Chapter 5123:2-9 HCBS Waiver Services

5123:2-9-01 Home and community-based services waivers - enrollment and disenrollment.

(A) Purpose

The purpose of this rule is to establish procedures for the enrollment, denial of enrollment, and disenrollment of individuals in home and community-based services waivers administered by the Ohio department of developmental disabilities.

(B) Definitions

(1) "Alternative services" means the various programs, services, and supports, regardless of funding source, other than home and community-based services, that exist as part of the developmental disabilities service system and other service systems including, but not limited to:

(a) Services provided directly by a county board;

(b) Services funded by a county board through providers;

(c) Services provided and funded outside the developmental disabilities service system; and

(d) Services provided at the state level.

(2) "County board" means a county board of developmental disabilities or a person or government entity, including a council of governments, with which a county board has contracted for assistance with its medicaid local administrative authority pursuant to section 5126.055 of the Revised Code.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Home and community-based services" means medicaid-funded home and community-based services provided under a medicaid component that the department administers pursuant to section 5166.21 of the Revised Code.

(5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(6) "Intermediate care facility" means an intermediate care facility for individuals with intellectual disabilities as defined in rule 5123:2-7-01 of the Administrative Code.

(7) "Natural supports" means the personal associations and relationships typically developed in the community that enhance the quality of life for individuals.

Natural supports may include family members, friends, neighbors, and others in the community or organizations that serve the general public who provide voluntary support to help an individual achieve agreed upon outcomes through the individual service plan development process.

(8) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(C) Requests for home and community-based services

The county board shall submit or assist the individual with submission of the Ohio department of job and family services form 02399, "Request for Medicaid Home and Community-Based Services" (revised May 2013), to the county department of job and family services. The department shall accept notification of requests for home and community-based services waiver enrollment that are referred by the county department of job and family services. The department shall notify the appropriate county board when it receives a notification of a request from the county department of job and family services.

(D) Eligibility criteria for enrollment in home and community-based services waivers

(1) To be eligible for enrollment in a home and community-based services waiver administered by the department an individual shall:

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

(b) Have an intermediate care facility level of care in accordance with rule 5101:3-3-07 of the Administrative Code;

(c) Choose enrollment in a home and community-based services waiver in lieu of an opportunity for placement in an intermediate care facility;

(d) Require, at a minimum, one waiver service;

(e) Participate in the development of his or her individual service plan; and

(f) Be able to have his or her health and welfare needs met through waiver services at or below the federally approved cost limitation, and through a combination of informal and formal supports including, but not limited to, waiver services, medicaid state plan services, private health insurance plan, non-waiver services, and/or natural supports.

(2) Specific to the transitions developmental disabilities waiver, an individual shall meet the criteria set forth in paragraphs (D)(1)(a) to (D)(1)(f) of this rule and:

(a) The individual shall meet one of the following criteria:

(i) Be enrolled in the Ohio home care waiver and subsequently experience a change in level of care from a skilled or intermediate level of care to an intermediate care facility level of care; or

(ii) For purposes of enrolling in the transitions developmental disabilities waiver through reserve capacity, the individual shall meet the criteria set forth in paragraph (D)(2)(a)(i) of this rule and require at least one skilled nursing service each day, seven days per week.

(b) The individual shall not reside in an institution, intermediate care facility, residential care facility, adult foster home, or other group living arrangement subject to state licensure or certification.

(E) Responsibilities for enrollment

(1) A county board shall enroll individuals in home and community-based services waivers in accordance with rule 5123:2-1-08 of the Administrative Code.

(2) When a county board intends to enroll an individual in a home and community-based services waiver, the county board shall request the department to authorize waiver capacity for the individual to be enrolled.

(3) Upon authorization by the department to enroll an individual in a home and community-based services waiver, the following activities shall take place:

(a) The county board shall determine the individual's eligibility for county board services. An individual determined to have an intermediate care facility level of care who meets all other eligibility criteria for home and community-based services waivers shall be eligible for home and community-based services waiver enrollment even if determined ineligible for county board services. In the event a county board determines an individual enrolled in a home and community-based services waiver to be ineligible for county board services, the department may review that determination.

(b) The county board shall complete the required assessments of the individual in accordance with rules 5101:3-3-07 and 5101:3-3-15.5 of the Administrative Code, as applicable, and any other assessments specific to the waiver in which the individual is seeking enrollment.

(c) With respect to the transitions developmental disabilities waiver, the department or entity under contract with the department to conduct assessments shall complete the required assessments of the individual in accordance with rule 5101:3-3-07 of the Administrative Code and any other assessments specific to that waiver in accordance with rules adopted by the department.

(d) Within ninety calendar days of the department's authorization to enroll an individual, the county board shall forward to the department all necessary enrollment information, including a request for an intermediate care facility level of care determination with respect to the individual.

(e) Upon receipt of a request for an intermediate care facility level of care determination from the county board or entity under contract with the department to conduct assessments, the department shall determine whether the individual meets the criteria for an intermediate care facility level of care as specified in rule 5101:3-3-07 of the Administrative Code.

(f) The department shall send notification to the individual upon completion of the level of care determination in accordance with paragraph (I) of this rule.

(F) Continued enrollment and disenrollment

(1) The county board shall submit an intermediate care facility level of care redetermination at least annually to the department in accordance with rules 5101:3-3-07 and 5101:3-3-15.5 of the Administrative Code, as applicable.

(2) Subsequent to initial enrollment of an individual in a home and community-based services waiver, the county board shall evaluate the current needs and circumstances of the individual in relationship to the services and activities described in the individual's most recent individual service plan and recommend appropriate action to the department, which may include a recommendation to disenroll the individual from the home and community-based services waiver, when any one of the following occur:

(a) There is a significant change of condition as defined in rule 5101:3-3-15.5 of the Administrative Code;

(b) The individual is admitted as an inpatient to a hospital, nursing facility, intermediate care facility, or is incarcerated if such admission or incarceration is reasonably anticipated to exceed ninety calendar days;

(c) The individual fails or refuses to use services in accordance with his or her individual service plan;

(d) The individual interferes with or otherwise refuses to cooperate with the county board and such interference or refusal to cooperate renders the county board unable to perform its medicaid local administrative authority under section 5126.055 of the Revised Code;

(e) The individual ceases to meet the eligibility criteria for enrollment in the home and community-based services waiver;

(f) The individual's health and welfare cannot be assured in accordance with the requirements of paragraph (D)(1)(f) of this rule; and/or

(g) The individual requests to be disenrolled from the home and community-based services waiver.

(3) When the cost of waiver services for the individual exceeds the amount authorized by the centers for medicare and medicaid services for the waiver in which the individual is enrolled, the county board shall evaluate the individual, consider the measures set forth in paragraphs (F)(3)(a) to (F)(3)(e) of this rule, and submit a recommendation to the department regarding whether or not the individual can remain enrolled in the waiver and have his or her health and welfare assured by one or more of the following measures:

(a) Adding more available natural supports;

(b) Accessing available non-waiver services, other than natural supports;

(c) Accessing additional medicaid state plan services;

(d) Accessing private health insurance plan benefits; and/or

(e) Sharing supports and services, such as natural supports and non-waiver services, by collaborating with other systems, organizations, agencies, and people with and without disabilities.

(4) Upon receipt of a recommendation from a county board in accordance with paragraph (F)(2) or (F)(3) of this rule, the department shall within a reasonable period of time, make a determination as to the individual's continued enrollment in the waiver and inform the county board accordingly. If the department determines that the individual cannot continue to be enrolled in the waiver and have his or her health and welfare assured by one or more of the measures set forth in paragraph (F)(2) or (F)(3) of this rule, the department shall propose to disenroll the individual from the waiver in accordance with the notice provisions in paragraph (I)(2) of this rule.

(5) When the department proposes to disenroll an individual in accordance with paragraph (F)(2) or (F)(3) of this rule, the county board shall do both of the following:

(a) Offer the individual the opportunity to apply for an alternative home and community-based services waiver for which the individual is eligible that may more adequately address the needs of the individual, to the extent that such waiver openings exist; and

(b) Assist the individual in identifying and obtaining alternative services that are available and may more adequately address the needs of the individual.

(6) In the event that options set forth in paragraphs (F)(5)(a) and (F)(5)(b) of this rule do not meet the individual's needs, the county board may offer the individual an opportunity for placement in an intermediate care facility.

(7) An individual who is disenrolled from the transitions developmental disabilities waiver shall have the opportunity to retain his or her transitions developmental disabilities waiver slot and re-enroll in the same waiver program year, if it is determined that the individual meets the eligibility criteria for the waiver.

(G) Suspension of medicaid waiver payment

(1) In the event an individual is admitted to a hospital, nursing facility, or intermediate care facility as an inpatient or is incarcerated, the county board shall notify the department.

(a) Upon receipt of notification, the department shall suspend medicaid waiver payments for the individual during the time the individual is admitted as an inpatient or is incarcerated.

(b) Within ninety calendar days of the date of admission, if the individual continues to remain in the hospital, nursing facility, or intermediate care facility, the county board shall recommend to the department either disenrollment from the waiver or continued suspension of medicaid waiver payments. If the county board recommends a continued suspension of medicaid waiver payments, it shall provide the following information to the department:

(i) Evidence of reasonable expectations that the individual will return to the community;

(ii) Evidence of active planning to ensure a successful transition to the community; and

(iii) An assurance that services outlined in the individual service plan are sufficient to ensure the individual's health and welfare in the community.

(c) Upon review of the county board's recommendation, the department may grant an extension for a period of time and under such conditions it deems appropriate.

(2) Upon receipt of a recommendation from a county board in accordance with paragraph (F) or (G) of this rule, the department shall within a reasonable period of time, make a determination, inform the county board accordingly, and take whatever additional actions may be required by law, which may include, but are not limited to, proposing to disenroll the individual from the home and community-based services waiver in accordance with paragraph (K) of this rule. If the department determines to disenroll an individual based on a recommendation by the county board, the county board may request a new waiver when the individual is discharged from the hospital, nursing facility, or immediate care facility or is no longer incarcerated.

(H) Waiver capacity

In accordance with section 5126.054 of the Revised Code, a county board shall annually inform the department of its waiver capacity request. Based on the county board's request, the department may authorize enrollment when the number of filled waivers for each year is less than the number of waivers approved by the centers for medicare and medicaid services for that year. The department shall provide notice of waiver capacity to county boards. Within ninety calendar days from receipt of such notice from the department, the county board shall submit the assessments and other necessary enrollment information pursuant to paragraph (E) of this rule. The county board may request and the department may grant for good cause, an extension of the deadline referenced in this paragraph. Failure of the county board to meet the requirements of this paragraph shall result in the department providing the county board with fifteen-calendar-day prior notice that the authorization to enroll pursuant to this rule is to be withdrawn.

(I) Required notices

(1) The department shall send written notice to an individual and the county board when the individual is enrolled in a home and community-based services waiver. The notice shall include the date on which waiver services may be initiated.

(2) The department shall send written notice to an individual and the county board when the individual is disenrolled from a home and community-based services waiver. The notice shall be made in accordance with paragraph (K) of this rule.

(J) Replacement of individuals disenrolled from individual options, level one, or self-empowered life funding waivers

Replacement of an individual disenrolled from the individual options, level one, or self-empowered life funding waiver may be initiated by the county board and authorized by the department when the federally authorized limit of participants and federal financial participation for the current waiver year have not been reached.

(1) The county board shall replace the disenrolled individual within ninety calendar days from the disenrollment notification with an individual selected pursuant to rule 5123:2-1-08 of the Administrative Code.

(2) Failure of the county board to replace a disenrolled individual within ninety calendar days from the disenrollment notification shall result in withdrawal of the waiver capacity by the department.

(K) Due process notification

When denial of enrollment in or disenrollment from a home and community-based services waiver is proposed, the department shall provide written notice to the individual no less than fifteen calendar days prior to the effective date of the proposed action. Notification shall inform the individual of his or her right to a state hearing under section 5101.35 of the Revised Code and Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. If the individual exercises his or her right to appeal within fifteen calendar days of the date of the notice, the proposed action shall not be taken pending the outcome of the state hearing.

Replaces: 5123:2-9-01

Effective: 11/22/2013
R.C. 119.032 review dates: 11/22/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5166.21
Rule Amplifies: 5123.04 , 5166.21
Prior Effective Dates: 06/02/1995 (Emer.), 12/09/1995, 02/28/1996 (Emer.), 05/28/1996, 07/12/1997, 03/21/2002, 04/28/2003

5123:2-9-02 [Rescinded]HCBS waivers - designation of local matching funds.

Effective: 11/18/2010
R.C. 119.032 review dates: 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04
Rule Amplifies: 5111.871 , 5123.04 , 5126.057
Prior Effective Dates: 04/28/2003, 02/16/2007

5123:2-9-03 [Rescinded]HCBS waivers - Allocation of waiver enrollment numbers to county boards.

Effective: 11/18/2010
R.C. 119.032 review dates: 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04
Rule Amplifies: 5111.871 , 5111.872 , 5123.04
Prior Effective Dates: 04/28/2003

5123:2-9-04 Medicaid local administrative authority.

(A) This rule identifies the duties of the medicaid local administrative authority (MLAA) and serves to outline the requirements for home and community-based services waiver administration by a county board that has MLAA in accordance with section 5126.055 of the Revised Code. Nothing in this rule shall be construed to limit the duties, obligations or requirements imposed on a county board as specified in Chapters 5111., 5123., and 5126. of the Revised Code and the Ohio Administrative Code, including but not limited to sections 5111.041 , 5126.055 , and 5126.057 of the Revised Code.

(B) Definitions

(1) "Applicable requirements" means:

(a) Federal and state laws and regulations that govern the conduct of the MLAA and/or the provider, including but not limited to Chapters 4723., 5111., 5123., and 5126. of the Revised Code and all administrative rules promulgated under the authority of these statutes.

(b) Requirements set forth in any waiver approved under the authority of section 1915(c) of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C. 1396n , as amended, under which federal reimbursement is provided for designated home and community-based services to eligible individuals, which is administered by ODMRDD pursuant to an interagency agreement between ODMRDD and ODJFS.

(2) "County board" means a county board of mental retardation and developmental disabilities established under Chapter 5126. of the Revised Code.

(3) "Home and community-based services (HCBS)" has the same meaning as in section 5126.01 of the Revised Code.

(4) "Individual" means a person with mental retardation or other developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for the mentally retarded under the applicable HCBS waiver. A guardian or authorized representative as defined in rule 5101:1-2-01 of the Administrative Code may take any action on behalf of an individual, may make choices for an individual or may receive notice on behalf of an individual to the extent permitted by applicable law.

(5) "Individual service needs addendum" means an individual service needs addendum as described in section 5126.035 of the Revised Code.

(6) "ISP" means the individual service plan, a written description of the services, supports, and activities to be provided to an individual.

(7) "MLAA" means a county board with medicaid local administrative authority pursuant to section 5126.055 of the Revised Code.

(8) "ODJFS" means the Ohio department of job and family services as established by section 121.02 of the Revised Code.

(9) "ODMRDD" means the Ohio department of developmental disabilities as established by section 121.02 of the Revised Code.

(10) "PAWS" means payment authorization for waiver services.

(11) "Provider" means a person who has a medicaid provider agreement issued by ODJFS and is certified by ODMRDD to provide HCBS.

(12) "Service and support administration" means the functions listed in section 5126.15 of the Revised Code.

(13) "Service contract" means a contract for HCBS under section 5126.035 of the Revised Code between the MLAA and the provider.

(C) Duties of MLAA for HCBS

(1) The MLAA shall perform assessments and evaluations of the individual in accordance with division (A)(1) of section 5126.055 of the Revised Code.

(2) ISPs shall be developed for each individual in accordance with applicable requirements and shall:

(a) Be written.

(b) Be developed by the person(s) employed by, or contracting with, the county board that is responsible for service and support administration with the active participation of the individual, other persons chosen by the individual, and, where applicable, the individual's provider in accordance with sections 5126.055 and 5126.15 of the Revised Code.

(c) Describe, regardless of funding source, medical and other services identified through the assessment process to be furnished to the recipient, the service frequency, the service duration, the type of provider who will furnish each service, and the completion and approval date(s) of the ISP.

(d) Be the fundamental tool by which the MLAA and state will ensure the health, safety, and welfare of the individuals served under the waiver. As such, it will be subject to periodic review and update. These reviews will take place to determine the appropriateness and adequacy of the services, and to ensure that the services furnished are consistent with the nature and severity of the individual's disability;

(e) Be updated annually. The ISP shall be updated more frequently if there is a change in the individual's condition, if the individual chooses a new provider or types of services. The county board shall convene an ISP meeting within ten working days of a request from an individual for a review of the ISP.

(f) Be subject to the approval of ODMRDD and ODJFS in accordance with sections 5111.871 and 5126.055 of the Revised Code.

(g) Identify the county board representative(s) responsible for service and support administration.

(h) Maximize the use of natural supports and generic resources.

(i) Be maintained in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(3) If the individual has been identified by ODMRDD as an individual to receive priority for HCBS pursuant to division (D)(3) of section 5126.042 of the Revised Code, the MLAA shall assist ODMRDD in expediting the transfer of the individual from an intermediate care facility for the mentally retarded or nursing facility to HCBS.

(4) In accordance with section 5126.046 of the Revised Code, the MLAA shall assist the individual(s) to choose a qualified and willing provider of the services and, at a hearing under section 5101.35 of the Revised Code, present evidence of the process for appropriate assistance in choosing providers.

(5) A provider is qualified to provide HCBS to an individual if the following requirements are met:

(a) The provider is certified by ODMRDD for the services.

(b) The provider is eligible to enter into or has entered into a service contract with the MLAA in accordance with rule 5123:2-9-05 of the Administrative Code.

(c) The provider has a medicaid provider agreement with ODJFS that covers the services.

(6) Contract for services

(a) The MLAA shall contract for services with service providers chosen by the individual in accordance with sections 5126.035 and 5126.055 of the Revised Code and rule 5123:2-9-05 of the Administrative Code.

(b) The service contract is a two-party contract between the MLAA and the provider.

(c) In the event that an employee of the county board is selected to provide an applicable HCBS waiver service (i.e., homemaker personal care or informal respite) in accordance with the individual options or level one waiver, the provisions of section 5126.033 of the Revised Code must be adhered to and the ethics council of the county board must approve a contract with the employee separate and apart from the employee's employment with the board.

(d) Pursuant to section 5126.046 of the Revised Code, the county board may provide any adult service when selected by an individual, including applicable waiver services as included with a waiver and which constitute adult services as defined in section 5126.01 of the Revised Code.

(7) If the MLAA is a county board that is certified under section 5123.045 of the Revised Code to provide the services and agrees to provide the services to the individual and the individual chooses the county board to provide the services in accordance with section 5126.046 of the Revised Code, the county board may furnish, in accordance with the county board's medicaid provider agreement and for the authorized reimbursement rate, the services the individual requires. The ISP shall be the full scope of the contractual requirement for such services and the individual shall have the right to change providers in accordance with section 5126.046 of the Revised Code. Pursuant to division (A)(6) of section 5126.055 of the Revised Code. ODMRDD shall provide monitoring of such services in addition to the monitoring that the board shall do of its own employees pursuant to applicable regulations.

(8) The MLAA shall monitor the services provided to the individual to ensure the individual's health, safety, and welfare. Monitoring by the MLAA shall include compliance by the provider with quality assurance activities, certification standards and provider adherence to applicable requirements. ODMRDD shall promulgate rules or use existing rules for MLAA monitoring of compliance with standards. Monitoring by the MLAA shall be conducted with strict adherence to rules governing monitoring as established by ODMRDD. If the county board provides the services, then ODMRDD shall also monitor the services provided by the county board.

(9) The MLAA shall take necessary action, in accordance with applicable requirements, to ensure the health, safety and welfare of individuals served.

(10) The MLAA shall take action in accordance with rule 5123:2-8-18 of the Administrative Code if it determines that a deficiency or violation of applicable requirements related to provider certification standards has occurred, but has not resulted in, and is not reasonably likely to result in, a risk to the individual's health, safety, or welfare. The MLAA shall conduct quality assurance reviews in accordance with section 5126.431 of the Revised Code and rule 5123:2-12-01 of the Administrative Code for individuals who receive HCBS in accordance with the definition of supported living in section 5126.01 of the Revised Code.

(11) The MLAA shall have an investigative agent conduct investigations under section 5123.313 of the Revised Code that concern the individual.

(12) The MLAA shall have a service and support administrator perform the duties under division (B)(9) of section 5126.15 of the Revised Code that concern the individual.

