteness with no ICF-MR LOC authorized. In the event an individual, or someone on their behalf, is not able to complete an authorized form in the time specified, ODJFS or designee shall, upon good cause, grant an extension when an extension is requested by the individual or someone on their behalf.

(2) Within thirty days of receipt of all required documentation, ODJFS or designee shall issue an ICF-MR LOC determination. An ICF-MR LOC determination will be issued pursuant to the criteria as set forth in rule 5101:3-3-07 of the Administrative Code.

(3) A request for an ICF-MR LOC will not be denied by ODJFS or designee for the reason that the individual does not meet the ICF-MR LOC criteria, as set forth in rule 5101:3-3-07 of the Administrative Code, until a qualified professional, whose qualifications include being a registered nurse or a qualified mental retardation professional, as specified at 42 C.F.R 483.430 , conducts a face-to-face assessment of the individual and reviews the medical records that accurately reflect the individual's condition. Authorized personnel other than the person who conducted the face-to-face assessment will review the face-to-face assessment and make the final ICF-MR LOC determination.

(F) Once a final ICF-MR LOC determination is made, ODJFS or designee shall notify the individual. The notice shall establish the individual's hearing rights, as set forth in rule 5101:6-2-02 to 5101:6-2-04 of the Administrative Code, and the time frames within which they must be exercised.

(1) If a hearing request is received in response to the notice specified in paragraph (F) of this rule and within the time frames specified in rule 5101:6-4-01 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(2) If the individual does not submit a hearing request within the time frame specified in paragraph (F) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of ODJFS' intent to terminate vendor payment.

(G) Federal financial participation (FFP) shall not be claimed for ICF-MR home and community based waiver services delivered prior to the ICF-MR LOC determination date.

Eff 11-1-01 (Emer.); 1-20-02
Rule promulgated under: RC Chapter 119.
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01 , 5111.02
Rule REVIEW DATE: 11/5/01, 11/5/06