5101:3-50-02 Transitions carve-out waiver: consumer eligibility for enrollment.

(A) Enrollment on the transitions carve-out waiver is only available to consumers who on the effective date of this rule were either enrolled on the Ohio home care waiver, receiving services through the core-plus benefit, or enrolled on an ODA-administered waiver and receiving core services. Transfer will occur after ODJFS or its designated case management agency (CMA) determines the criteria set forth in paragraph (B) of this rule are met.

(B) To be eligible and maintain eligibility, a transitions carve-out waiver consumer must:

(1) Be eligible for Ohio medicaid in accordance with rule 5101:1-38-01.6 of the Administrative Code; and

(2) Be determined program eligible for the transitions carve-out waiver by meeting the following requirements:

(a) Participate in the assessment process as defined in rule 5101:3-45-01 of the Administrative Code;

(b) Be either age sixty or older;

(c) Have either an intermediate level of care in accordance with rule 5101:3-3-06 of the Administrative Code or a skilled level of care in accordance with rule 5101:3-3-05 of the Administrative Code;

(d) Need services that are not available through other sources in amounts sufficient to meet the consumer's needs;

(e) Not reside in an institution, residential care facility, adult foster home or other group living arrangement subject to state licensure or certification;

(f) In the absence of the transitions carve-out waiver, require NF placement or long term hospitalization;

(g) Continue to elect to receive transitions carve-out waiver services instead of institutional services by signing a JFS 02379 agency-consumer agreement;

(h) Participate in the development of a all services plan;

(i) Be able to have the services identified in the all services plan met within the funding range established in accordance with rule 5101:3-50-05 of the Administrative Code; and

(j) Accept the all services plan by signing and dating the plan.

(C) A transitions carve-out waiver consumer shall be reassessed at least annually, and more frequently if there is a significant change in the consumer's situation that may impact the consumer's health and welfare. If the annual reassessment determines that the consumer no longer meets the eligibility criteria set forth in paragraph (B) of this rule, then the consumer shall be disenrolled from the transitions carve-out waiver. In such instances, the consumer shall be afforded notice and hearing rights in accordance with division-level 5101:6 of the Administrative Code.

(D) If a transitions carve-out waiver consumer does not receive any waiver services for ninety consecutive days, ODJFS shall, within ten days of the ninetieth day, reassess the consumer's need for waiver services. If it is determined that waiver services are no longer needed, the consumer shall be disenrolled from the transitions carve-out waiver. The consumer will be afforded notice and hearing rights in accordance with division-level 5101:6 of the Administrative Code.

(E) If, at any time, a consumer ceases to meet any of the eligibility criteria set forth in paragraph (B) of this rule, the consumer shall be disenrolled from the transitions carve-out waiver. In such instances, the consumer shall be afforded notice and hearing rights in accordance with division-level 5101:6 of the Administrative Code.

Replaces: Part of 5101:3-12-04

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85 , 5111.856
Prior Effective Dates: 4/4/77, 12/21/77, 6/1/80, 5/1/87, 4/1/88, 5/15/89, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/30/93, 7/1/98, 9/29/00, 3/1/02 (Emer), 5/30/02