(13) The MLAA shall develop and maintain a file for each individual, which, at a minimum, includes the following information:

(a) Copies of required assessments;

(b) Initial and subsequent ISPs, including evidence of the ISP's approval date;

(c) Evidence of ICF/MR level of care determination and redetermination of eligibility at a minimum of each twelve months;

(d) ODMRDD's confirmation of PAWS;

(e) Patient liability amounts and identification of HCBS provider(s) to whom each amount is assigned in accordance with paragraph (M)(2) of rule 5123:1-2-08 , paragraph (L) of rule 5123:1-2-11 of the Administrative Code, paragraph (K)(2) of rule 5123:2-8-16 of the Administrative Code, or paragraph (H)(3) of rule 5123:2-9-06 of the Administrative Code, as applicable.

(f) Evidence of an ISP review at a minimum of every twelve months to determine the appropriateness and adequacy of the services, and to ensure that the services furnished will ensure the individual's health, safety and welfare and are consistent with the nature and severity of the individual's disability.

(g) Evidence that the individual was provided appropriate prior notice of any action to approve, reduce, deny, or terminate HCBS and notice of an opportunity for a fair hearing in accordance with rule 5101:6-2-04 of the Administrative Code.

(h) Identification of the person employed by or under contract with the county board that is responsible for overall service and support administration for the individual.

(14) The county board shall perform its medicaid local administrative authority in accordance with applicable requirements.

(15) The MLAA shall abide by all terms and conditions set forth in the federallyapproved waiver document, including any appendices and attachments. ODMRDD shall assure that each MLAA has a current copy of the HCBS waivers and shall provide training to the MLAA on the terms, conditions, appendices and attachments of each waiver. ODMRDD shall also make such training available to providers.

(16) The MLAA shall maintain current knowledge of state and federal requirements related to HCBS waivers, using information as provided by ODMRDD and ODJFS.

(17) The MLAA may not delegate its medicaid local administrative authority granted under section 5126.055 of the Revised Code, but may contract with a person or government entity, including a council of governments, for assistance with its medicaid local administrative authority. The MLAA that enters into such a contract shall notify the director of ODMRDD. The notice shall include the tasks and responsibilities that the contract gives to the person or government entity. The person or government entity shall comply in full with all requirements to which the MLAA is subject regarding the person or government entity's tasks and responsibilities under the contract. The MLAA remains ultimately responsible for tasks and responsibilities.

(18) The MLAA shall, through ODMRDD and ODJFS, reply to, and cooperate in arranging compliance with, a program or fiscal audit or program violation exception that a state or federal audit or review discovers as required by division (F) of section 5126.055 of the Revised Code. The MLAA, in conjunction with ODMRDD, shall cooperate fully with ODJFS and shall timely prepare and send to ODMRDD a written plan of correction or response to any adverse findings. The MLAA is liable for any adverse findings that result from an action that the MLAA takes or fails to take in its implementation of medicaid local administrative authority.

(19) The MLAA shall correct all deficiencies in the manner and times required by division

(G) of section 5126.055 of the Revised Code.

(20) The MLAA shall pay to ODMRDD an annual fee equal to one per cent of the total value of all medicaid paid claims for home and community-based services for which the MLAA contracts or provides itself as required by section 5123.0412 of the Revised Code. The ODMRDD shall utilize this fee in accordance with section 5123.0412 of the Revised Code.

(21) A county board that has MLAA shall pay the nonfederal share of HCBS waiver expenditures as required by section 5126.057 of the Revised Code and rule 5123:2-9-02 of the Administrative Code, unless ODMRDD is required to pay the nonfederal share under division

(C)

(2) of section 5123.047 of the Revised Code.

(22) The MLAA shall submit a PAWS from to ODMRDD in the format required by ODMRDD within fourteen days of authorization of new services or modification to existing services. Upon receiving confirmation from ODMRDD, the MLAA shall provide a copy of the PAWS to the individual and any service providers that the individual has chosen within fourteen days.

(23) The MLAA shall issue a notice of hearing rights to an individual in accordance with section 5101.35 of the Revised Code when the MLAA recommends the approval, reduction, denial, or termination of the individual's HCBS and such recommendation is not reversed by ODMRDD or ODJFS.

(D) Responsibilities of the ODMRDD for medicaid waiver administration functions

(1) ODMRDD shall oversee MLAA activities to ensure compliance with applicable laws. If ODMRDD determines that the MLAA is deficient in its administration of medicaid waiver services, then ODMRDD may take appropriate actions authorized by applicable law including, but not limited to, division (G) of section 5126.055 of the Revised Code or section 5126.056 of the Revised Code to ensure MLAA compliance with applicable laws.

(2)

(a) If a county board's medicaid local administrative authority for HCBS is terminated in accordance with section 5126.056 of the Revised Code, ODMRDD shall do either of the following:

(i) Contract under section 5126.056 of the Revised Code with another county board that has not had any of its medicaid local administrative authority terminated or another entity to perform waiver administrative activities in accordance with this rule.

(ii) Appoint under section 5126.056 of the Revised Code an administrative receiver to perform waiver administrative activities in accordance with this rule.

(b) A county board whose medicaid local administrative authority for HCBS has been terminated in accordance with section 5126.056 of the Revised Code shall comply with its duties under that statute.

(3) ODMRDD and ODJFS shall seek federal financial participation (FFP) at fifty per cent of total cost for HCBS waiver administration provided in accordance with this rule subject to allowance by federal government.

(a) ODMRDD and ODJFS shall not seek FFP for HCBS waiver administration claims if either agency determines that all or part of the claims do not comply with standards set forth in federal law and OMB circulars and other directives or guidelines issued by the federal government.

(b) ODMRDD and ODJFS shall not seek FFP for HCBS waiver administration claims for any county board that does not have a contract with ODMRDD obligating the county board to abide by federal law including but not limited to the requirements set forth in federal law, OMB circulars, and other directives or guidelines issued by the federal government. The contract required shall be in the form as set forth in appendix A to this rule.

(4) Claims for FFP for HCBS waiver administration activities performed in accordance with this rule shall comply with the following requirements:

(a) The MLAA shall identify the employees and/or persons paid under contract who perform HCBS waiver administration activities and identify for each whether such activities are one hundred per cent or less than one hundred per cent of their time.

(b) The MLAA shall accurately reflect in the employee position description and/or the terms of the contract with the contract entity the HCBS waiver administration activities for which FFP is claimed.

(c) The MLAA shall not claim FFP for HCBS waiver administration, activities billed as targeted case management or service coordination according to rules 5123:2-15-41 and 5101:3-37-19 of the Administrative Code.

(d) The MLAA shall meet the documentation requirements described in paragraph (E) of this rule and the cost reporting requirements described in paragraph (F) of this rule.

(e) The MLAA shall not claim reimbursement as HCBS waiver administration activities functions or services that are not expressly set forth in paragraph (C) of this rule.

(f) The superintendent of a county board shall sign a certification with each claim submission that the claim has been reviewed, and that the claim is in compliance with this rule and federal law, OMB circulars, and other directives or guidelines issued by the federal government.

(5) The MLAA shall be responsible for repayment of any FFP it received for HCBS waiver administration activities if the FFP is required to be repaid to the federal government as the result of a federal or state audit. The MLAA shall immediately reimburse ODMRDD or ODJFS if either state agency is required to repay FFP to the federal government for incorrect payments to the county board for HCBS waiver administrative activities, or if the claims are otherwise denied or deferred by the federal government.

(6) ODMRDD shall assure that PAWS forms appropriately submitted by the MLAA are entered into the medicaid payment system within ten working days of receipt from the county board so that providers are able to receive payment in a timely manner.

(7) If ODMRDD receives from a provider repayment of payments for HCBS under a service contract, ODMRDD shall refund to or otherwise credit the MLAA with the nonfederal share of the repayment if the MLAA paid the nonfederal share.

(E) Documentation requirements for MLAAs for reimbursement of salaries and benefits of persons who perform HCBS waiver administration activities

(1) "Total salary cost," defined as base wages plus fringe benefits, shall be reimbursed on an ongoing basis in accordance with paragraph (E) of this rule.

(2) When MLAA employees and/or persons paid under a contract with a MLAA spend less than one hundred per cent of their time performing HCBS waiver administration activities for which FFP is claimed, each person shall complete a department-approved HCBS waiver activity form. The purpose of the HCBS waiver activity form is to allocate total salary cost between HCBS waiver administration activities and other MLAA activities performed by the person.

(3) The MLAA shall select for all persons who spend less than one hundred per cent of their time performing HCBS waiver administration activities either the periodic or continuous methodology to document the amount of time spent in the performance of these activities.

(a) A periodic methodology requires HCBS waiver administration activities to be documented for one week each month as specified by the department.

(b) A continuous methodology requires HCBS waiver administration activities to be documented on a daily basis.

(c) The MLAA may elect to change this methodology on January first of each year upon providing written notification to the department.

(d) HCBS waiver administration activities provided under these conditions shall be documented in quarter-hour increments.

(4) Clerical/support staff shall document their performance of HCBS waiver administration activities for which FFP is claimed using the HCBS waiver activity form. Documentation is to be completed following completion of the administration activity.

(5) Supporting documentation shall verify that the HCBS waiver administration activity noted on the waiver activity form occurred. The documentation may include, but is not limited to, individual's records, copies of ISPs, employee calendars, appointment schedules, mileage records, copies of letters, and activity check lists.

(6) To obtain FFP reimbursement, the MLAA shall submit an invoice, department-approved employee rosters, and supporting activity sheets to the department on a monthly basis.

(7) The MLAA shall ensure that all necessary financial and statistical data supporting the claim for reimbursement is made available to ODMRDD, ODJFS, the United States department of health and human services, and any other state or federal agency having audit authority.

(8) The MLAA shall maintain all records and forms necessary to fully disclose the extent of services provided and related business transactions for a period of seven years from the date of receipt of payment, or for six years after any initiated audit is completed and adjudicated, whichever is longer.

(9) ODMRDD shall provide training, at least annually, to MLAAs on proper methods for documentation and billing of FFP.

(F) Cost reporting requirement for MLAAs for allowable waiver administration overhead and other costs

(1) Total overhead and other costs shall be reimbursed on an annual basis in accordance with paragraph (F) of this rule.

(a) "Overhead costs" are defined as the approved portion of administration, capital, and building service costs allocated to HCBS waiver administration activities.

(b) "Other costs" are defined as travel, equipment less than five hundred dollars, equipment repairs, supplies, liability insurance, advertisement, printing, and other miscellaneous expenses directly assignable to HCBS waiver administration activities.

(2) The MLAA shall identify and report all HCBS waiver administration activity costs on the operating and expenditure report submitted to ODMRDD pursuant to section 5126.12 of the Revised Code.

(3) An annual reconciliation shall be performed by ODMRDD for all medicaid allowable overhead costs and other costs as reported for waiver administration activities.

(4) All HCBS waiver administration costs reported shall be subject to audit and final cost settlement. ODMRDD or ODJFS may audit any funds a county board or contractor receives for waiver administration, including any source documentation supporting the receipts and disbursements associated with such funds.

(G) Medicaid recipient and medicaid applicant appeals

(1) Any recipient of or applicant for HCBS may utilize the process set forth in section 5101.35 of the Revised Code for any purpose authorized by that statute or rules promulgated implementing that statute. The process set forth in section 5101.35 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives.

(2) Providers shall not utilize, or attempt to utilize, the process set forth in section 5101.35 of the Revised Code. Providers shall not appeal or pursue any other legal challenge to a decision resulting from the process set forth in section 5101.35 of the Revised Code.

(3) Applicants for and recipients of HCBS shall use the process set forth in section 5101.35 of the Revised Code for any challenge to the type, amount, scope or duration of services included or excluded from an ISP or an individual service needs addendum. Providers shall have no standing in an appeal under section 5101.35 of the Revised Code, or in any other forum to challenge the type, amount, scope or duration of services included or excluded from an ISP or an individual service needs addendum.

(4) The MLAA shall implement any final state hearing decision or administrative appeal decision issued by ODJFS, unless a court of competent jurisdiction modifies such decision as the result of an appeal by the medicaid applicant or recipient.

(H) Provider challenges to the MLAA's actions in the performance of its duties

(1) Any action proposed or initiated by the MLAA regarding a service contract for non-medicaid services shall not be governed by this rule.

(2) A provider shall follow the procedures set forth in rule 5123:2-8-18 of the Administrative Code to challenge any recommendations, determinations, or corrective action plans issued by the MLAA resulting from the MLAA's monitoring. Those procedures shall be the exclusive remedies for resolving any such provider challenge.

(3) Except as provided in paragraphs (H)(2) and (I) of this rule, a provider may follow the procedures set forth in section 5126.036 of the Revised Code to challenge any of the following:

(a) Recommendations, determinations, or corrective action plans issued by the MLAA relating to or resulting from any of its duties enumerated in paragraph (C) of this rule.

(b) An action the MLAA has taken or has not taken that is required by a service contract for HCBS.

(c) The MLAA's refusal to enter into a service contract for HCBS with the provider.

(d) The MLAA's termination of a service contract for HCBS between the provider and the MLAA.

(I) Provider certification disputes and medicaid provider agreement disputes

(1) Providers of HCBS may pursue all remedies for disputes regarding their certification or their medicaid provider agreements available to them under Chapter 119. of the Revised Code as presently authorized by law.

(2) No action taken by the MLAA shall constitute an adjudication entitling a HCBS provider with the right to pursue a remedy under Chapter 119. of the Revised Code. Any recommendation by the MLAA for decertification of a provider shall be referred to ODMRDD for any action it determines is necessary.

(J) Immediate corrective action by the MLAA to ensure health, safety, and welfare

The MLAA may take immediate action to ensure the health, safety and welfare of an individual receiving HCBS where there is substantial risk of immediate harm to the individual only as expressly provided for in law. Nothing in this rule shall limit the authority of county boards to take immediate action to ensure an individual's health, safety, and welfare as provided for under law.

(K) Federal financial participation (FFP)

(1) The MLAA shall not authorize payment for HCBS prior to the approval date of the ISP including approval of emergency services.

(2) The MLAA shall ensure that FFP is not claimed for the cost of room and board, except when provided as part of respite care in a facility approved by ODMRDD that is not a private residence.

(3) FFP shall not be claimed for waiver services furnished to recipients while they are inpatients of a hospital, a nursing facility, or an ICF/MR (except for respite or institutional respite appropriately provided in a licensed facility).

Appendix A

Contract Between Ohio Department of Developmental Disabilities and _____________County Board of MR/DD

The parties agree to allow the _________ County Board of MR/DD to administer Home and Community-Based Services within _________ County. The _________ County Board of MR/DD shall administer these services in accordance with rule 5123:2-9-04 of the Administrative Code. The_________ County Board of MR/DD may submit claims for HCBS waiver administrative reimbursement to the Ohio Department of Developmental Disabilities. By claiming or receiving federal funds under the Medicaid program the _________ County Board of MR/DD shall be subject to audits by the Ohio Department of Developmental Disabilities, and by the Ohio Department of Job and Family Services in accordance with section 5111.85 of the Revised Code.

Approved by:

___________________ _________________

President Director

___________ County Board of MR/DD Ohio Department of Mental Retardation

[INSERT ADDRESS] and Developmental Disabilities

1810 Sullivant Avenue

Columbus, Ohio 43223-1239

Eff 6-2-95 (Emer.); 8-31-95; 8-18-96; 7-12-97; 1-1-98; 10-16-03
Rule promulgated under: RC 119.03
Rule authorized by: RC 5126.05 , 5126.08 , 5111.871 , 5123.04
Rule amplifies: RC 5123.04 , 5126.036 , 5126.05 , 5126.055 , 5126.08 , 5126.056 , 5126.057 , 5126.15 , 5111.871
Replaces 5123:1-2-02 R.C. 119.032 review dates: 10/16/2008

5123:2-9-05 [Rescinded]HCBS waivers - waiver service documentation requirements for services provided to individuals.

Effective: 04/19/2012
R.C. 119.032 review dates: 11/22/2011
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04
Rule Amplifies: 5111.871 , 5123.04
Prior Effective Dates: 09/30/2005

5123:2-9-06 Home and community-based services waivers - documentation and payment for services under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to establish the standards governing documentation and payment for home and community-based services under the individual options waiver and level one waiver components of the medicaid program that the Ohio department of developmental disabilities administers pursuant to section 5111.871 of the Revised Code.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "Cost projection and payment authorization" means the process followed and the form used by county boards of developmental disabilities (including the payment authorization for waiver services) to communicate the frequency, duration, scope, and amount of payment requested for each home and community-based services waiver service that is identified in the individual service plan.

(3) "Cost projection tool" means the web-based analytical tool, developed and administered by the department, used to project the cost of home and community-based services waiver services identified in the individual service plans of individuals enrolled in individual options and level one waivers. The department shall publish any changes to the cost projection tool thirty days prior to implementation.

(4) "County board" means a county board of developmental disabilities.

(5) "Department" means the Ohio department of developmental disabilities.

(6) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(7) "Funding range" means one of the dollar ranges contained in appendix A to this rule to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(8) "Guardian" means a guardian appointed by the probate court under Chapter 2111. of the Revised Code. If the individual is a minor, "guardian" means the individual's parents. If no guardian has been appointed for a minor under Chapter 2111. of the Revised Code and the minor is in the legal or permanent custody of a government agency or person other than the minor's natural or adoptive parents, "guardian" means that government agency or person. "Guardian" includes an agency under contract with the department for the provision of protective service under sections 5123.55 to 5123.59 of the Revised Code.

(9) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised Code.

(10) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(11) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(12) "Individual funding level" means the total funds, calculated on a twelve-month basis, that result from applying the payment rates in service-specific rules in Chapter 5123:2-9 of the Administrative Code to the units of all waiver services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation established by the individual service plan development process to be sufficient in frequency, duration, and scope to meet the health and welfare needs of an individual enrolled in the individual options waiver. Unless prior authorization has been obtained in accordance with rule 5123:2-9-07 of the Administrative Code, the individual funding level for services paid in accordance with this rule shall be within or below the funding range assigned to the individual as the result of administration of the Ohio developmental disabilities profile.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual in accordance with paragraph (H) of rule 5101:3-40-01 of the Administrative Code or paragraph (H) of rule 5101:3-42-01 of the Administrative Code, as applicable.

(14) "Natural supports" means the personal associations and relationships typically developed in the community that enhance the quality of life for individuals. Natural supports may include family members, friends, neighbors, and others in the community or organizations that serve the general public who provide voluntary support to help an individual achieve agreed upon outcomes through the individual service plan development process.

(15) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(16) "Prior authorization" means the process to be followed in accordance with rule 5123:2-9-07 of the Administrative Code to authorize an individual funding level for an individual enrolled in the individual options waiver that exceeds the maximum value of the funding range.

(17) "Provider" means an agency provider or independent provider that:

(a) Is certified by the department to provide home and community-based services waiver services; and

(b) Has a medicaid provider agreement with the Ohio department of medicaid.

(18) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(19) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in service-specific rules in Chapter 5123:2-9 of the Administrative Code to validate payment for medicaid services.

(20) "Team" has the same meaning as in rule 5123:2-1-11 of the Administrative Code.

(21) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(22) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Funding ranges and individual funding levels for individuals enrolled in the individual options waiver

(1) Individuals enrolled in the individual options waiver shall be assigned to a funding range based on completion and scoring of the Ohio developmental disabilities profile and the cost-of-doing-business category that applies to the county in which the individual receives the preponderance of services. The funding ranges are contained in appendix A to this rule. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) The funding ranges shall consider:

(a) The natural supports available to the individual;

(b) The individual's living arrangement;

(c) The individual's behavior support and medical assistance needs;

(d) The individual's mobility;

(e) The individual's ability for self care; and

(f) Any other variable that significantly impacts the individual's needs as determined by the department through statistical analysis.

(3) The service and support administrator shall ensure that an Ohio developmental disabilities profile is completed with input from the individual and the team. The service and support administrator shall inform the individual, and the team with consent of the individual, of the assigned funding range at the time of enrollment and any time the Ohio developmental disabilities profile is reviewed or updated. The service and support administrator shall ensure the individual, and the team with consent of the individual, have access to review the Ohio developmental disabilities profile and other assessments used in relation to completion of the Ohio developmental disabilities profile.

(4) Following assignment of a funding range, an individual service plan that ensures health and welfare shall be reviewed, revised, or developed with the individual. The service and support administrator shall ensure that individuals share services to whatever extent practical and with the agreement of the team. Paid services should be used in conjunction with available natural supports. The service and support administrator shall ensure that development or revision of the individual service plan addresses the availability of natural supports that currently exist or could be developed to meet assessed needs, including:

(a) Supports that family members provide including, but not limited to, basic personal care, performing health care activities, transportation, attending family/social/recreational activities, laundry, meal preparation, and grocery shopping; and

(b) Supports that friends, neighbors, and others in the community provide.

(5) The county board shall apply rates for the units of each waiver service, other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation, resulting from completion of the individual service plan development process to calculate the individual funding level.

(6) The county board shall determine whether the individual funding level is within, exceeds, or is below the assigned funding range for the individual. The service and support administrator shall inform the individual of this determination in accordance with procedures developed by the department.

(7) When an individual service plan is revised and a new funding level is determined, the providers of waiver services to the individual shall verify to the county board the number of units of each waiver service delivered during the individual's current waiver eligibility span so that the county board may accurately calculate the number of units of services available for the individual's use during the remainder of the waiver eligibility span.

(8) The county board shall complete the cost projection and payment authorization and the service and support administrator shall ensure waiver services are initiated for an individual whose funding level is within the funding range determined by the Ohio developmental disabilities profile. The service and support administrator shall inform the individual in writing and in a form and manner the individual can understand of the individual's due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

(9) When the individual funding level exceeds the assigned funding range:

(a) The county board shall inform the individual of the individual's right to request prior authorization to obtain services that result in an individual funding level that exceeds the funding range using the process described in rule 5123:2-9-07 of the Administrative Code.

(b) If, through the prior authorization process, the request for the funding level is approved, the county board shall ensure the cost projection and payment authorization is completed and waiver services are initiated.

(c) If, through the prior authorization process, the request for the funding level is denied, the service and support administrator shall continue the individual service plan development process to determine if an individual service plan that assures the individual's health and welfare can be developed within the individual's funding range.

(i) If an individual service plan that meets these conditions is developed, the county board shall ensure the cost projection and payment authorization is completed and shall ensure waiver services are initiated.

(ii) If an individual service plan that meets these conditions cannot be developed, the county board shall propose to deny the individual's initial or continuing enrollment in the waiver and inform the individual of the individual's due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

(10) The department shall use the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date to verify that cumulative payments made for waiver services remain within the approved funding range for each individual or that cumulative payments made for waiver services remain within the approved funding range when prior authorization has been granted.

(11) The department shall periodically re-examine the scoring of the Ohio developmental disabilities profile and the linkage of the scores to the funding ranges.

(D) Payment limitations under the level one waiver

(1) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, residential respite, and transportation, alone or in combination, shall not exceed five thousand dollars per waiver eligibility span.

(2) Under the level one waiver, payment for environmental accessibility adaptations, home-delivered meals, personal emergency response systems, remote monitoring, remote monitoring equipment, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

(3) In accordance with rule 5123:2-9-27 of the Administrative Code, payment for emergency assistance under the level one waiver shall not exceed eight thousand dollars within a three-year period.

(E) Changes to individual funding levels and funding ranges

(1) The individual funding level may increase or decrease based on the outcome of the individual service plan development process. In no instance shall the individual funding level exceed the cost cap approved for the waiver in which the individual is enrolled. The county board has the authority and responsibility to make changes to individual funding levels which result from the individual service plan development process in accordance with paragraph (C) of this rule. Changes to individual funding levels are subject to review by the department.

(2) A funding range established for an individual shall change only when changes in assessment variable scores on the Ohio developmental disabilities profile justify assignment of a new funding range. Any or all Ohio developmental disabilities profile variables may be revised at any time at the request of the individual or at the discretion of the service and support administrator, with the individual's knowledge.

(3) Neither the department nor the county board shall recommend a change in individual funding level within the funding range or assign a new funding range after notification that the individual has requested a hearing pursuant to section 5101.35 of the Revised Code concerning the approval, denial, reduction, or termination of services.

(F) Staffing ratios

(1) In situations where more than one staff member serves more than one individual simultaneously, the individuals' needs and circumstances shall determine staffing ratios, based on a unit of one staff to the portion of the total group that includes the individual. Only when it is impractical to determine staff ratios based on a unit of one staff, the provider shall, as authorized in the individual service plan, use the applicable service codes and payment rates established in service-specific rules in Chapter 5123:2-9 of the Administrative Code to indicate both staff size and group size.

(2) Staffing ratios do not change at times when one or more individuals, for whom the staff is responsible, are not physically present, but are within verbal, visual, or technological supervision of the staff providing the service. Technological supervision includes staff contact with individuals through telecommunication and/or electronic signaling devices.

(G) Projection of the cost of an individual's services

(1) Prior to the beginning of an individual's waiver eligibility span, the individual's service and support administrator or other county board designee shall prepare a projection of the annual cost of every individual options or level one waiver service that is authorized in the individual service plan for the waiver eligibility span using the cost projection tool.

(2) The cost projection shall be based on staffing ratios and the total estimated number of service units the individual is expected to receive in accordance with his or her individual service plan during the waiver eligibility span. Staffing ratios contained in the cost projection tool shall be considered a part of the individual service plan.

(3) The total number of service units shall be determined with input from the individual and his or her team as part of the individual service plan development process.

(4) The cost projection tool shall project the cost of services based on the payment rates established in service-specific rules in Chapter 5123:2-9 of the Administrative Code.

(5) Rule 5123:2-9-31 of the Administrative Code shall govern the circumstances when an individual receives the homemaker/personal care daily billing unit.

(6) The cost projection tool shall be utilized to project costs based on medicaid payment rates for individuals, regardless of funding source, who share services with individuals enrolled in home and community-based services waivers.

(7) The individual's provider shall have access to the cost projection tool including, but not limited to, the detail and summary information. At the request of the individual, other persons shall have access to the detail and summary information in the cost projection tool.

(8) When changes occur that the team determines affect the total estimated direct service hours, the county board shall enter changes to the cost projection tool. These changes shall be made along with any necessary revisions to the individual service plan, daily rate application, cost projection and payment authorization, and prior authorization request (as applicable) for the individual or individuals affected by the changes.

(9) County boards shall complete a cost projection using the cost projection tool when an individual is initially enrolled in an individual options or level one waiver and when an individual is annually re-determined eligible for continued enrollment in an individual options or level one waiver. The cost projection tool shall be the only authorized cost projection instrument.

(H) Service documentation

(1) Providers shall maintain service documentation in accordance with this rule and service-specific rules in Chapter 5123:2-9 of the Administrative Code.

(2) Invoices a provider submits to the department for payment for services delivered shall not be considered service documentation. Any information contained in the submitted invoice may not and shall not be substituted for any required service documentation information that a provider is required to maintain to validate payment for medicaid services.

(3) Each provider shall maintain all service documentation in an accessible location. The service documentation shall be available, upon request, for review by the centers for medicare and medicaid services, the Ohio department of medicaid, the department, a county board or regional council of governments that submits to the department payment authorization for the service, and those designated or assigned authority by the Ohio department of medicaid or the department to review service documentation.

(4) If a provider discontinues operations, the provider shall, within seven days of discontinuance, notify the county boards for the counties in which individuals to whom the provider has provided services reside, of the location where the service documentation will be stored, and provide the county board with the name and telephone number of the person responsible for maintaining the service documentation.

(I) Payment for waiver services

(1) Providers shall be paid at the lesser of their usual and customary rate or the payment rate for each waiver service that is delivered. The department shall establish a mechanism through which providers shall communicate their usual and customary rates to the department. A single provider may charge different usual and customary rates for the same service when the service is provided in different geographic areas of the state. In this instance, the usual and customary rates charged shall be declared for each cost-of-doing-business category contained in appendix B to this rule that identifies the counties in which the provider intends to provide specific services. Upon notification of a provider's usual and customary rate or change in usual and customary rate, the department shall provide notice to the appropriate county board.

(2) The billing units, service codes, and payment rates for waiver services are contained in service-specific rules in Chapter 5123:2-9 of the Administrative Code including, but not limited to:

(a) 5123:2-9-14 (vocational habilitation under the individual options and level one waivers);

(b) 5123:2-9-15 (supported employment-community under the individual options and level one waivers);

(c) 5123:2-9-16 (supported employment-enclave under the individual options and level one waivers);

(d) 5123:2-9-17 (adult day support under the individual options and level one waivers);

(e) 5123:2-9-18 (non-medical transportation under the individual options and level one waivers);

(f) 5123:2-9-21 (informal respite under the level one waiver);

(g) 5123:2-9-22 (community respite under the individual options and level one waivers);

(h) 5123:2-9-23 (environmental accessibility adaptations under the individual options and level one waivers);

(i) 5123:2-9-24 (transportation under the individual options and level one waivers);

(j) 5123:2-9-25 (specialized medical equipment and supplies under the individual options and level one waivers);

(k) 5123:2-9-26 (personal emergency response systems under the level one waiver);

(l) 5123:2-9-27 (emergency assistance under the level one waiver);

(m) 5123:2-9-28 (nutrition services under the individual options waiver);

(n) 5123:2-9-29 (home-delivered meals under the individual options and level one waivers);

(o) 5123:2-9-30 (homemaker/personal care under the individual options and level one waivers);

(p) 5123:2-9-31 (homemaker/personal care daily billing unit under the individual options waiver);

(q) 5123:2-9-32 (adult family living under the individual options waiver);

(r) 5123:2-9-33 (adult foster care under the individual options waiver);

(s) 5123:2-9-34 (residential respite under the individual options and level one waivers);

(t) 5123:2-9-35 (remote monitoring and remote monitoring equipment under the individual options and level one waivers);

(u) 5123:2-9-36 (interpreter services under the individual options waiver); and

(v) 5123:2-9-38 (social work under the individual options waiver).

(3) The department shall periodically collect payment information for a comprehensive, statistically valid sample of individuals from providers of home and community-based services at the time the information is collected. Based upon the department's review of the information, the department shall recommend to the Ohio department of medicaid any changes necessary to assure that the payment rates are sufficient to enlist enough waiver providers so that waiver services are readily available to individuals, to the extent that these types of services are available to the general population, and that provider payment is consistent with efficiency, economy, and quality of care.

(4) Payment for a home and community-based services waiver service constitutes payment in full. Payment shall be made for home and community-based services waiver services when:

(a) The service is identified in an approved individual service plan;

(b) The service is recommended for payment through the cost projection and payment authorization process; and

(c) The service is provided by a provider selected by an individual enrolled in the waiver.

(5) Payment for waiver services shall not exceed amounts authorized through the cost projection and payment authorization for the individual's corresponding waiver eligibility span.

(J) Claims for payment for home and community-based services waiver services

(1) When home and community-based services are also available on the state plan, state plan services shall be billed first. Only those home and community-based services waiver services in excess of those covered under the state plan shall be authorized.

(2) Claims for payment for home and community-based services waiver services shall be submitted to the department in the format prescribed by the department. The department shall inform county boards of the billing information submitted by providers in a manner and at a frequency necessary to assist the county boards to manage the waiver expenditures being authorized.

(3) Claims for payment shall be submitted within three hundred fifty days after the home and community-based services waiver service is provided. Payment shall be made in accordance with the requirements of rule 5101:3-1-19 of the Administrative Code. Claims for payment shall include the number of units of service. Except for claims for homemaker/personal care daily billing unit, claims for payment shall include the number of staff providing the service and the number of individuals sharing the service.

(4) All home and community-based services waiver service providers shall take reasonable measures to identify any third-party health care coverage available to the individual and file a claim with that third party in accordance with the requirements of rule 5101:3-1-08 of the Administrative Code.

(5) For individuals with a monthly patient liability for the cost of home and community-based services waiver services, as defined in rule 5101:1-39-24 of the Administrative Code, and determined by the county department of job and family services for the county in which the individual resides, payment is available only for the home and community-based services waiver services delivered to the individual that exceed the amount of the individual's monthly patient liability. Verification that patient liability has been satisfied shall be accomplished as follows:

(a) The department shall provide notification to the appropriate county board identifying each individual who has a patient liability for home and community-based services waiver services and the monthly amount of the patient liability.

(b) The county board shall assign the home and community-based services waiver services to which each individual's patient liability shall be applied and assign the corresponding monthly patient liability amount to the home and community-based services waiver service provider that provides the preponderance of home and community-based services waiver services. The county board shall notify each individual and home and community-based services waiver service provider, in writing, of this assignment.

(c) Upon submission of a claim for payment, the designated home and community-based services waiver services provider shall report the home and community-based services waiver service to which the patient liability was assigned and the applicable patient liability amount on the claim for payment using the format prescribed by the department.

(6) The department, the Ohio department of medicaid, the centers for medicare and medicaid services, and/or the auditor of state may audit any funds a provider of home and community-based services waiver services receives pursuant to this rule, including any source documentation supporting the claiming and/or receipt of such funds.

(7) Overpayments, duplicate payments, payments for services not rendered, payments for which there is no documentation of services delivered or for which the documentation does not include all of the items required in service-specific rules in Chapter 5123:2-9 of the Administrative Code, or payments for services not in accordance with an approved individual service plan are recoverable by the department, the Ohio department of medicaid, the auditor of state, or the office of the attorney general. All recoverable amounts are subject to the application of interest in accordance with rules 5101:3-1-25 and 5101:6-51-03 of the Administrative Code, as applicable.

(8) Providers of home and community-based services waiver services shall maintain the records necessary and in such form to disclose fully the extent of home and community-based services waiver services provided, for a period of six years from the date of receipt of payment or until an initiated audit is resolved, whichever is longer. The records shall be made available upon request to the department, the Ohio department of medicaid, the centers for medicare and medicaid services, and/or the auditor of state. Providers who fail to produce the records requested within thirty days following the request shall be subject to decertification and/or loss of their medicaid provider agreement.

(K) Due process rights and responsibilities

(1) Any applicant for or recipient of waiver services administered by the department may utilize the process set forth in section 5101.35 of the Revised Code, in accordance with division 5101:6 of the Administrative Code, for any purpose authorized by that statute and the rules implementing the statute. The process set forth in section 5101.35 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives. Providers shall have no standing in an appeal under this section.

(2) Applicants for and recipients of waiver services administered by the department shall use the process set forth in section 5101.35 of the Revised Code for any challenge related to the administration and/or scoring of the Ohio developmental disabilities profile or to the type, amount, level, scope, or duration of services included on or excluded from an individual service plan or individual behavior plan addendum. A change in staff to waiver recipient service ratios does not necessarily result in a change in the level of services received by an individual.

(L) Ohio department of medicaid authority

The Ohio department of medicaid retains final authority to establish funding ranges for waiver services; to establish payment rates for waiver services; to review and approve each service identified in an individual service plan that is funded through a home and community-based services waiver; and to authorize the provision of and payment for waiver services through the cost projection and payment authorization.

Replaces: 5123:2-9-06

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 09/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04
Rule Amplifies: 5111.871 , 5111.873 , 5123.04
Prior Effective Dates: 07/01/2005, 09/30/2005, 07/01/2007, 12/21/2007 (Emer.), 03/20/2008, 07/01/2010, 04/19/2012

5123:2-9-07 Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver.

(A) Purpose

The purpose of this rule is to establish standards and procedures for prior authorization of waiver services when an individual funding level exceeds the funding range determined by the Ohio developmental disabilities profile for individuals enrolled in the individual options waiver.

(B) Definitions

(1) "Cost projection tool" means the web-based analytical tool, developed and administered by the department, used to project the cost of waiver services identified in the individual service plans of individuals enrolled in individual options and level one waivers.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123:2-9-06 of the Administrative Code to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(6) "Individual funding level" means the total funds, calculated on a twelve-month basis, that result from applying the payment rates in service-specific rules in Chapter 5123:2-9 of the Administrative Code to the units of all waiver services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation established by the individual service plan development process to be sufficient in frequency, duration, and scope to meet the health and welfare needs of an individual enrolled in the individual options waiver.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "Medicaid services system" means the comprehensive information system that integrates cost projection, prior authorization, daily rate calculation, and payment authorization of waiver services.

(9) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(10) "Prior authorization" means the process to be followed in accordance with this rule to authorize an individual funding level for an individual enrolled in the individual options waiver that exceeds the maximum value of the funding range.

(11) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(12) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility redetermination date.

(C) Standards

(1) The county board shall inform an individual, in writing, of the individual's right to request prior authorization whenever development or proposed revision of the individual service plan results in an individual funding level that exceeds the funding range assigned to the individual.

(2) Unless a request for prior authorization has been approved in accordance with this rule, the individual funding level for services shall be within or below the funding range assigned to the individual.

(3) Approval of a request for prior authorization is valid only for the duration of the individual's waiver eligibility span for which the request was made.

(D) Procedures

(1) An individual shall initiate the prior authorization process by submitting a signed and dated request to the county board. A county board shall assist in the preparation of the request when the individual requests assistance.

(2) The county board shall submit the request for prior authorization with the current or proposed individual service plan and supporting documentation to the department through the medicaid services system within ten business days of receiving the individual's request. Supporting documentation shall provide evidence that requested services are medically necessary in accordance with criteria set forth in paragraph (D)(6) of this rule.

(3) When the county board is unable to support the request based on the county board's documentation that the services do not meet the criteria set forth in paragraph (D)(6) of this rule, the county board shall provide to the department:

(a) A detailed description of the county board's efforts to develop an individual service plan that results in an individual funding level within the funding range assigned to the individual; and

(b) An alternative cost projection that ensures the health and safety of the individual and the date the alternative cost projection was reviewed and declined by the individual.

(4) Within ten business days of receiving the request, the department shall notify the county board if additional information is needed to make a determination.

(5) The department shall review the request and make a determination within ten business days of receiving all necessary information.

(6) When reviewing a request, the department shall determine whether the waiver services for which prior authorization is requested are medically necessary. The department shall determine the services to be medically necessary if the services:

(a) Are appropriate for the individual's health and welfare needs, living arrangement, circumstances, and expected outcomes; and

(b) Are of an appropriate type, amount, duration, scope, and intensity; and

(c) Are the most efficient, effective, and lowest cost alternative that, when combined with non-waiver services, ensure the health and welfare of the individual receiving the services; and

(d) Protect the individual from substantial harm expected to occur if the requested services are not authorized.

(7) The department may limit its review to the individual's request in the medicaid services system and the cost projection tool that produced an individual funding level that exceeds the funding range assigned to the individual when the county board supports the request and:

(a) The projected individual funding level exceeds the funding range assigned to the individual by no more than ten per cent; or

(b) The request is for an individual for whom prior authorization has been approved for a previous waiver eligibility span and the request includes an attestation by the service and support administrator that the individual's needs, waiver services, and cost of waiver services have not changed since the preceding request.

(8) Based on its review, the department shall:

(a) Approve the request if it finds that the services for which prior authorization is requested meet the criteria set forth in paragraph (D)(6) of this rule; or

(b) Deny the request; or

(c) Approve the request for a partial or full waiver eligibility span for all or some of the services provided the criteria set forth in paragraph (D)(6) of this rule are met.

(9) When the department approves a request for prior authorization, the department shall:

(a) Issue written notification to the individual which reflects the total amount authorized for the current waiver eligibility span and includes the individual's right to request a hearing in accordance with section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code; and

(b) Update the prior authorization status to reflect its determination in the medicaid services system.

(10) When the department denies a request for prior authorization, the department shall:

(a) Issue written notification to the individual which includes the individual's right to request a hearing in accordance with section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code; and

(b) Update the prior authorization status to reflect its determination in the medicaid services system.

(11) When the request for prior authorization is denied, the individual and the service and support administrator shall meet to revise the individual service plan.

(E) If the individual requests a hearing in accordance with paragraph (D)(9)(a) or (D)(10)(a) of this rule, the county board shall offer a county conference in accordance with rule 5101:6-5-01 of the Administrative Code and comply with applicable requirements of division 5101:6 of the Administrative Code.

(F) Failure by a county board or the department to comply with the timelines established in this rule shall not constitute approval of a request for prior authorization.

(G) The department shall submit to the Ohio office of medical assistance, on a quarterly basis, a summary of requests for prior authorization received. The department shall also systematically evaluate compliance with prior authorization requirements by verifying that each individual funding level is maintained within the prior authorized amount and providing the results of this evaluation in writing to the Ohio office of medical assistance no less than quarterly.

Replaces: Part of 5101:3-41-12

Effective: 01/17/2013
R.C. 119.032 review dates: 01/17/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04
Rule Amplifies: 5111.871 , 5123.04
Prior Effective Dates: 07/01/2005

5123:2-9-08 [Rescinded]HCBS waivers - Compliance reviews of certified HCBS waiver providers.

Effective: 03/14/2013
R.C. 119.032 review dates: 11/30/2012
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04 , 5123.045 , 5123.19 , 5126.05 , 5126.08 , 5126.431
Rule Amplifies: 5111.871 , 5123.04 , 5123.045 , 5123.19 , 5126.05 , 5126.08 , 5126.431
Prior Effective Dates: 10/16/2003, 07/08/2004, 07/01/2005

5123:2-9-09 HCBS waivers - application, issuance, and denial procedures. [Rescinded].

Rescinded eff 10-1-09

5123:2-9-10 HCBS waivers - day habilitation. [Rescinded].

Rescinded eff 10-5-08

5123:2-9-11 HCBS waivers - free choice of provider.

(A) Purpose

The purpose of this rule is to establish procedures for individuals to choose qualified and willing providers of home and community-based services in accordance with provisions set forth in sections 5126.046 and 5123.044 of the Revised Code. This rule clarifies the department's role in assuring the free choice of provider processes are adhered to and is intended to emphasize the right of individuals to choose any qualified provider of home and community-based services. Nothing in this rule shall have the effect or shall be interpreted as limiting that choice.

(B) Application

(1) This rule applies to all county boards; to all persons responsible for service and support administration in accordance with section 5126.15 of the Revised Code when assisting individuals/guardians who may be eligible for services through a county board to select home and community-based service providers; and to qualified providers of home and community-based services. This rule is applicable to qualified providers of home and community-based services when these services are provided in a facility licensed by the department in accordance with section 5123.19 of the Revised Code. The requirements of this rule supersede the requirements contained in paragraphs (C)(4), (C)(5), (C)(6), (C)(7) and (G)(1)(a) of rule 5123:2-3-05 of the Administrative Code.

(2) Notwithstanding paragraph (G)(1) of this rule, the SSA shall follow the provider choice process set forth in paragraphs (H) and (I) of this rule for each service specified in an ISP, at the time of an individual's enrollment in a home and community-based services program, annually at the time of re-determination, and at any other time the individual/guardian expresses an interest in or makes a request to choose a new, different or additional provider.

(C) Definitions

(1) "County board" means a county board of mental retardation and developmental disabilities established under Chapter 5126. of the Revised Code or a regional council of government comprised of two or more county boards and formed under section 5126.13 of the Revised Code.

(2) "Department" means the Ohio department of developmental disabilities as established by section 121.02 of the Revised Code.

(3) "Guardian" means a guardian appointed by the probate court under Chapter 2111. of the Revised Code. If the individual is a minor for whom no guardian has been appointed under that chapter, "guardian" means the individual's parents. If no guardians have been appointed for a minor and the minor is in the legal or permanent custody of a government agency or person other than the minor's natural or adoptive parents, "guardian" means that government agency or person. "Guardian" also includes an agency under contract with the department for the provision of protective service under sections 5123.55 to 5123.59 of the Revised Code.

(4) "Home and community-based services" means medicaid funded home and community-based services provided under a medicaid component the department administers pursuant to section 5111.871 of the Revised Code, as described and modified through rules promulgated by ODJFS and the department.

(5) "Individual" means a person with mental retardation or other developmental disability who is eligible to receive home and community-based services as an alternative to receiving services in an intermediate care facility for the mentally retarded under the applicable waiver. A guardian may take any action on behalf of the individual, make choices for an individual, or may receive notice on behalf of an individual to the extent permitted by applicable law.

(6) "ISP" means the individual service plan, a written description of the services, supports and activities to be provided to an individual.

(7) "ODJFS" means the Ohio department of job and family services as established by section 121.02 of the Revised Code.

(8) "Qualified provider" means an agency or individual certified by the department to provide home and community-based services and who has a medicaid agreement with ODJFS that covers the services.

(9) "Service and support administration" means the duties performed by individuals employed or under contract with a county board to provide service and support administration as identified in section 5126.15 of the Revised Code.

(10) "SSA" means service and support administrators who are certified in accordance with rules adopted by the department under Chapter 5123:2-5 of the Administrative Code and who provides the functions of service and support administration.

(11) "Willing provider" means a qualified provider who, in accordance with the provider choice process contained in paragraphs (H) and (I) of this rule, agrees to provide home and community-based services. When determining willingness to provide federally funded waiver services to an individual, neither the provider nor any person acting on behalf of the provider shall discriminate, by reason of race, color, religion, sex, age, handicap, national origin or ancestry, against any individual eligible to receive home and community-based services.

(D) Decision-making responsibility

(1) An individual shall be responsible for making all decisions regarding free choice of providers unless the individual has a guardian, in which case the guardian shall be responsible for making such decisions.

(2) Individuals, including those with guardians, have the right to participate in decisions regarding the free choice of providers.

(3) An individual who does not have a guardian or an individual's guardian may designate another person, including a member of the individual's family, to participate in the process of making decisions regarding free choice of providers in accordance with paragraph (P) of rule 5123:2-1-11 of the Administrative Code.

(E) Provider lists

(1) The department shall create and maintain on its website lists of all providers of home and community-based services who meet the requirements of paragraph (C)(8) of this rule. The department shall update the list at least monthly. Providers shall update their information at the frequency and in the manner determined by the department.

(2) The SSA shall utilize the lists of providers created by the department to assist the individual in identifying potential providers, in accordance with paragraph (H) of this rule.

(F) Notification process

(1) Annually, the county board shall provide to each individual, guardian and/or person designated by the individual the following information in writing and in a form and manner the individual can understand:

(a) A description of the individual's right to choose any qualified provider from among all those available statewide and not limited to those who provide services currently in a given county.

(b) Procedures the SSA will follow, in accordance with paragraph (H) of this rule, to assist an individual/guardian in the selection of providers of home and community-based services. The procedures shall be based upon written guidance developed and approved by the department and ODJFS and shall be made available to each individual without modification of the guidance provided.

(c) A description of information available on the department's website pertaining to providers of home and community-based services and instructions to access the information.

(d) A description of the individual's hearing rights pursuant to section 5101.35 of the Revised Code that are contained in a handbook developed and approved by the department and ODJFS.

(2) The county board shall maintain documentation to verify compliance with the requirements of paragraph (F)(1) of this rule, including the list of individuals contacted, the date(s) on which the notification occurred, and the text of the notification.

(G) Provider choice options available to an individual

(1) When an individual/guardian identifies and/or chooses a qualified provider who is also willing to provide home and community-based services to the individual, the SSA shall honor the individual's/guardian's request and shall not utilize the provider selection process set forth in paragraphs (H) and (I) of this rule. The SSA shall document this selection.

(2) An individual/guardian may choose homemaker/personal care services providers under the home and community-based services waivers through two options:

(a) If an individual currently resides in a facility licensed by the department in accordance with section 5123.19 of the Revised Code in which the operator is certified to provide home and community-based services, or desires to reside in a licensed facility in the future, the individual/guardian is choosing both the place of residence and the homemaker/personal care services provider. To change providers of homemaker/personal care services, with assistance provided by the SSA, the individual/guardian shall:

(i) Obtain the agreement of the licensee to permit another provider of homemaker/personal care services to provide services within the licensed home; or

(ii) Relocate from the licensed home.

(b) If the individual resides in any other setting in which it is permissible to receive home and community-based services, the individual/guardian may choose any qualified and willing provider using the processes described in this rule.

(H) Responsibilities of the county board in the choice process

Except as provided in paragraph (G)(1) of this rule, the county board shall adhere to the following processes to assist an individual/guardian to choose qualified providers of home and community-based services:

(1) The county board shall inform the individual/guardian of the department's website containing the list of providers qualified to provide home and community-based services.

(2) The county board shall assist the individual/guardian to access the website, if assistance is needed.

(3) The county board shall assist the individual/guardian, if requested by the individual/guardian, to obtain outcomes of past internal and/or external monitoring reviews of home and community-based services provided.

(4) Following the individual's/guardian's review of the list of qualified providers and identification of the individual's/ guardian's preliminary consideration of a qualified provider, the county board shall contact the provider(s) selected preliminarily by the individual to determine the provider's interest in providing services to the individual. This contact shall be made within five working days following the county board's receipt of the preliminary provider selections by the individual/guardian, unless the individual/ guardian or a person designated by the individual/guardian wishes to contact the provider(s) directly.

(I) Responsibilities of the SSA, provider, and individual in the choice process

(1) If at any time during the process protected health information is requested, the SSA shall obtain a HIPAA-compliant release of information from the individual/guardian before such information shall be provided.

(2) At the time of the initial contact with the provider(s) who is the preliminary choice of the individual, the SSA shall describe the services and supports desired by the individual and the anticipated frequency, duration, and location of the services to be delivered.

(3) The provider shall inform the SSA of the provider's preliminary determination to proceed with the selection process within two working days following this initial contact by the SSA.

(4) In each instance when the provider has indicated a preliminary interest in providing waiver services to the individual, the SSA shall assure that the individual/guardian is aware of his/her opportunity to meet with the provider. If the individual/guardian indicates the desire for this meeting, if requested, the SSA shall assist the individual/guardian to meet with the provider at a place and time acceptable to both parties.

(5) When an agency provider has agreed to be available for consideration by an individual/guardian, if requested by the individual/guardian, the agency shall make available:

(a) Description of all home and community-based services the provider is certified to provide;

(b) Qualifications of the chief executive officer of the agency;

(c) Written policies and procedures related to the provision of the home and community-based services desired by the individual; and

(d) Additional information the provider elects to make available, including outcomes of past internal and/or external monitoring reviews of the home and community-based services provided.

(6) When an individual provider has agreed to be available for consideration by an individual/guardian, if requested by the individual/guardian, the provider shall make available:

(a) A description of all home and community-based services the provider is certified to provide; and

(b) Additional information the provider considers to be relevant, including past experiences providing services and supports.

(7) Unless the individual/guardian does not desire to have a meeting, within three working days following the meeting with the individual/guardian, the provider shall inform the county board whether the provider is interested in pursuing the referral.

(8) If the provider is not interested in pursuing the referral, the county board shall notify the individual/guardian within two working days and resume the provider choice process with an alternative provider.

(9) Nothing in this rule shall be construed to prohibit an individual/guardian from engaging simultaneously in the provider selection process with more than one provider.

(10) If the provider is interested in pursuing the referral, the county board shall forward information to the provider sufficient to enable the provider to determine whether he/she can provide the desired waiver services and meet the health and welfare needs of the individual within the standards governing payment for the home and community-based services. This information shall be released within three working days following the county board's receipt of an indication of interest by the provider and only upon consent from the individual/guardian.

(a) When the potential provider indicates that supplemental information and/or assessments are needed to enable the provider to evaluate the service delivery strategy that will best support the individual and reach a conclusion concerning the provider's willingness to serve the individual, based upon the reasonableness of the request, the individual/guardian shall determine the type and extent of supplemental information to be provided.

(b) The county board shall obtain the individual's consent to obtain the supplemental information. When consent is obtained, the county board shall initiate activities needed to obtain the information. In no instance shall the county board forward the supplemental material to the provider more than twenty working days following the date on which the individual's/guardian's consent was obtained.

(11) The potential provider shall inform the individual/guardian and the county board of the provider's determination to serve or not to serve the individual within five working days following receipt of the information described in paragraph (I)(10) of this rule or receipt of the supplemental information authorized for release, as described in paragraphs (I)(10)(a) and

(I)

(10)

(b) of this rule, whichever is the later date. This communication shall be made in a form and manner the individual can understand. The notification also shall be made in writing to the county board.

(12) Any timelines contained in paragraphs (H) and/or (I) of this rule may be extended with the written consent of the individual/guardian, county board and the involved waiver service provider.

(13) The county board shall utilize all elements of the checklist described in appendix A to this rule to document compliance with the activities and timelines contained in paragraphs

(G) to (I) of this rule. The checklist shall be completed in each instance when an individual engages in the free choice of a provider process, as described in paragraph (B)(2) of this rule. The county board shall retain completed checklists as a part of the individual's service record.

(J) Initiating services

(1) The SSA shall assist the individual in making arrangements for initiation of home and community-based services with the chosen provider.

(2) The SSA shall document the chosen provider and the type, frequency, duration, and location of home and community-based services on the individual's ISP. The ISP shall indicate ratios at which services are to be delivered when individuals share waiver services.

(K) Due process and appeal rights for individuals

(1) Any recipient or applicant for home and community-based services may utilize the process set forth in section 5101.35 of the Revised Code, in accordance with division-level designation 5101:6 of the Administrative Code, for any purpose authorized by that statute and the rules implementing the statute, including being denied the choice of a provider who is qualified and willing to provide a home and community-based service. The process set forth in section 5101.35 of the Revised Code is available only to applicants, recipients, and their lawfully authorized representatives.

(2) Providers shall not utilize or attempt to utilize the process set forth in section 5101.35 of the Revised Code. Providers shall not appeal or pursue any other legal challenge to a decision resulting from the process set forth in section 5101.35 of the Revised Code.

(3) The county board shall inform the individual or guardian, in writing and in a manner the individual can understand, of the individual's right to request a hearing in accordance with division-level designation 5101:6 of the Administrative Code.

(4) The county board shall immediately implement any final state hearing decision or administrative appeal decision relative to free choice of provider for HCBS waiver services issued by ODJFS, unless a court of competent jurisdiction modifies such a decision as the result of an appeal by the medicaid applicant or recipient.

(L) Department training and oversight

(1) The department shall provide periodic training and assistance to familiarize individuals with the rights and responsibilities contained in this rule and to enable county boards and providers of home and community-based services to meet their respective obligations when implementing the rule.

(2) The department shall assure the county board's compliance with this rule and initiate appropriate remedial action, when warranted, in accordance with sections 5123.044 and 5126.055 of the Revised Code.

(3) The department shall investigate or cause an investigation of complaints when it is alleged by the individual/guardian that the individual is being denied free choice of a provider of home and community-based services. On receipt of these complaints, the department shall do either of the following:

(a) Conduct an independent review or investigation of the complaint in accordance with section 5123.14 of the Revised Code;

(b) Request that an independent review or investigation of the complaint be conducted by a county board that is not implicated in the report, a regional council of government, or any other entity authorized to conduct such investigations.

(4) The department shall conduct an individual quality assurance review, at the frequency determined by the department, in accordance with rule 5123:2-12-01 of the Administrative Code to verify through an interview process with the individual, guardian and involved family members the extent of their participation in the choice of a provider.

(5) The department shall utilize the accreditation process in accordance with rule 5123:2-4-01 of the Administrative Code to monitor county board compliance with requirements of this rule.

(M) Assistance to parties interested in becoming providers

(1) The county board shall refer all parties interested in becoming a provider of home and community-based services to the department's website.

(2) The department shall include on the website a description of the entire certification process including an application for certification as a home and community-based service provider.

(3) The department shall assist all parties interested in becoming providers.

(4) The county board shall not require current or potential providers of home and community-based services to meet standards and/or training expectations that exceed or are separate from the provider certification requirements adopted by the department and contained in the Ohio Administrative Code.

Appendix A

Elements of a Checklist for Provider Choice Process

______________________________/__________________ ______________/_____________

Individual's Name IIF Number Waiver Type and Service

Reason Provider Choice Process Initiated

( ) New service, ( ) Indiv. requested provider change, ( ) Provider termination, or ( ) Other, specify________________________________________________________________

__________________ /_________________ /________________ /_______________________

County Board SSA's Name Telephone # E-mail address

Activity____________________________________________________________ Date_______

Individual requests Provider - Name of Provider ________________________________

If an Indiv. selected a Provider in accordance with paragraph (G)(1) of rule 5123:2-9-11 of the Administrative Code, the following information elements DO NOT need to be provided:

County Board informs Indiv. of website __________________________________________

County Board assists Indiv. to use website _______________________________________

Individual selects prelim. Provider(s) ___________________________________________

County Board contacts Providers, describes services, freq.(5 working days after selection)______________________________________________________________________________

Provider indicates prelim.

( ) Ok or ( ) not Ok (2 working days after County Board contact)________________________________________________________________________________

Meeting of Indiv.& Provider held (If no mtg., specify why) _______________________

Provider indicates interest in pursuing referral ( ) Yes or ( ) No (3 working days after mtg.)___________________________________________________________________________________

If no, County Board notifies Indiv. & resumes selection process___________________

If ok, County Board gains release & forwards

collateral info. to Provider (3 working days after ok & consent)__________________

Provider indicates ( ) Yes or ( ) No;

informs Indiv.& County Board (5 working days after interview)_____________________

or

Provider desires supplemental information ________________________________________

If supplemental info. requested, County Board gains release;

authorizes activities to gather info.

& forwards supplemental info. to Provider (20 working days after consent) ________

Provider indicates ( ) Yes or ( ) No;

informs Indiv.& County Board (5 working days after supplemental info. recv'd) ____

If no, reason given ______________________________________________________________

__________________________________________________________________________________

Timeline extensions noted (attach verification)___________________________________

Effective: 07/01/2005
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5126.046 , 5126.055
Rule Amplifies: 5123.04 , 5123.044 , 5126.035 , 5126.046 , 5126.055 , 5126.15 , 5111.871

5123:2-9-12 HCBS waivers - payment standards for day habilitation. [Rescinded].

Rescinded eff 10-5-08

5123:2-9-13 HCBS waivers - supported employment. [Rescinded].

Rescinded eff 10-5-08

5123:2-9-14 Home and community-based services waivers - vocational habilitation under the individual options, level one, and self-empowered life funding waivers.

(A) Purpose

The purpose of this rule is to define vocational habilitation and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Acuity assessment instrument" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(2) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(4) "Budget limitation" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Daily billing unit" means a billing unit and corresponding payment rate that shall be used when between five and seven hours of adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation are provided by the same provider to the same individual during one calendar day.

(7) "Department" means the Ohio department of developmental disabilities.

(8) "Fifteen-minute billing unit" means a billing unit that is equivalent to fifteen minutes of actual service delivery time. Minutes of service provided to an eligible individual for adult day support, supported employment-community, supported employment-enclave, vocational habilitation, and/or a combination of adult day support and vocational habilitation may be accrued by one provider over one calendar day. The number of units is equivalent to the total number of minutes of each type of service, as distinguished by service codes, provided during the day to the individual, divided by fifteen minutes. One additional unit of service may be added to this quotient if the remainder equals eight or more minutes of service.

(9) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(10) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(11) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(12) "Integrated community work setting" means the paid employment of an individual in competitive employment, supported employment (as one person or as a member of a group), or self-employment through the operation of a business that takes place outside of a segregated, sheltered, or facility-based program.

(13) "Mentor" means a person with experience providing direct services to persons with developmental disabilities who is available on a regular basis to provide guidance to new direct support staff regarding techniques and practices that enhance the effectiveness of the direct provision of vocational habilitation.

(14) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(15) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(16) "Staff intensity" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(17) "Supported employment-community" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(18) "Supported employment-enclave" has the same meaning as in rule 5123:2-9-16 of the Administrative Code.

(19) "Vocational habilitation" means services designed to teach and reinforce habilitation concepts related to work including responsibility, attendance, task completion, problem solving, social interaction, motor skill development, and safety. Activities that constitute vocational habilitation include:

(a) Vocational assessment that is conducted through formal and informal means for the purpose of developing a vocational profile and employment goals. The profile may contain information about the individual's educational background, work history, and job preferences; will identify the individual's strengths, values, interests, abilities, available natural supports, and access to transportation; and will identify the earned and unearned income available to the individual.

(b) Ongoing support which includes direct supervision, telephone and/or in-person monitoring and/or counseling, and the provision of some or all of the following supports to promote the individual's adjustment and retention.

(i) Developing a systematic plan of instruction and support, including task analyses.

(ii) Assisting the individual to perform activities that result in his or her social integration with other individuals and persons employed at the worksite.

(iii) Supporting and training the individual in the use of generic and/or individualized transportation services.

(iv) Providing services and training that assist the individual with problem-solving and meeting job-related expectations.

(v) Assisting the individual to use natural supports and generic community resources.

(vi) Providing training to the individual to maintain current skills, enhance personal hygiene, learn new work skills, attain self-determination goals, improve social skills, and/or modify behaviors that would interfere with employment.

(vii) Developing and implementing a plan to assist the individual to transition from his or her vocational habilitation setting to supported and/or competitive employment, emphasizing the use of natural supports.

(viii) Assisting the individual with self-medication or provision of medication administration for prescribed medication and assisting the individual with or performing health-related activities as identified in rule 5123:2-6-01 of the Administrative Code, which a licensed nurse agrees to delegate in accordance with the requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters. With nursing delegation, a provider may:

(a) Perform health-related activities;

(b) Administer oral and topical prescribed medications;

(c) Administer prescribed medications through gastronomy and jejunostomy tubes if the tubes are stable and labeled; and/or

(d) Perform routine tube feedings if the gastronomy and jejunostomy tubes are stable and labeled.

(C) Provider qualifications

(1) Vocational habilitation shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Vocational habilitation shall not be provided by an independent provider.

(3) An applicant seeking approval to provide vocational habilitation shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of vocational habilitation successfully completes, within ninety days of employment or contract, either:

(a) The "Ohio Alliance of Direct Support Professionals Professional Advancement Through Training and Education in Human Services (PATHS) Certificate of Initial Proficiency" program; or

(b) An orientation program of at least eight hours that addresses, but is not limited to:

(i) Organizational background of the agency provider, including:

(a) Mission, vision, values, principles, and goals;

(b) Organizational structure;

(c) Key policies, procedures, and work rules;

(d) Ethical and professional conduct and practice;

(e) Avoiding conflicts of interest; and

(f) Working effectively with individuals, families, and other team members.

(ii) Components of quality care for individuals served, including:

(a) Interpersonal relationships and trust;

(b) Cultural and personal sensitivity;

(c) Effective communication;

(d) Person-centered philosophy and practice;

(e) Development of individual service plans;

(f) Roles and responsibilities of team members; and

(g) Recordkeeping including progress notes and incident/accident reports.

(iii) Health and safety, including:

(a) Signs and symptoms of illness or injury and procedure for response;

(b) Building/site-specific emergency response plans; and

(c) Program-specific transportation safety.

(iv) Positive behavior support, including:

(a) Principles of positive intervention culture;

(b) Role of direct service staff in creating a positive culture;

(c) General requirements for behavior support plans and intervention strategies and direct service staff role including documentation;

(d) Behavior support review and human rights committees; and

(e) Crisis intervention techniques.

(v) Services that comprise vocational habilitation as it is defined in paragraph (B)(19) of this rule including the expectation that vocational habilitation will eventually lead to an individual's employment in an integrated community work setting.

(5) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of vocational habilitation, during the first year of employment or contract with the agency provider:

(a) Is assigned and has access to a mentor employed by the agency provider or contractor;

(b) Successfully completes on-the-job training specific to each individual he or she serves that includes, but is not limited to:

(i) Requirements set forth in the individual service plan including skill development goals, service/support activities, behavior support plan, planned interventions, and related documentation requirements;

(ii) The individual's preferences and strengths;

(iii) The individual's diagnoses and related needs;

(iv) The individual's care needs including nutrition, diet and mealtime support, restroom assistance, mobility needs, lifting, and general supervision/support requirements;

(v) Medication administration and delegated nursing, as applicable;

(vi) Teaching techniques and related documentation requirements; and

(vii) The employee's or contractor's role regarding management of the individual's funds and related documentation requirements.

(c) Successfully completes at least eight hours of training specific to the provision of vocational habilitation that includes, but is not limited to:

(i) Skill building in vocational assessment, ongoing job supports, task analysis, job-seeking skills, on-the-job instruction and support, developing natural supports, identifying community resources, personal adjustment, work adjustment, and vocational planning; and

(ii) Self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(6) An agency provider shall develop and implement a written plan identifying training priorities for employees, contractors, and employees of a contractor who are engaged in direct provision of vocational habilitation. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish employees' and contractors' competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(7) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of vocational habilitation, commencing in the second year of employment or contract with the agency provider, annually completes at least eight hours of training, in accordance with the written plan of training priorities.

(a) The training shall enhance the skills and competencies of the employee or contractor relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training;

(iii) The requirements relative to the employee's or contractor's role in providing behavior support to the individuals he or she serves; and

(iv) Best practices related to the provision of vocational habilitation.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(8) An agency provider shall ensure that a written record of training completed for each employee, contractor, and employee of a contractor who is engaged in direct provision of vocational habilitation is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(9) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Vocational habilitation is available to individuals who are no longer eligible for educational services based on their graduation and/or receipt of a diploma or equivalency certificate and/or their permanent discontinuation of educational services within parameters established by the Ohio department of education.

(2) Vocational habilitation shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable. The optimal outcome of vocational habilitation is competitive, integrated employment; accordingly, vocational habilitation is expected to occur over a defined period of time and employment-related goals shall be specified in the individual service plan.

(3) The service and support administrator shall ensure that an acuity assessment instrument is completed, the individual is assigned to a staff intensity group, and a budget limitation is determined in accordance with rule 5123:2-9-19 of the Administrative Code when the need for vocational habilitation has been identified through development of the individual service plan.

(4) The service and support administrator shall ensure that documentation is maintained to demonstrate that the service provided as vocational habilitation to an individual enrolled in a waiver is not otherwise available as vocational rehabilitation services funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 730 .

(5) Individuals receiving vocational habilitation shall be compensated in accordance with applicable federal laws and regulations. Individuals who participate in a work program that meets the criteria for employment of workers with disabilities under certificates at special minimum wage rates issued by the department of labor, as required by the Fair Labor Standards Act of 1938, and in accordance with the requirements of 29 C.F.R. Part 525, "Employment of Workers with Disabilities Under Special Certificates," are eligible for vocational habilitation.

(6) Vocational habilitation shall generally be made available four or more hours per day on a regularly scheduled basis for one or more days per week, unless provided as an adjunct to other day activities included in an individual service plan.

(7) Vocational habilitation shall take place in a non-residential setting separate from any home or facility in which any individual resides.

(8) A provider of vocational habilitation shall ensure that appropriate staff are knowledgeable in benefits, work incentives, and employer tax credits for individuals with developmental disabilities and ensure that individuals served receive this information.

(9) A provider of vocational habilitation shall comply with applicable laws, rules, and regulations of the federal, state, and local governments pertaining to the physical environment (building and grounds) where vocational habilitation is provided. A provider of vocational habilitation shall be informed of and comply with standards (e.g., Americans with Disabilities Act of 1990) applicable to the service setting.

(10) A provider of vocational habilitation shall recognize changes in the individual's condition and behavior as well as safety and sanitation hazards, report to the service and support administrator, and record the changes in the individual's written record.

(E) Documentation of services

Service documentation for vocational habilitation shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contact number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Staff intensity ratio (i.e., the portion of one direct services staff needed per individual served as expressed in decimals in appendix A to rule 5123:2-9-19 of the Administrative Code).

(12) Service codes that correlate to the service codes listed in appendix A to this rule and the billing documents submitted by the provider for payment of waiver services delivered.

(13) Minutes of service delivered each day, by service code. When adult day support and vocational habilitation are provided to the same individual on one day by one provider, the minutes of service may be documented for the day and billed using the adult day support and vocational habilitation service code identified in appendix A to this rule.

(14) Verification of staff intensity ratios per calendar day for each individual enrolled in a waiver, including:

(a) The names of other individuals present when waiver services are provided.

(b) The names of the direct services staff who delivered services.

(c) The initials of the direct services staff indicating all time periods/spans during which they provided waiver services to the individual. (Legends indicating signatures and initials of direct services staff may be retained separately from documentation sheets.)

(d) The average staff intensity ratio for the combined time periods when one or more waiver services are provided during the calendar day by direct services staff employed by the same provider.

(15) As applicable, the name of the individual's employer, the number of hours worked by the individual, and the hourly wage earned by the individual.

(F) Payment standards

(1) The billing units, service codes, and payment rates for vocational habilitation are contained in appendix A to this rule. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business category for an individual is the category assigned to the county in which the service is actually provided for the preponderance of time. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) The minimum number of direct services staff required to support the billing for adult day support, supported employment-enclave, and/or vocational habilitation may be determined by aggregating the staff intensity needs for all individuals (including individuals who are enrolled in waivers and those who are not) receiving services from one provider in one service delivery location during a calendar day. Calculation of the minimum number of direct services staff required to meet the staff intensity needs at a waiver service delivery location will depend on the number of individuals receiving services in one day, the times during the day in which they receive services, and their staff intensity needs. A provider shall bill only for those times during the day in which waiver services were delivered to individuals whose staff intensity needs were met.

(3) Payment for adult day support, supported employment-community, supported employment-enclave, and vocational habilitation, alone or in combination, shall not exceed the budget limitations contained in appendix C to rule 5123:2-9-19 of the Administrative Code.

Replaces: Part of 5123:2-9-17, Part of 5123:2-9-19

Click to view Appendix

Click to view Appendix

Effective: 07/23/2012
R.C. 119.032 review dates: 07/23/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 01/01/2007, 10/01/2007

5123:2-9-15 Home and community-based services waivers - supported employment-community under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to define supported employment-community and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Acuity assessment instrument" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(2) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(4) "Budget limitation" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Department" means the Ohio department of developmental disabilities.

(7) "Fifteen-minute billing unit" means a billing unit that is equivalent to fifteen minutes of actual service delivery time. Minutes of service provided to an eligible individual for adult day support, supported employment-community, supported employment-enclave, vocational habilitation, and/or a combination of adult day support and vocational habilitation may be accrued by one provider over one calendar day. The number of units is equivalent to the total number of minutes of each type of service, as distinguished by service codes, provided during the day to the individual, divided by fifteen minutes. One additional unit of service may be added to this quotient if the remainder equals eight or more minutes of service.

(8) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(9) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(10) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(11) "Integrated community work setting" means the paid employment of an individual in competitive employment, supported employment (as one person or as a member of a group), or self-employment through the operation of a business that takes place outside of a segregated, sheltered, or facility-based program.

(12) "Mentor" means a person with experience providing direct services to persons with developmental disabilities who is available on a regular basis to provide guidance to new direct support staff regarding techniques and practices that enhance the effectiveness of the direct provision of supported employment-community.

(13) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(14) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(15) "Staff intensity" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(16) "Supported employment services" means intensive, ongoing supports that enable participants, for whom competitive employment at or above the minimum wage is unlikely absent the provision of supports, and who because of their disabilities need supports, to perform in a regular work setting. Supported employment services does not include sheltered work or other similar types of vocational services furnished in specialized facilities.

(17) "Supported employment-community" means supported employment services provided in an integrated community work setting where individuals enrolled in a waiver and persons without disabilities are employed to perform the same or similar work tasks.

(a) Activities that constitute supported employment-community include:

(i) Vocational assessment that is conducted through formal and informal means for the purpose of developing a vocational profile and employment goals. The profile may contain information about the individual's educational background, work history, and job preferences; will identify the individual's strengths, values, interests, abilities, available natural supports, and access to transportation; and will identify the earned and unearned income available to the individual.

(ii) Job development and placement which includes some or all of the following activities provided directly to or on behalf of the individual:

(a) Developing a resume that identifies the individual's job-related and/or relevant vocational experiences;

(b) Training and assisting the individual to develop job-seeking skills;

(c) Targeting jobs on behalf of the individual that are available in the individual's work location of choice;

(d) Assisting the individual to find jobs that are well matched to his or her employment goals;

(e) Developing job opportunities on behalf of the individual through direct and indirect promotional strategies and relationship-building with employers;

(f) Conducting worksite analyses, including customizing jobs; and

(g) Increasing potential employers' awareness of available incentives that could result from employment of the individual.

(iii) Job training/coaching which includes some or all of the following activities:

(a) Developing a systematic plan of on-the-job instruction and support, including task analyses;

(b) Assisting the individual to perform activities that result in his or her social integration with other individuals and persons employed at the worksite;

(c) Supporting and training the individual in the use of generic and/or individualized transportation services;

(d) Providing off-site services and training that assist the individual with problem-solving and meeting job-related expectations; and

(e) Developing and implementing a plan to assist the individual to transition from his or her prior vocational or educational setting to employment, emphasizing the use of natural supports.

(iv) Ongoing job support which includes direct supervision, telephone and/or in-person monitoring and/or counseling, and the provision of some or all of the following supports to promote the individual's job adjustment and retention:

(a) Following-up with the employer and/or the individual at the frequency required to assist the individual to retain employment;

(b) Assisting the individual to use natural supports and generic community resources;

(c) Providing training to the individual to maintain work skills, enhance personal hygiene, learn new work skills, improve social skills, and/or modify behaviors that are interfering with the continuation of his or her employment; and

(d) Assisting the individual with self-medication or provision of medication administration for prescribed medication and assisting the individual with or performing health-related activities as identified in rule 5123:2-6-01 of the Administrative Code, which a licensed nurse agrees to delegate in accordance with requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters.

(v) Worksite accessibility which includes some or all of the following activities:

(a) Time spent identifying the need for and assuring the provision of reasonable worksite accommodations that allow the individual to gain and retain employment;

(b) Time spent assuring the provision of these accommodations through partnership efforts with the employer; and

(c) Purchasing or modifying equipment that will be retained by the individual on the current employment site and/or in other settings. The billing unit, service codes, and payment rate that shall be used to obtain payment for the purchase and/or modification of equipment obtained in accordance with this paragraph are contained in appendix A to this rule.

(vi) Training in self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(b) Supported employment-community may also include services and supports that assist an individual to achieve self-employment through the operation of a business. Such assistance may be provided in the individual's home or the residence of another person and may include aiding the individual to identify potential business opportunities, participating in development of a business plan, identifying potential sources of business financing, gaining assistance to launch a business, identifying supports necessary for the individual to operate the business, and providing ongoing counseling and guidance once the business has been launched. Supported employment-community shall not be used to start-up or operate a business.

(18) "Supported employment-enclave" has the same meaning as in rule 5123:2-9-16 of the Administrative Code.

(19) "Vocational habilitation" has the same meaning in rule 5123:2-9-14 of the Administrative Code.

(C) Provider qualifications

(1) Supported employment-community shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) An applicant seeking approval to provide supported employment-community shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of that rule do not apply to an independent provider who is the individual's coworker or otherwise employed at the worksite.

(3) Supported employment-community shall be provided by a person who is:

(a) An independent provider who is the individual's coworker or otherwise employed at the worksite as long as the services that are furnished are not part of that person's regular duties for which he or she is compensated by the employer;

(b) An independent provider, other than an independent provider who is the individual's coworker or otherwise employed at the worksite, who has at least one year of full-time, paid work experience or thirty hours of formal training related to supporting individuals to acquire and maintain jobs in the general workforce; or

(c) An employee or contractor of an agency provider.

(4) An independent provider who is the individual's coworker or otherwise employed at the worksite, shall annually complete training in:

(a) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training.

(5) An independent provider, other than an independent provider who is the individual's coworker or otherwise employed at the worksite, shall annually complete at least eight hours of training that enhances his or her skills and competencies relevant to the services he or she provides which shall include, but is not limited to:

(a) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training; and

(c) Services that comprise supported employment-community as it is defined in paragraph (B)(17) of this rule.

(6) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-community successfully completes, within ninety days of employment or contract, either:

(a) The "Ohio Alliance of Direct Support Professionals Professional Advancement Through Training and Education in Human Services (PATHS) Certificate of Initial Proficiency" program; or

(b) An orientation program of at least eight hours that addresses, but is not limited to:

(i) Organizational background of the agency provider, including:

(a) Mission, vision, values, principles, and goals;

(b) Organizational structure;

(c) Key policies, procedures, and work rules;

(d) Ethical and professional conduct and practice;

(e) Avoiding conflicts of interest; and

(f) Working effectively with individuals, families, and other team members.

(ii) Components of quality care for individuals served, including:

(a) Interpersonal relationships and trust;

(b) Cultural and personal sensitivity;

(c) Effective communication;

(d) Person-centered philosophy and practice;

(e) Development of individual service plans;

(f) Roles and responsibilities of team members; and

(g) Recordkeeping including progress notes and incident/accident reports.

(iii) Health and safety, including:

(a) Signs and symptoms of illness or injury and procedure for response;

(b) Building/site-specific emergency response plans; and

(c) Program-specific transportation safety.

(iv) Positive behavior support, including:

(a) Principles of positive intervention culture;

(b) Role of direct service staff in creating a positive culture;

(c) General requirements for behavior support plans and intervention strategies and direct service staff role including documentation;

(d) Behavior support review and human rights committees; and

(e) Crisis intervention techniques.

(v) Services that comprise supported employment-community as it is defined in paragraph (B)(17) of this rule.

(7) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-community, during the first year of employment or contract with the agency provider:

(a) Is assigned and has access to a mentor employed by the agency provider or contractor;

(b) Successfully completes on-the-job training specific to each individual he or she serves that includes, but is not limited to:

(i) Requirements set forth in the individual service plan including skill development goals, service/support activities, behavior support plan, planned interventions, and related documentation requirements;

(ii) The individual's preferences and strengths;

(iii) The individual's diagnoses and related needs;

(iv) The individual's care needs including nutrition, diet and mealtime support, restroom assistance, mobility needs, lifting, and general supervision/support requirements;

(v) Medication administration and delegated nursing, as applicable;

(vi) Teaching techniques and related documentation requirements; and

(vii) The employee's or contractor's role regarding management of the individual's funds and related documentation requirements.

(c) Successfully completes at least eight hours of training specific to the provision of supported employment-community that includes, but is not limited to:

(i) Skill-building in vocational assessment, job development and placement, job training/coaching, ongoing job supports, worksite accessibility, developing natural supports, personal adjustment, work adjustment, and vocational planning; and

(ii) Self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(8) An agency provider shall develop and implement a written plan identifying training priorities for employees, contractors, and employees of a contractor who are engaged in direct provision of supported employment-community. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish employees' and contractors' competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(9) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-community, commencing in the second year of employment or contract with the agency provider, annually completes at least eight hours of training, in accordance with the written plan of training priorities.

(a) The training shall enhance the skills and competencies of the employee or contractor relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training;

(iii) The requirements relative to the employee's or contractor's role in providing behavior support to the individuals he or she serves; and

(iv) Best practices related to the provision of supported employment-community.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(10) An agency provider shall ensure that a written record of training completed for each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-community is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(11) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Supported employment-community shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code or paragraph (H) of rule 5101:3-42-01 of the Administrative Code, as applicable.

(2) The service and support administrator shall ensure that an acuity assessment instrument is completed, the individual is assigned to a staff intensity group, and a budget limitation is determined in accordance with rule 5123:2-9-19 of the Administrative Code when the need for supported employment-community has been identified through development of the individual service plan.

(3) The service and support administrator shall ensure that documentation is maintained to demonstrate that the service provided as supported employment-community to an individual enrolled in a waiver is not otherwise available as vocational rehabilitation services funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 730 , or as special education or related services as those terms are defined in section 602 of the Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1401 .

(4) Supported employment-community, other than services and supports that assist an individual to achieve self-employment through the operation of a business as described in paragraph (B)(17)(b) of this rule, shall take place in a setting separate from any home or facility in which the individual receiving the services resides.

(5) Supported employment-community services extend to those times when the individual is not physically present and the provider is performing supported employment-community on behalf of the individual (e.g., job development and placement).

(6) An independent provider or appropriate staff of an agency provider shall be knowledgeable in benefits, work incentives, and employer tax credits for individuals with developmental disabilities and ensure that individuals served receive this information.

(7) A provider of supported employment-community shall recognize changes in the individual's condition and behavior, report to the service and support administrator, and record the changes in the individual's written record.

(8) A provider of supported employment-community shall report identified safety and sanitation hazards that occur at the worksite to employers having the responsibility to remedy the condition.

(E) Documentation of services

Service documentation for supported employment-community shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified and the goals established in the approved individual service plan, including:

(a) Results of formal and informal assessments (e.g., vocational evaluation, situational assessment, discovery process, and resource exploration);

(b) Progress notes relative to the individual's goals, job-seeking activities, and/or work performance (e.g., punctuality, attendance, hygiene, resume writing, and interview skills);

(c) Career exploration and employment planning activities and outcomes (e.g., job tryouts, interviews, volunteer opportunities, employers contacted, and job offers received);

(d) Job coaching/follow-along reports (e.g., goals addressed, skills developed, and natural supports identified or utilized); and

(e) Other outcomes (e.g., job placement, promotion, or change in duties).

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Times the delivered service started and stopped.

(12) As applicable, the name of the individual's employer, the number of hours worked by the individual, and the hourly wage earned by the individual.

(F) Payment standards

(1) The billing units, service codes, and payment rates for supported employment-community are contained in appendix A to this rule. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business category for an individual is the category assigned to the county in which the service is actually provided for the preponderance of time. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) Payment rates for supported employment-community are established separately for services provided by independent providers and services provided through agency providers.

(3) The base rate paid to a provider of supported employment-community shall be adjusted to reflect the number of individuals sharing services.

(4) Payment for adult day support, supported employment-community, supported employment-enclave, and vocational habilitation, alone or in combination, shall not exceed the budget limitations contained in appendix C to rule 5123:2-9-19 of the Administrative Code.

(G) Data reporting and analysis

(1) The department shall develop a system that shall be used by providers, other than an independent provider who is an individual's coworker or otherwise employed at the worksite, to submit on a monthly basis, data regarding the provision and outcomes of supported employment-community, including but not limited to:

(a) Job placement rates;

(b) Duration of job placements;

(c) Hours worked by individuals; and

(d) Wages earned by individuals.

(2) The department shall make available reports generated from the data submitted.

(3) By January 1, 2014 and periodically thereafter, the department shall review the collected data and develop any changes necessary to ensure that the service as implemented is advancing employment outcomes for individuals served and that provider payment is consistent with efficiency, economy, and quality of care.

Replaces: Part of 5123:2-9-16, Part of 5123:2-9-19

Click to view Appendix

Click to view Appendix

Effective: 07/23/2012
R.C. 119.032 review dates: 07/23/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 01/01/2007, 10/01/2007

5123:2-9-16 Home and community-based services waivers - supported employment-enclave under the individual options, level one, and self-empowered life funding waivers.

(A) Purpose

The purpose of this rule is to define supported employment-enclave and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Acuity assessment instrument" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(2) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(4) "Budget limitation" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Daily billing unit" means a billing unit and corresponding payment rate that shall be used when between five and seven hours of adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation are provided by the same provider to the same individual during one calendar day.

(7) "Department" means the Ohio department of developmental disabilities.

(8) "Fifteen-minute billing unit" means a billing unit that is equivalent to fifteen minutes of actual service delivery time. Minutes of service provided to an eligible individual for adult day support, supported employment-community, supported employment-enclave, vocational habilitation, and/or a combination of adult day support and vocational habilitation may be accrued by one provider over one calendar day. The number of units is equivalent to the total number of minutes of each type of service, as distinguished by service codes, provided during the day to the individual, divided by fifteen minutes. One additional unit of service may be added to this quotient if the remainder equals eight or more minutes of service.

(9) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(10) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(11) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(12) "Mentor" means a person with experience providing direct services to persons with developmental disabilities who is available on a regular basis to provide guidance to new direct support staff regarding techniques and practices that enhance the effectiveness of the direct provision of supported employment-enclave.

(13) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(14) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(15) "Staff intensity" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(16) "Supported employment services" means intensive, ongoing supports that enable participants, for whom competitive employment at or above the minimum wage is unlikely absent the provision of supports, and who because of their disabilities need supports, to perform in a regular work setting. Supported employment services does not include sheltered work or other similar types of vocational services furnished in specialized facilities.

(17) "Supported employment-community" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(18) "Supported employment-enclave" means supported employment services provided to individuals who work as a team, generally at a single worksite of a host community business or industry, with initial training, supervision, and ongoing support provided by on-site staff.

(a) Two unique service arrangements have been identified in which supported employment-enclave is provided:

(i) Dispersed enclaves in which individuals work in a self-contained unit within a company or service site in the community or perform multiple jobs in the company, but are not integrated with non-disabled employees of the company.

(ii) Mobile work crews comprised solely of individuals operating as distinct units and/or self-contained businesses working in several locations within the community.

(b) Activities that constitute supported employment-enclave include:

(i) Vocational assessment that is conducted through formal and informal means for the purpose of developing a vocational profile and employment goals. The profile may contain information about the individual's educational background, work history, and job preferences; will identify the individual's strengths, values, interests, abilities, available natural supports, and access to transportation; and will identify the earned and unearned income available to the individual.

(ii) Job development and placement which includes some or all of the following activities provided directly to or on behalf of the individual:

(a) Developing a resume that identifies the individual's job-related and/or relevant vocational experiences;

(b) Training and assisting the individual to develop job-seeking skills;

(c) Targeting jobs on behalf of the individual that are available in the individual's work location of choice;

(d) Assisting the individual to find jobs that are well matched to his or her employment goals;

(e) Developing job opportunities on behalf of the individual through direct and indirect promotional strategies and relationship-building with employers;

(f) Conducting worksite analyses, including customizing jobs; and

(g) Increasing potential employers' awareness of available incentives that could result from employment of the individual.

(iii) Job training/coaching which includes some or all of the following activities:

(a) Developing a systematic plan of on-the-job instruction and support, including task analyses;

(b) Assisting the individual to perform activities that result in his or her social integration with other individuals and persons employed at the worksite;

(c) Supporting and training the individual in the use of generic and/or individualized transportation services;

(d) Providing off-site services and training that assist the individual with problem-solving and meeting job-related expectations; and

(e) Developing and implementing a plan to assist the individual to transition from his or her prior vocational or educational setting to employment, emphasizing the use of natural supports.

(iv) Ongoing job support which includes direct supervision, telephone and/or in-person monitoring and/or counseling, and the provision of some or all of the following supports to promote the individual's job adjustment and retention:

(a) Following-up with the employer and/or the individual at the frequency required to assist the individual to retain employment;

(b) Assisting the individual to use natural supports and generic community resources;

(c) Providing training to the individual to maintain work skills, enhance personal hygiene, learn new work skills, improve social skills, and/or modify behaviors that are interfering with the continuation of his or her employment; and

(d) Assisting the individual with self-medication or provision of medication administration for prescribed medication and assisting the individual with or performing health-related activities as identified in rule 5123:2-6-01 of the Administrative Code, which a licensed nurse agrees to delegate in accordance with requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters.

(v) Worksite accessibility which includes some or all of the following activities:

(a) Time spent identifying the need for and assuring the provision of reasonable worksite accommodations that allow the individual to gain and retain employment;

(b) Time spent assuring the provision of these accommodations through partnership efforts with the employer; and

(c) Purchasing or modifying equipment that will be retained by the individual on the current employment site and/or in other settings. The billing unit, service codes, and payment rate that shall be used to obtain payment for the purchase and/or modification of equipment obtained in accordance with this paragraph are contained in appendix A to this rule.

(vi) Training in self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(19) "Vocational habilitation" has the same meaning in rule 5123:2-9-14 of the Administrative Code.

(C) Provider qualifications

(1) Supported employment-enclave shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Supported employment-enclave shall not be provided by an independent provider.

(3) An applicant seeking approval to provide supported employment-enclave shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-enclave successfully completes, within ninety days of employment or contract, either:

(a) The "Ohio Alliance of Direct Support Professionals Professional Advancement Through Training and Education in Human Services (PATHS) Certificate of Initial Proficiency" program; or

(b) An orientation program of at least eight hours that addresses, but is not limited to:

(i) Organizational background of the agency provider, including:

(a) Mission, vision, values, principles, and goals;

(b) Organizational structure;

(c) Key policies, procedures, and work rules;

(d) Ethical and professional conduct and practice;

(e) Avoiding conflicts of interest; and

(f) Working effectively with individuals, families, and other team members.

(ii) Components of quality care for individuals served, including:

(a) Interpersonal relationships and trust;

(b) Cultural and personal sensitivity;

(c) Effective communication;

(d) Person-centered philosophy and practice;

(e) Development of individual service plans;

(f) Roles and responsibilities of team members; and

(g) Recordkeeping including progress notes and incident/accident reports.

(iii) Health and safety, including:

(a) Signs and symptoms of illness or injury and procedure for response;

(b) Building/site-specific emergency response plans; and

(c) Program-specific transportation safety.

(iv) Positive behavior support, including:

(a) Principles of positive intervention culture;

(b) Role of direct service staff in creating a positive culture;

(c) General requirements for behavior support plans and intervention strategies and direct service staff role including documentation;

(d) Behavior support review and human rights committees; and

(e) Crisis intervention techniques.

(v) Services that comprise supported employment-enclave as it is defined in paragraph (B)(18) of this rule.

(5) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-enclave, during the first year of employment or contract with the agency provider:

(a) Is assigned and has access to a mentor employed by the agency provider or contractor;

(b) Successfully completes on-the-job training specific to each individual he or she serves that includes, but is not limited to:

(i) Requirements set forth in the individual service plan including skill development goals, service/support activities, behavior support plan, planned interventions, and related documentation requirements;

(ii) The individual's preferences and strengths;

(iii) The individual's diagnoses and related needs;

(iv) The individual's care needs including nutrition, diet and mealtime support, restroom assistance, mobility needs, lifting, and general supervision/support requirements;

(v) Medication administration and delegated nursing, as applicable;

(vi) Teaching techniques and related documentation requirements; and

(vii) The employee's or contractor's role regarding management of the individual's funds and related documentation requirements.

(c) Successfully completes at least eight hours of training specific to the provision of supported employment-enclave that includes, but is not limited to:

(i) Skill-building in vocational assessment, job development and placement, job training/coaching, ongoing job supports, worksite accessibility, developing natural supports, personal adjustment, work adjustment, and vocational planning; and

(ii) Self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(6) An agency provider shall develop and implement a written plan identifying training priorities for employees, contractors, and employees of a contractor who are engaged in direct provision of supported employment-enclave. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish employees' and contractors' competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(7) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-enclave, commencing in the second year of employment or contract with the agency provider, annually completes at least eight hours of training, in accordance with the written plan of training priorities.

(a) The training shall enhance the skills and competencies of the employee or contractor relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training;

(iii) The requirements relative to the employee's or contractor's role in providing behavior support to the individuals he or she serves; and

(iv) Best practices related to the provision of supported employment-enclave.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(8) An agency provider shall ensure that a written record of training completed for each employee, contractor, and employee of a contractor who is engaged in direct provision of supported employment-enclave is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(9) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Supported employment-enclave shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable.

(2) The service and support administrator shall ensure that an acuity assessment instrument is completed, the individual is assigned to a staff intensity group, and a budget limitation is determined in accordance with rule 5123:2-9-19 of the Administrative Code when the need for supported employment-enclave has been identified through development of the individual service plan.

(3) The service and support administrator shall ensure that documentation is maintained to demonstrate that the service provided as supported employment-enclave to an individual enrolled in a waiver is not otherwise available as vocational rehabilitation services funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 730 , or as special education or related services as those terms are defined in section 602 of the Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1401 .

(4) Supported employment-enclave shall take place in a setting separate from any home or facility in which the individual receiving the services resides.

(5) Individuals receiving supported employment-enclave shall be compensated in accordance with applicable federal laws and regulations. Individuals who participate in a work program that meets the criteria for employment of workers with disabilities under certificates at special minimum wage rates issued by the department of labor, as required by the Fair Labor Standards Act of 1938, and in accordance with the requirements of 29 C.F.R. Part 525, "Employment of Workers with Disabilities Under Special Certificates," are eligible for supported employment-enclave.

(6) Supported employment-enclave shall generally be made available four or more hours per day on a regularly scheduled basis for one or more days per week, unless provided as an adjunct to other day activities included in an individual service plan.

(7) Supported employment-enclave services extend to those times when the individual is not physically present and the provider is performing supported employment-enclave on behalf of the individual.

(8) A provider of supported employment-enclave shall ensure that appropriate staff are knowledgeable in benefits, work incentives, and employer tax credits for individuals with developmental disabilities and ensure that individuals served receive this information.

(9) A provider of supported employment-enclave shall recognize changes in the individual's condition and behavior, report to the service and support administrator, and record the changes in the individual's written record.

(10) A provider of supported employment-enclave shall report identified safety and sanitation hazards that occur at the worksite to employers having the responsibility to remedy the condition.

(E) Documentation of services

Service documentation for supported employment-enclave shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Staff intensity ratio (i.e., the portion of one direct services staff needed per individual served as expressed in decimals in appendix A to rule 5123:2-9-19 of the Administrative Code).

(12) Service codes that correlate to the service codes listed in appendix A to this rule and the billing documents submitted by the provider for payment of waiver services delivered.

(13) Minutes of service delivered each day, by service code.

(14) Verification of staff intensity ratios per calendar day for each individual enrolled in a waiver, including:

(a) The names of other individuals present when waiver services are provided.

(b) The names of the direct services staff who delivered services.

(c) The initials of the direct services staff indicating all time periods/spans during which they provided waiver services to the individual. (Legends indicating signatures and initials of direct services staff may be retained separately from documentation sheets.)

(d) The average staff intensity ratio for the combined time periods when one or more waiver services are provided during the calendar day by direct services staff employed by the same provider.

(15) As applicable, the name of the individual's employer, the number of hours worked by the individual, and the hourly wage earned by the individual.

(F) Payment standards

(1) The billing units, service codes, and payment rates for supported employment-enclave are contained in appendix A to this rule. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business category for an individual is the category assigned to the county in which the service is actually provided for the preponderance of time. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) The minimum number of direct services staff required to support the billing for adult day support, supported employment-enclave, and/or vocational habilitation may be determined by aggregating the staff intensity needs for all individuals (including individuals who are enrolled in waivers and those who are not) receiving services from one provider in one service delivery location during a calendar day. Calculation of the minimum number of direct services staff required to meet the staff intensity needs at a waiver service delivery location will depend on the number of individuals receiving services in one day, the times during the day in which they receive services, and their staff intensity needs. A provider shall bill only for those times during the day in which waiver services were delivered to individuals whose staff intensity needs were met.

(3) Payment for adult day support, supported employment-community, supported employment-enclave, and vocational habilitation, alone or in combination, shall not exceed the budget limitations contained in appendix C to rule 5123:2-9-19 of the Administrative Code.

Replaces: Part of 5123:2-9-16, Part of 5123:2-9-19

Click to view Appendix

Click to view Appendix

Click to view Appendix

Effective: 07/23/2012
R.C. 119.032 review dates: 07/23/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 01/01/2007, 10/01/2007

5123:2-9-17 Home and community-based services waivers - adult day support under the individual options, level one, and self-empowered life funding waivers.

(A) Purpose

The purpose of this rule is to define adult day support and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Acuity assessment instrument" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(2) "Adult day support" means non-vocational day services provided in a non-residential setting. Activities that constitute adult day support include:

(a) Assessment that is conducted through formal and informal means for the purpose of developing components of an individual service plan pertaining to the provision of adult day support.

(b) Personal care including supports and supervision in the areas of personal hygiene, eating, communication, mobility, toileting, and dressing to ensure an individual's ability to experience and participate in community living.

(c) Skill reinforcement including the implementation of behavior support plans, assistance in the use of communication and mobility devices, and other activities that reinforce skills learned by the individual that are necessary to ensure his or her initial and continued participation in community living.

(d) Training in self-determination which includes assisting the individual to develop self-advocacy skills; to exercise his or her civil rights; to exercise control and responsibility over the services he or she receives; and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(e) Recreation and leisure including supports identified in the individual service plan as being therapeutic in nature, rather than merely providing a diversion, and/or as being necessary to assist the individual to develop and/or maintain social relationships and family contacts.

(f) Assisting the individual with self-medication or provision of medication administration for prescribed medication and assisting the individual with or performing health-related activities as identified in rule 5123:2-6-01 of the Administrative Code, which a licensed nurse agrees to delegate in accordance with the requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under those chapters. With nursing delegation, a provider may:

(i) Perform health-related activities;

(ii) Administer oral and topical prescribed medications;

(iii) Administer prescribed medications through gastrostomy and jejunostomy tubes if the tubes are stable and labeled; and /or

(iv) Perform routine tube feedings if the gastrostomy and jejunostomy tubes are stable and labeled.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(4) "Budget limitation" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Daily billing unit" means a billing unit and corresponding payment rate that shall be used when between five and seven hours of adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation are provided by the same provider to the same individual during one calendar day.

(7) "Department" means the Ohio department of developmental disabilities.

(8) "Fifteen-minute billing unit" means a billing unit that is equivalent to fifteen minutes of actual service delivery time. Minutes of service provided to an eligible individual for adult day support, supported employment-community, supported employment-enclave, vocational habilitation, and/or a combination of adult day support and vocational habilitation may be accrued by one provider over one calendar day. The number of units is equivalent to the total number of minutes of each type of service, as distinguished by service codes, provided during the day to the individual, divided by fifteen minutes. One additional unit of service may be added to this quotient if the remainder equals eight or more minutes of service.

(9) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(10) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(11) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(12) "Mentor" means a person with experience providing direct services to persons with developmental disabilities who is available on a regular basis to provide guidance to new direct support staff regarding techniques and practices that enhance the effectiveness of the direct provision of adult day support.

(13) "Non-medical transportation" has the same meaning as in rule 5123:2-9-18 of the Administrative Code.

(14) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(15) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(16) "Staff intensity" has the same meaning as in rule 5132:2-9-19 of the Administrative Code.

(17) "Supported employment-community" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(18) "Supported employment-enclave" has the same meaning as in rule 5123:2-9-16 of the Administrative Code.

(19) "Vocational habilitation" has the same meaning as in rule 5123:2-9-14 of the Administrative Code.

(C) Provider qualifications

(1) Adult day support shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Adult day support shall not be provided by an independent provider.

(3) An applicant seeking approval to provide adult day support shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of adult day support successfully completes, within ninety days of employment or contract, either:

(a) The "Ohio Alliance of Direct Support Professionals Professional Advancement Through Training and Education in Human Services (PATHS) Certificate of Initial Proficiency" program; or

(b) An orientation program of at least eight hours that addresses, but is not limited to:

(i) Organizational background of the agency provider, including:

(a) Mission, vision, values, principles, and goals;

(b) Organizational structure;

(c) Key policies, procedures, and work rules;

(d) Ethical and professional conduct and practice;

(e) Avoiding conflicts of interest; and

(f) Working effectively with individuals, families, and other team members.

(ii) Components of quality care for individuals served, including:

(a) Interpersonal relationships and trust;

(b) Cultural and personal sensitivity;

(c) Effective communication;

(d) Person-centered philosophy and practice;

(e) Development of individual service plans;

(f) Roles and responsibilities of team members; and

(g) Recordkeeping including progress notes and incident/accident reports.

(iii) Health and safety, including:

(a) Signs and symptoms of illness or injury and procedure for response;

(b) Building/site-specific emergency response plans; and

(c)Program-specific transportation safety.

(iv) Positive behavior support, including:

(a) Principles of positive intervention culture;

(b) Role of direct service staff in creating a positive culture;

(c) General requirements for behavior support plans and intervention strategies and direct service staff role including documentation;

(d) Behavior support review and human rights committees; and

(e) Crisis intervention techniques.

(v) Services that comprise adult day support as it is defined in paragraph (B)(2) of this rule.

(5) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of adult day support, during the first year of employment or contract with the agency provider:

(a) Is assigned and has access to a mentor employed by the agency provider or contractor;

(b) Successfully completes on-the-job training specific to each individual he or she serves that includes, but is not limited to:

(i) Requirements set forth in the individual service plan including skill development goals, service/support activities, behavior support plan, planned interventions, and related documentation requirements;

(ii) The individual's preferences and strengths;

(iii) The individual's diagnoses and related needs;

(iv) The individual's care needs including nutrition, diet and mealtime support, restroom assistance, mobility needs, lifting, and general supervision/support requirements;

(v) Medication administration and delegated nursing, as applicable;

(vi) Teaching techniques and related documentation requirements; and

(vii) The employee's or contractor's role regarding management of the individual's funds and related documentation requirements.

(c) Successfully completes at least eight hours of training specific to the provision of adult day support that includes, but is not limited to:

(i) Skill building in assessment, personal care, skill reinforcement, recreation and leisure as therapeutic activities, and community inclusion/living;

(ii) Developing natural supports; and

(iii) Self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(6) An agency provider shall develop and implement a written plan identifying training priorities for employees, contractors, and employees of a contractor who are engaged in direct provision of adult day support. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish employees' and contractors' competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(7) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of adult day support, commencing in the second year of employment or contract with the agency provider, annually completes at least eight hours of training, in accordance with the written plan of training priorities.

(a) The training shall enhance the skills and competencies of the employee or contractor relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training;

(iii) The requirements relative to the employee's or contractor's role in providing behavior support to the individuals he or she serves; and

(iv) Best practices related to the provision of adult day support.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(8) An agency provider shall ensure that a written record of training completed for each employee, contactor, and employee of a contractor who is engaged in direct provision of adult day support is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(9) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Adult day support is available to individuals who are no longer eligible for educational services based on their graduation and/or receipt of a diploma or equivalency certificate and/or their permanent discontinuation of educational services within parameters established by the Ohio department of education.

(2) Adult day support shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable.

(3) The service and support administrator shall ensure that an acuity assessment instrument is completed, the individual is assigned to a staff intensity group, and a budget limitation is determined in accordance with rule 5123:2-9-19 of the Administrative Code when the need for adult day support has been identified through development of the individual service plan.

(4) Adult day support shall generally be made available four or more hours per day on a regularly scheduled basis for one or more days per week, unless provided as an adjunct to other day activities included in the individual service plan.

(5) Adult day support shall take place in a non-residential setting separate from any home or facility in which any individual resides.

(6) A provider of adult day support shall comply with applicable laws, rules, and regulations of the federal, state, and local governments pertaining to the physical environment (building and grounds) where adult day support is provided. A provider of adult day support shall be informed of and comply with standards (e.g., Americans with Disabilities Act of 1990) applicable to the service setting.

(7) A provider of adult day support shall recognize changes in the individual's condition and behavior as well as safety and sanitation hazards, report to the service and support administrator, and record the changes in the individual's written record.

(E) Documentation of services

Service documentation for adult day support shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Staff intensity ratio (i.e., the portion of one direct services staff needed per individual served as expressed in decimals in appendix A to rule 5123:2-9-19 of the Administrative Code).

(12) Service codes that correlate to the service codes listed in appendix A to this rule and the billing documents submitted by the provider for payment of waiver services delivered.

(13) Minutes of service delivered each day, by service code. When adult day support and vocational habilitation are provided to the same individual on one day by one provider, the minutes of service may be documented for the day and billed using the adult day support and vocational habilitation service code identified in appendix A to this rule.

(14) Verification of staff intensity ratios per calendar day for each individual enrolled in a waiver, including:

(a) The names of other individuals present when waiver services are provided.

(b) The names of the direct services staff who delivered services.

(c) The initials of the direct services staff indicating all time periods/spans during which they provided waiver services to the individual. (Legends indicating signatures and initials of direct services staff may be retained separately from documentation sheets.)

(d) The average staff intensity ratio for the combined time periods when one or more waiver services are provided during the calendar day by direct services staff employed by the same provider.

(F) Payment standards

(1) The billing units, service codes, and payment rates for adult day support are contained in appendix A to this rule. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business category for an individual is the category assigned to the county in which the service is actually provided for the preponderance of time. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) The minimum number of direct services staff required to support the billing for adult day support, supported employment-enclave, and/or vocational habilitation may be determined by aggregating the staff intensity needs for all individuals (including individuals who are enrolled in waivers and those who are not) receiving services from one provider in one service delivery location during a calendar day. Calculation of the minimum number of direct services staff required to meet the staff intensity needs at a waiver service delivery location will depend on the number of individuals receiving services in one day, the times during the day in which they receive services, and their staff intensity needs. A provider shall bill only for those times during the day in which waiver services were delivered to individuals whose staff intensity needs were met.

(3) Payment for adult day support, supported employment-community, supported employment-enclave, and vocational habilitation, alone or in combination, shall not exceed the budget limitations contained in appendix C to rule 5123:2-9-19 of the Administrative Code.

(G) Providers certified by the Ohio department of aging

(1) An agency provider certified by the department to provide adult day support may contract with and reimburse a provider certified by the Ohio department of aging for adult day support provided to individuals enrolled in individual options, level one, and self-empowered life funding waivers.

(2) A provider certified by the Ohio department of aging that is under contract with an agency provider certified by the department to provide adult day support is not subject to the requirements set forth in paragraph (C) of this rule.

(3) A provider certified by the Ohio department of aging that is under contract with an agency provider certified by the department to provide adult day support shall:

(a) Meet the conditions of participation for a long-term care agency provider in accordance with rule 173-39-02 of the Administrative Code;

(b) Be certified as a long-term care agency to provide enhanced adult day service and/or intensive adult day service in adult day service centers, as defined in rule 173-39-02.1 of the Administrative Code;

(c) Require all employees and contractors who provide adult day support to comply with rule 5123:2-17-02 of the Administrative Code relating to incidents affecting health and safety;

(d) Participate in annual on-site provider structural compliance reviews conducted by the Ohio department of aging in accordance with rule 173-39-04 of the Administrative Code; and

(e) Meet the requirements of rule 173-39-04 of the Administrative Code within forty-five business days from each date a structural compliance review report is mailed from the Ohio department of aging designee.

(4) The agency provider certified by the department to provide adult day support shall retain documentation that verifies that the provider certified by the Ohio department of aging complies with the requirements set forth in paragraph (G)(3) of this rule.

(5) Notwithstanding paragraph (D)(3) of rule 5123:2-9-19 of the Administrative Code, the individual service plan of an individual who receives adult day support provided through contract with a provider certified by the Ohio department of aging need not indicate the staff intensity ratio at which adult day support is provided.

(6) A unit of adult day support provided through contract with a provider certified by the Ohio department of aging does not include transportation time.

(7) Notwithstanding paragraph (E) of this rule, service documentation for the provision of adult day support provided through contract with a provider certified by the Ohio department of aging shall comply with the provisions of rule 173-39-02.1 of the Administrative Code.

(8) Notwithstanding the requirements of paragraph (F) of rule 173-39-02.1 of the Administrative Code, a provider certified by the Ohio department of aging is not required to arrange or provide non-medical transportation for individuals, but may provide non-medical transportation directly or through a contract, if selected by the individual.

(9) Except as otherwise set forth in this rule, all of the provisions of this rule and rule 5123:2-9-19 of the Administrative Code are applicable to adult day support provided through contract with a provider certified by the Ohio department of aging.

Replaces: Part of 5123:2-9-17, Part of 5123:2-9-19, 5123:2-9-20

Click to view Appendix

Click to view Appendix

Effective: 07/23/2012
R.C. 119.032 review dates: 07/23/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 01/01/2007, 10/01/2007, 12/21/2007 (Emer.), 03/20/2008

5123:2-9-18 Home and community-based services waivers - non-medical transportation under the individual options, level one, and self-empowered life funding waivers.

(A) Purpose

The purpose of this rule is to define non-medical transportation and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(2) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(3) "Attendant" means a person employed by a provider of non-medical transportation separate from the driver of the vehicle. Attendants are not required to be present during the provision of non-medical transportation but when present, are required to comply with this rule.

(4) "Budget limitation" has the same meaning as in rule 5123:2-9-19 of the Administrative Code.

(5) "Commercial vehicles" means buses, livery vehicles, and taxicabs that are available for public use.

(6) "Community inclusion" has the same meaning as in rule 5123:2-9-42 of the Administrative Code.

(7) "Commute" means the number of miles driven when one or more individual is riding in a vehicle while non-medical transportation at the per-mile rate is being provided.

(8) "County board" means a county board of developmental disabilities.

(9) "Department" means the Ohio department of developmental disabilities.

(10) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(11) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(12) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(13) "Integrated employment" has the same meaning as in rule 5123:2-9-44 of the Administrative Code.

(14) "Modified vehicle" means a motor vehicle that has been designed, constructed, or fabricated and equipped to be used upon public streets and/or highways for transportation of individuals who require use of a wheelchair.

(15) "Non-medical transportation" means transportation that is used by individuals enrolled in individual options, level one, and self-empowered life funding waivers to get to and/or from a place of employment or to access adult day support, integrated employment, supported employment-community, supported employment-enclave, and/or vocational habilitation. Whenever possible, family, neighbors, friends, or community agencies that provide transportation without charge shall be utilized.

(a) Billing for the provision of non-medical transportation is limited to those times when an individual is transported to, from, and/or between the individual's place of employment and/or sites where adult day support, integrated employment, supported employment-community, supported employment-enclave, and/or vocational habilitation are provided to the individual.

(b) Billing for the provision of non-medical transportation may occur when an individual is transported to a drop-off or transfer location from which the individual is then transported to and/or from his or her place of employment or the site where adult day support, integrated employment, supported employment-community, supported employment-enclave, and/or vocational habilitation are provided to the individual.

(c) There are three modes of non-medical transportation:

(i) Non-medical transportation at the per-trip rate;

(ii) Non-medical transportation at the per-mile rate; and

(iii) Non-medical transportation provided by operators of commercial vehicles at the usual and customary fare.

(d) Nothing in this rule shall be interpreted to prohibit a provider of homemaker/personal care from transporting an individual to and/or from the individual's place of employment or the site where adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation are provided and billing for homemaker/personal care and transportation in accordance with rules 5123:2-9-30 and 5123:2-9-24 of the Administrative Code.

(16) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(17) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (H) of this rule to validate payment for medicaid services.

(18) "Supported employment-community" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(19) "Supported employment-enclave" has the same meaning as in rule 5123:2-9-16 of the Administrative Code.

(20) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(21) "Vocational habilitation" has the same meaning as in rule 5123:2-9-14 of the Administrative Code.

(C) Provider qualifications

(1) Non-medical transportation shall be provided by an independent provider, an agency provider, or an operator of commercial vehicles that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) An applicant seeking approval to provide non-medical transportation shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), (D)(1), (D)(3), and (K) of that rule do not apply to operators of commercial vehicles.

(3) An applicant seeking approval to provide non-medical transportation as an independent provider shall present his or her driving record prepared by the bureau of motor vehicles no earlier than fourteen days prior to the date of his or her application for initial or renewal provider certification. A person having six or more points on his or her driving record is prohibited from providing non-medical transportation.

(4) An independent provider of non-medical transportation shall:

(a) Hold a valid driver's license as specified by Ohio law.

(b) Have valid liability insurance as specified by Ohio law.

(c) Immediately notify the department, in writing, if he or she accumulates six or more points on his or her driving record or if his or her driver's license is suspended or revoked.

(d) Complete testing for controlled substances by a laboratory certified for such testing and be determined to be drug free prior to initially providing non-medical transportation.

(e) Complete testing for controlled substances by a laboratory certified for such testing within thirty-two hours and complete testing for blood alcohol level by an entity certified for such testing within eight hours of a motor vehicle accident involving the driver while he or she was providing non-medical transportation when:

(i) The accident involves the loss of human life; or

(ii) The driver receives a citation under state or local law for a moving traffic violation arising from the accident, if the accident involved:

(a) Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or

(b) One or more motor vehicles incurred disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle.

(5) An agency provider of non-medical transportation shall:

(a) Ensure that each driver holds a valid driver's license as specified by Ohio law.

(b) Have or ensure that each driver has valid liability insurance as specified by Ohio law.

(c) Obtain, for each driver, a driving record prepared by the bureau of motor vehicles no earlier than fourteen days prior to the date of initial employment as a driver and at least once every three years thereafter. A person having six or more points on his or her driving record is prohibited from providing non-medical transportation.

(d) Require each driver to immediately notify the agency provider, in writing, if the driver accumulates six or more points on his or her driving record or if his or her driver's license is suspended or revoked.

(e) Ensure that each driver completes testing for controlled substances by a laboratory certified for such testing and be determined to be drug free prior to initially providing non-medical transportation.

(f) Ensure that each driver completes testing for controlled substances by a laboratory certified for such testing within thirty-two hours and completes testing for blood alcohol level by an entity certified for such testing within eight hours of a motor vehicle accident involving the driver while he or she was providing non-medical transportation when:

(i) The accident involves the loss of human life; or

(ii) The driver receives a citation under state or local law for a moving traffic violation arising from the accident, if the accident involved:

(a) Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or

(b) One or more motor vehicles incurred disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle.

(g) Develop and maintain written policies and procedures regarding the requirements of its drivers.

(6) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) General requirements for service delivery

(1) Non-medical transportation shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 of the Administrative Code. The individual service plan shall indicate whether non-medical transportation is to be provided in a modified vehicle or non-modified vehicle, at the per-trip or per-mile rate, and/or by operators of commercial vehicles.

(2) The service and support administrator shall ensure that a budget limitation for non-medical transportation is determined in accordance with rule 5123:2-9-19 of the Administrative Code when the need for non-medical transportation has been identified through development of the individual service plan.

(3) A vehicle used for non-medical transportation shall be equipped with:

(a) Secure storage space for removable equipment and passenger property;

(b) A communication system, that may include cellular communication, capable of two-way communication; and

(c) A fire extinguisher and an emergency first-aid kit that are safely secured.

(4) On each day a vehicle is used to provide non-medical transportation, the first driver of the vehicle shall conduct and document inspection and testing of the lights, windshield washers/wipers, emergency equipment, mirrors, horn, tires, and brakes prior to transporting an individual.

(5) A vehicle used for non-medical transportation shall, at a frequency of at least once every twelve months, be inspected by the Ohio state highway patrol safety inspection unit or a certified mechanic and be determined to be in good working condition.

(6) Each driver and attendant in the vehicle shall comply with federal, state, and local laws and regulations.

(7) A provider shall not bill for adult day support, integrated employment, supported employment-community, supported employment-enclave, or vocational habilitation during the same time non-medical transportation is provided.

(8) A provider shall not bill for community inclusion or homemaker/personal care provided by the driver during the same time non-medical transportation is provided.

(E) Requirements for service delivery of non-medical transportation at the per-trip rate

(1) Non-medical transportation at the per-trip rate shall be provided in:

(a) A non-modified vehicle with a passenger capacity of nine or more; or

(b) A modified vehicle that:

(i) Has permanent fasteners to secure wheelchairs to the floor or side of the vehicle to prevent wheelchair movement;

(ii) Has safety restraints in the vehicle for the purpose of restraining individuals in wheelchairs;

(iii) Is equipped with a stable access ramp or hydraulic lift; and

(iv) On each day the vehicle is used to provide non-medical transportation, the first driver of the vehicle shall conduct and document inspection and testing of the wheelchair fasteners, restraints, and access ramp or hydraulic lift prior to transporting an individual in a wheelchair.

(2) Individuals shall be in the vehicle during the times the provider bills the per-trip rate.

(3) Each driver shall provide a form, completed and signed by a person who is licensed, certified, and/or registered in accordance with Ohio law to perform physical examinations, establishing the driver's physical qualification to provide non-medical transportation. A person employed by an agency provider as a driver prior to January 1, 2007 is not required to meet the requirements of this paragraph when the agency provider maintains verification that a physical examination was completed at the time of the person's hire.

(F) Requirements for service delivery of non-medical transportation at the per-mile rate

(1) Non-medical transportation at the per-mile rate shall be provided in a non-modified vehicle with a passenger capacity of eight or fewer.

(2) Individuals shall be in the vehicle during the times the provider bills the per-mile rate except that billing may occur when non-medical transportation is being provided on behalf of an individual who is receiving job development and placement, job training/coaching, ongoing job support, or worksite accessibility in accordance with rules 5123:2-9-15 , 5123:2-9-16 , and 5123:2-9-44 of the Administrative Code.

(3) Calculation of the per-mile payment rate for a commute ensures that each passenger in the vehicle shares equally in the total cost of the commute.

(a) Passengers include individuals enrolled in waivers and individuals who are not enrolled in waivers for purposes of determining the number of individuals in the vehicle during the commute.

(b) The number of miles for each commute is calculated from the point where the first individual who is enrolled in an individual options, level one, or self-empowered life funding waiver riding in the vehicle is picked up and the point where the last individual who is enrolled in an individual options, level one, or self-empowered life funding waiver in the same vehicle is dropped off at his or her destination.

(G) Requirements for service delivery of non-medical transportation by operators of commercial vehicles

(1) Operators of commercial vehicles that provide non-medical transportation are not subject to the requirements set forth in paragraphs (D)(3), (D)(4), and (D)(5) of this rule.

(2) Operators of commercial vehicles shall comply with federal, state, and local laws and regulations pertaining to the maintenance and operation of the commercial vehicles.

(H) Documentation of services

(1) Service documentation for non-medical transportation at the per-trip rate and non-medical transportation at the per-mile rate shall include each of the following to validate payment for medicaid services:

(a) Type of non-medical transportation service (i.e., per-trip or per-mile) provided.

(b) Date of service.

(c) License plate number of vehicle used to provide service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Signature of driver of the vehicle or initials of the driver of the vehicle if the signature and corresponding initials are on file with the provider.

(i) Number of miles in each distinct trip and/or commute, as indicated by recording beginning and ending odometer readings.

(j) Names of all other passengers/riders, including paid staff and volunteers, who were in the vehicle during any portion of the trip and/or commute.

(k) Begin and end times of the trip and/or commute.

(2) Service documentation for non-medical transportation by operators of commercial vehicles shall include each of the following to validate payment for medicaid services:

(a) Type of non-medical transportation service (i.e., by bus, livery vehicle, or taxicab) provided.

(b) Date of service or, in the case of a purchase of bus fares, taxicab tokens, or similar types of travel vouchers to be used on more than one date, date of purchase.

(c) Name of individual receiving service.

(d) Medicaid identification number of individual receiving service.

(e) Name of provider.

(f) Provider identifier/contract number.

(g) Receipt issued by operator of commercial vehicles indicating the amount paid.

(I) Payment standards

(1) The billing units, service codes, and payment rates for non-medical transportation are contained in appendix A to this rule. Payment rates for non-medical transportation at the per-trip rate and non-medical transportation at the per-mile rate include an adjustment based on the county cost-of-doing-business category for the county in which the preponderance of service was provided. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) Operators of commercial vehicles shall be paid their usual and customary fares.

(3) Payment for non-medical transportation shall not exceed the budget limitations contained in appendix C to rule 5123:2-9-19 of the Administrative Code.

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Click to view Appendix

Effective: 07/01/2014
R.C. 119.032 review dates: 07/23/2017
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5123.045 , 5123.049 , 5123.16 , 5166.21 , 5166.23
Rule Amplifies: 5123.04 , 5123.045 , 5123.049 , 5123.16 , 5166.21 , 5166.23
Prior Effective Dates: 01/01/2007, 10/01/2007, 07/23/2012

5123:2-9-19 Home and community-based services waivers - general requirements for adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation.

(A) Purpose

The purpose of this rule is to establish general requirements governing provision of and payment for adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation provided to individuals enrolled in home and community-based services waivers administered by the department.

(B) Definitions

(1) "Acuity assessment instrument" means the standardized instrument utilized by the department to assess the relative non-residential services needs and circumstances of an adult individual compared to other adult individuals for purposes of receiving adult day support, supported employment-community, supported employment-enclave, and vocational habilitation. Scores resulting from administration of the acuity assessment instrument have been grouped into ranges and subsequently linked with staff intensity expectations that result in four payment rates calibrated on group size that apply to adult day support, supported employment-enclave, and vocational habilitation.

(2) "Administrative review" means the processes internal to the department and subject to oversight by the Ohio department of job and family services available to individuals who believe that their acuity assessment instrument scores, their placement in staff intensity group A, A-1, or B, and the subsequent calculation of their budget limitation prohibit their access to or continuation in the adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation services they have selected. This review is not applicable to individuals with placement in staff intensity group C or to non-medical transportation.

(3) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(4) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(5) "Budget limitation" means the funding amount available to enable an individual to receive adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation within each waiver eligibility span. A separate budget limitation shall be established to enable an individual to receive non-medical transportation within each waiver eligibility span. The budget limitation applicable to adult day support, supported employment-community, supported employment-enclave, and vocational habilitation and the budget limitation applicable to non-medical transportation are above and beyond the funding range to which an individual enrolled in the individual options waiver has been assigned.

(6) "County board" means a county board of developmental disabilities.

(7) "Daily billing unit" means a billing unit and corresponding rate that shall be used when between five and seven hours of adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation are provided by the same provider to the same individual during one calendar day.

(8) "Department" means the Ohio department of developmental disabilities.

(9) "Fifteen-minute billing unit" means a billing unit that is equivalent to fifteen minutes of actual service delivery time. Minutes of service provided to an eligible individual for adult day support, supported employment-community, supported employment-enclave, vocational habilitation, and/or a combination of adult day support and vocational habilitation may be accrued by one provider over one calendar day. The number of units is equivalent to the total number of minutes of each type of service, as distinguished by service codes, provided during the day to the individual, divided by fifteen minutes. One additional unit of service may be added to this quotient if the remainder equals eight or more minutes of service.

(10) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123:2-9-06 of the Administrative Code to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation.

(11) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(12) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(13) "Non-medical transportation" has the same meaning as in rule 5123:2-9-18 of the Administrative Code.

(14) "Professional staff" includes licensed nurses, physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, psychologists, speech therapists/audiologists, social workers, dietitians, and physicians.

(15) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(16) "Staff intensity" means the minimum portion of time, as calculated in decimals and reflected in appendix A to this rule, that one direct services staff position is required to provide adult day support, supported employment-enclave, and/or vocational habilitation to an individual. When determining that a sufficient number of direct services staff are available to provide services at the staff intensity ratio indicated by each individual's acuity assessment instrument score, an agency provider may aggregate the staff intensity needs for all individuals (including those who are enrolled in home and community-based services waivers and those who are not) receiving services in one service delivery location during one calendar day.

(17) "Supported employment-community" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(18) "Supported employment-enclave" has the same meaning as in rule 5123:2-9-16 of the Administrative Code.

(19) "Vocational habilitation" has the same meaning as in rule 5123:2-9-14 of the Administrative Code.

(20) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Acuity assessments, staff intensity group assignments, and budget limitations

(1) Service and support administrators shall review and approve information contained on the acuity assessment instrument for each individual enrolled in a waiver for whom adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation services have been authorized through the individual service plan development process.

(2) Information needed to complete the acuity assessment instrument shall be provided by informants who know the capabilities and needs of the individual outside of his or her residence, in the adult day service setting. Informants may include the individual, direct services providers, guardians, advocates, and family members. The service and support administrator and/or a person designated by the service and support administrator shall submit information in electronic format to the department. The information will be automatically scored.

(3) The score resulting from administration of the acuity assessment instrument will result in the assignment of the individual by the service and support administrator to one of four staff intensity groups. These group assignments will be applied to determine the rates paid when individuals receive adult day support, supported employment-enclave, and/or vocational habilitation. The scores and related staffing calculations are contained in appendix A to this rule.

(4) Following assignment of the individual to one of four staff intensity groups, the service and support administrator shall determine the individual's budget limitation for adult day support, supported employment-community, supported employment-enclave, and vocational habilitation. When the need for non-medical transportation has been identified through the individual service plan development process, the service and support administrator shall also determine the individual's budget limitation for non-medical transportation. Budget limitations are calculated on a per-person basis for each waiver eligibility span and are adjusted based on the cost-of-doing-business category that applies to the county in which the individual receives the preponderance of services. The cost-of-doing-business categories are contained in appendix B to this rule. The budget limitations are contained in appendix C to this rule. The budget limitation for non-medical transportation shall not be combined with the budget limitation for adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation to enable an individual to increase the availability of one or more of these services or for any other purpose.

(5) The service and support administrator shall inform each individual of the acuity assessment instrument score, the resulting staff intensity group assignment, and budget limitations:

(a) At the time the acuity assessment instrument is initially administered;

(b) At any time the acuity assessment instrument is re-administered and results in a score that places an individual in a different staff intensity group; and

(c) At any time the individual receives the preponderance of adult day services in a county with a different cost-of-doing-business category.

(6) A budget limitation established for an individual shall change only when changes in assessment variable scores on the acuity assessment instrument that justify assignment of a new staff intensity group have occurred and/or the individual receives the preponderance of adult day services in a county with a different cost-of-doing-business category. Responses to any or all acuity assessment instrument variables can be revised at any time at the request of the individual or at the discretion of the service and support administrator, with the individual's knowledge.

(7) The department shall periodically re-examine the scoring of the acuity assessment instrument and the linkage of the scores to staff intensity groups.

(D) Individual service plan development process

(1) An eligible individual may elect to receive one, some, or all of the adult day support, supported employment-community, supported employment-enclave, and vocational habilitation services plus non-medical transportation to access one or more of these services. The services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable, and developed through the process set forth in rule 5123:2-1-11 of the Administrative Code.

(2) Home and community-based services are intended to increase an individual's community participation. Therefore, the individual service plans of individuals who begin receiving adult day support and/or vocational habilitation in sheltered environments on or after the effective date of this rule shall include a justification as to why a sheltered environment is more appropriate than an integrated community setting.

(3) Individual service plans shall indicate the staff intensity ratios at which adult day support, supported employment-enclave, and vocational habilitation are to be delivered, in accordance with appendix A to this rule. When an individual enrolled in a waiver receives one or more of these services in a group setting with one or more individuals who are not enrolled in a waiver, the staff intensity ratios of the individuals who are not enrolled in a waiver shall be identified through the applicable individual service plan development process. Providers are not required to use, but may use, the acuity assessment instrument to determine the staff intensity ratios of individuals who are not enrolled in a waiver.

(4) The county board shall determine whether the annual cost for adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation can be met by or exceeds the assigned budget limitation for the individual. The county board also shall determine whether the annual cost for non-medical transportation can be met by or exceeds the assigned budget limitation for the individual. The service and support administrator shall inform the individual of these determinations in accordance with procedures developed by the department.

(5) If an individual requests a change in the frequency and/or duration of adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and/or vocational habilitation, the request may result in an increase or decrease in the annual cost for these services, based on the outcome of the individual service plan development process. The county board has the authority and responsibility to make changes which result from the individual service plan development process when the services are within the budget limitations determined in accordance with paragraph (C) of this rule.

(6) Prior state level review shall not be required for the initiation and/or changes in services that can occur within the budget limitation resulting from a revision to the individual service plan that has been agreed to by an individual through the individual service plan development process.

(7) Changes in budget limitations made by county boards are subject to review by the department and approval by the Ohio department of job and family services.

(8) Neither the department nor the county board shall approve a change in a budget limitation or assign a new budget limitation after notification that the individual has requested a hearing pursuant to section 5101.35 of the Revised Code concerning the approval, denial, reduction, or termination of services in an individual service plan that has been developed within the funding parameters of this rule.

(E) Staff intensity groups, billing units, documentation, and payment conditions

(1) When an individual has been assigned to a staff intensity group for the purpose of receiving adult day support, supported employment-enclave, and/or vocational habilitation, billing must correspond to the rates assigned for that group. Because acuity assessment instrument scores relating to assignment of an individual to the A and A-1 staff intensity groups are identical, assignment of an individual to one of these two groups will be based upon the staffing needs of the individual as identified in the individual service plan development process and reflected in the individual service plan.

(2) Changes in staff intensity group assignments, other than changes between groups A and A-1, may be made only as the result of a change in the acuity assessment instrument score of an individual, an administrative review decision made by the department, or receipt of a formal due process appeal decision rendered by the Ohio department of job and family services.

(3) When a single agency provider provides between five hours and seven hours of adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation during one calendar day to the same individual, the provider shall use a daily billing unit.

(4) When a single agency provider provides less than five hours or more than seven hours of adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation during one calendar day to the same individual, the provider shall use fifteen-minute billing units.

(5) When more than one agency provider provides adult day support, supported employment-enclave, vocational habilitation, or a combination of these services during one calendar day to the same individual, all providers shall use fifteen-minute billing units.

(6) Daily billing units and fifteen-minute billing units shall not be combined during the same calendar day for the same individual.

(7) For purposes of calculating staff intensity groups, staff ratios do not change during those times when individuals, for whom staff is responsible, are not present physically, but are within verbal, visual, or technological supervision of the staff providing the service. Technological supervision includes staff contact with individuals through telecommunication and/or electronic signaling devices.

(8) Documentation and payment for adult day support, supported employment-community, supported employment-enclave, and vocational habilitation shall be based on fifteen-minute billing units or a daily billing unit or both types of units. A combination of daily billing units and fifteen-minute billing units may be used for the same individuals during any calendar week, subject to the provisions of this rule.

(9) Each provider is responsible to document that sufficient numbers of staff are assigned to provide adult day support, supported employment-enclave, and/or vocational habilitation to one individual who is enrolled in a waiver and/or individual who is enrolled in a waiver and individuals who are not enrolled in a waiver, when combined in one grouping, at the staff intensity ratio required by each individual. The determination of each individual's staff intensity ratio is to be derived using the procedures described in this rule.

(10) For purposes of delivering adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation, no more than sixteen individuals may be combined into one program group, irrespective of the waiver enrollment/non-enrollment status or funding source of the individual participants.

(11) Providers billing on a daily billing unit basis or fifteen-minute billing unit basis must ensure that individuals receive waiver services at the staff intensity ratios for their assigned groups, based upon their acuity assessment instrument scores, for seventy-five per cent of the time they receive adult day support, supported employment-enclave, vocational habilitation, or a combination of adult day support and vocational habilitation by the same provider during one calendar day. Calculation of the seventy-five per cent expectation related to group size applies to the number of persons present in the group at the time during each day when the provider actually bills the waiver for services provided.

(12) Only direct services staff who meet certification standards for the waiver service being provided and who are providing waiver services are eligible to bill for the provision of adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation. The daily responsibilities of direct services staff are to assist, supervise, and provide supports to individuals who receive these services. Direct services are intended to reinforce the objectives contained in the individual service plan developed for each individual.

(13) Neither supervisors nor professional staff are considered to be direct services staff for the purposes of meeting the staff intensity ratio requirements related to provision of the services addressed in this rule unless they meet the certification standards to provide and are providing one or more of the services.

(F) Payment authorization and administrative review

(1) The county board shall complete a payment authorization and the service and support administrator shall ensure waiver services are initiated for an individual whose annual cost for adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation and whose annual cost for non-medical transportation are within or below the budget limitations determined in accordance with this rule. The service and support administrator shall inform the individual in writing, and in a form and manner the individual can understand, of his or her due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

(2) When the annual cost for adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation exceeds the assigned budget limitation, the service and support administrator shall inform the individual of his or her right to request an administrative review to obtain adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation services that result in a new staff intensity group assignment and budget limitation that exceeds the budget limitation calculated initially by the county board in accordance with paragraph (C) of this rule.

(3) Applicants for and recipients of waiver services who demonstrate that situational demands associated with the adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation services in which they desire to participate require a staffing ratio and resulting budget limitation that is greater than the group assignment resulting from administration of the acuity assessment instrument may submit a request for administrative review. Administrative review requests shall not be accepted for individuals having a group C assignment.

(4) The department considers the budget limitations contained in appendix C to this rule sufficient to meet the service requirements of any adult participating in out-of-facility day services. Therefore, in no instance will the group assignment and resulting total budget limitation approved through the administrative review process exceed the published amount for group C in the cost-of-doing-business category in which the individual receives the preponderance of the services addressed in this rule.

(5) An individual or the county board, with the concurrence of the individual, may submit a request for administrative review to the department. County boards shall assist an individual to request an administrative review when asked to do so by the individual.

(6) The individual or county board requesting administrative review shall submit the information requested by the department, including, but not limited to:

(a) The proposed staff intensity ratio for each waiver service;

(b) The duration of the proposed staff intensity ratio for each waiver service; and

(c) A statement justifying the proposed staff intensity ratio with supporting documentation.

(7) The department shall make a determination within thirty calendar days following receipt of all information as defined in paragraph (F)(6) of this rule and shall notify the individual and county board in writing of the determination.

(8) The administrative review approval shall apply to the individual's current waiver eligibility span. The department may extend the approval to one or more months in the consecutive waiver eligibility span. Requests for administrative review may be submitted on an as-needed basis and will be considered for approval if the individual continues to meet the criteria established by the department.

(9) Following completion of the administrative review process, the department shall inform the individual in writing, and in a form and manner the individual can understand, of his or her due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

(10) If, through the administrative review process, the department approves the request for an increased budget limitation, the county board shall ensure a payment authorization is completed within fifteen days following the determination by the department and shall ensure that waiver services are initiated.

(11) If, through the administrative review process, the department denies the request for an increased budget limitation or if the service is not subject to an administrative review, the service and support administrator shall initiate the individual service plan development process to determine if an individual service plan can be developed that is acceptable to the individual and is within the assigned budget limitation.

(a) If an individual service plan that meets these conditions is developed, the county board shall ensure a payment authorization is completed and shall ensure waiver services are initiated.

(b) If an individual service plan that meets these conditions cannot be developed, the county board shall propose to deny the initial or continuing provision of adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation and inform the individual of his or her due process rights and responsibilities as set forth in section 5101.35 of the Revised Code.

(12) The department shall use the twelve-month period following either an individual's initial enrollment date or the date the individual transitions to one or more of the services addressed in this rule to verify that cumulative payments made for waiver services remain within the approved budget limitations specified in this rule.

(13) The Ohio department of job and family services retains the final authority, based on the recommendation of the department, to review, revise, and approve any element of the decision process resulting in a determination made under this rule.

(G) Due process rights and responsibilities

Applicants for and recipients of waiver services administered by the department shall use the process set forth in section 5101.35 of the Revised Code for any challenge related to the administration and/or scoring of the acuity assessment instrument or to the type, amount/level, scope, or duration of services included or excluded from an individual service plan. For purposes of clarity, a change in staff to waiver recipient service ratios does not automatically result in a change in the level of services received by an individual.

Replaces: 5123:2-9-19

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Effective: 07/23/2012
R.C. 119.032 review dates: 07/23/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04
Rule Amplifies: 5111.871 , 5111.873 , 5123.04
Prior Effective Dates: 01/01/2007, 10/01/2007

5123:2-9-20 [Rescinded]HCBS waivers - adult day support services provided through contract with ODA-certified providers.

Effective: 07/23/2012
R.C. 119.032 review dates: 12/30/2011
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045
Prior Effective Dates: 12/21/2007 (Emer.), 03/20/2008

5123:2-9-21 Home and community-based services waivers - informal respite under the level one waiver.

(A) Purpose

The purpose of this rule is to define informal respite and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "Community respite" has the same meaning as in rule 5123:2-9-22 of the Administrative Code.

(3) "County board" means a county board of developmental disabilities.

(4) "Department" means the Ohio department of developmental disabilities.

(5) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Informal respite" means services provided to an individual unable to care for himself or herself, furnished by a person known to the individual, on a short-term basis because of the absence or need for relief of those persons normally providing the care. Informal respite may be provided in the individual's home or place of residence, home of a friend or family member, or at sites of community activities.

(10) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(11) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(14) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Informal respite shall be provided by an independent provider known to the individual who:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of medicaid; and

(c) Has completed and submitted an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adheres to the requirements of rule 5123:2-2-01 of the Administrative Code.

(2) Informal respite shall not be provided by an agency provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Informal respite shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-42-01 of the Administrative Code.

(2) In order to be eligible for informal respite, the individual or his or her designee must be able and willing to accept responsibility for training the provider and monitoring health management activities, behavior support, major unusual incident reporting, and other activities required to meet the needs of the individual as identified in the individual service plan. The individual or his or her designee shall document the following on forms and according to procedures prescribed by the department:

(a) Orientation and training of the provider, prior to the delivery of services, about activities required to meet the needs and preferences of the individual, including any training specified for the individual in his or her individual service plan and other information related to health and welfare needs of the individual.

(b) Annual training of the provider to ensure that the provider understands the following:

(i) The reporting requirements set forth in rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety and the reasonable steps necessary to prevent the occurrence or recurrence of incidents adversely affecting health and safety;

(ii) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(iii) The activities required to meet the needs and preferences of the individual, including any training specified for the individual in his or her individual service plan and other information related to health and welfare needs of the individual.

(3) The individual or his or her designee shall:

(a) Ensure the provider is delivering informal respite as specified in the individual service plan.

(b) Ensure the provider is documenting the delivery of informal respite in accordance with paragraph (E) of this rule.

(c) Upon knowledge of an unusual incident or a major unusual incident, take immediate actions as necessary to maintain the health, safety, and welfare of the individual receiving informal respite.

(4) Failure of the individual or his or her designee to fulfill the requirements of this rule shall render the individual ineligible for informal respite under the waiver and, subsequent to prior notice and hearing rights in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, informal respite shall be terminated.

(E) Documentation of services

Service documentation for informal respite shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Begin and end time of the delivered service.

(9) Written or electronic signature of the person delivering the service.

(10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service code, and payment rate for informal respite are contained in the appendix to this rule.

(2) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, residential respite, and transportation, alone or in combination, shall not exceed five thousand dollars per waiver eligibility span.

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Effective: 09/01/2013
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012

5123:2-9-22 Home and community-based services waivers - community respite under the individual options, level one, and self-empowered life funding waivers.

(A) Purpose

The purpose of this rule is to define community respite and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "Community inclusion" has the same meaning as in rule 5123:2-9-42 of the Administrative Code.

(3) "Community respite" means services provided to individuals unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individuals. Community respite shall only be provided outside of an individual's home in a camp, recreation center, or other place where an organized community program or activity occurs.

(4) "Community respite fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(5) "Community respite full day billing unit" means a billing unit that shall be used when community respite is provided for more than seven hours during the day and the individual stays overnight at the community respite service delivery location.

(6) "Community respite partial day billing unit" means a billing unit that shall be used when community respite is provided for between five and seven hours during the day and the individual does not stay overnight at the community respite service delivery location.

(7) "County board" means a county board of developmental disabilities.

(8) "Department" means the Ohio department of developmental disabilities.

(9) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123:2-9-06 of the Administrative Code, to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(10) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(11) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(12) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(14) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(15) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(16) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(17) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(18) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(19) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(20) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Community respite shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) Community respite shall not be provided by an independent provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) An applicant seeking approval to provide community respite shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(4) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(5) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(6) The provider shall provide written assurance and ensure that all employees, contractors, and employees of contractors delivering community respite shall hold the required certification or license (e.g., water safety instructor) or be trained for any specialized activity (e.g., high ropes or archery) in which an individual may participate.

(D) Requirements for service delivery

(1) Community respite shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable.

(2) The individual service plan shall address all emergency and replacement coverage should the individual unexpectedly need to leave the community respite service delivery location.

(3) Community respite is limited to sixty calendar days of service per waiver eligibility span.

(4) Community respite shall not be simultaneously provided to an individual at the same location where homemaker/personal care or community inclusion is being provided to that individual.

(5) Community respite shall not be provided in any residence.

(6) Community respite shall not be simultaneously provided at the same location where adult day services are being provided.

(E) Documentation of services

Service documentation for community respite shall include each of the following to validate payment for medicaid services:

(1) Type of service (i.e., community respite full day billing unit, community respite partial day billing unit, or community respite fifteen-minute billing unit).

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Date and time of the individual's arrival at and departure from the community respite service delivery location.

(9) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing units, service codes, and payment rates for community respite are contained in appendix A to this rule.

(a) The community respite full day billing unit shall be used when community respite is provided for more than seven hours during the day and the individual stays overnight at the community respite service delivery location. Only one provider of community respite shall use the community respite full day billing unit on any given day.

(b) The community respite partial day billing unit shall be used when community respite is provided for between five and seven hours on a given day and the individual does not stay overnight at the community respite service delivery location.

(c) The community respite fifteen-minute billing unit shall be used for all other community respite scenarios not addressed in paragraph (F)(1)(a) or (F)(1)(b) of this rule.

(d) The community respite full day billing unit, the community respite partial day billing unit, and the community respite fifteen-minute billing unit shall not be combined during the same calendar day for the same individual.

(2) Payment rates for community respite include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(3) Payment rates for community respite are subject to behavior support and medical assistance rate modifications in accordance with criteria established in paragraph (F)(4) of rule 5123:2-9-30 of the Administrative Code.

(4) Community respite provided to individuals enrolled in the individual options waiver is subject to the funding ranges and individual funding levels set forth in paragraph (C) of rule 5123:2-9-06 of the Administrative Code.

(5) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, residential respite, and transportation, alone or in combination, shall not exceed five thousand dollars per waiver eligibility span.

(6) Under the self-empowered life funding waiver, payment for community inclusion, community respite, remote monitoring, and residential respite, alone or in combination, shall not exceed twenty-five thousand dollars per waiver eligibility span.

(7) Payment for community respite shall not include payment for room and board or transportation.

(8) Services delivered prior to October 1, 2013 that meet the definition of community respite as set forth in paragraph (B)(3) of this rule may be billed as homemaker/personal care for individuals enrolled in the level one waiver.

Replaces: Part of 5123:2-9-34

Click to view Appendix

Click to view Appendix

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 09/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 07/15/2011, 07/01/2012

5123:2-9-23 Home and community-based services waivers - environmental accessibility adaptations under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to define environmental accessibility adaptations and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Environmental accessibility adaptations" means those physical adaptations to the home, required by the individual service plan, which are necessary to ensure the health, welfare, and safety of the individual, or which enable the individual to function with greater independence in the home, and without which, the individual would require institutionalization. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual. Excluded are adaptations that add to the total square footage of the home and adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, or central air conditioning. All adaptations shall be provided in accordance with applicable state or local building codes.

(5) "Home-delivered meals" has the same meaning as in rule 5123:2-9-29 of the Administrative Code.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Personal emergency response systems" has the same meaning as in rule 5123:2-9-26 of the Administrative Code.

(10) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(11) "Remote monitoring equipment" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Specialized medical equipment and supplies" has the same meaning as in rule 5123:2-9-25 of the Administrative Code.

(14) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(15) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Environmental accessibility adaptations shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide environmental accessibility adaptations only when no other certified provider is willing and able.

(3) An applicant seeking approval to provide environmental accessibility adaptations shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) An applicant seeking approval to provide environmental accessibility adaptations shall submit to the department documentation verifying the applicant's experience in providing environmental accessibility adaptations.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Environmental accessibility adaptations shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code or paragraph (H) of rule 5101:3-42-01 of the Administrative Code, as applicable.

(2) The provider of environmental accessibility adaptations shall comply with all applicable state and local regulations that apply to the operation of the provider's business or trade.

(E) Documentation of services

Service documentation for environmental accessibility adaptations shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for environmental accessibility adaptations are provided in the appendix to this rule.

(2) Claims for payment for environmental accessibility adaptations shall be submitted to the department with verification from the county board that the project meets the requirements specified in the approved individual service plan, the project is satisfactorily completed, and the project is in compliance with applicable state and local requirements, including building codes. The verification shall be submitted in the format prescribed by the department.

(3) Under the individual options waiver, payment for environmental accessibility adaptations shall not exceed seven thousand five hundred dollars per project.

(4) Under the level one waiver, payment for environmental accessibility adaptations, home-delivered meals, personal emergency response systems, remote monitoring, remote monitoring equipment, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012

5123:2-9-24 Home and community-based services waivers - transportation under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to define transportation and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "Commercial vehicles" means buses, livery vehicles, and taxicabs that are available for public use.

(3) "Community respite" has the same meaning as in rule 5123:2-9-22 of the Administrative Code.

(4) "Department" means the Ohio department of developmental disabilities.

(5) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(10) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(11) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(12) "Transportation" means a service that enables individuals enrolled in individual options and level one waivers to access waiver and other community services, activities, and resources. This service is offered in addition to, and shall not replace, medical transportation required under 42 C.F.R. 431.53 as in effect on the effective date of this rule, transportation services under the medicaid state plan as defined in 42 C.F.R. 440.170(a) as in effect on the effective date of this rule, if applicable, and non-medical transportation as defined in rule 5123:2-9-18 of the Administrative Code. Whenever possible, family, neighbors, friends, or community agencies that provide transportation without charge shall be utilized.

(13) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Transportation shall be provided by an independent provider, an agency provider, or an operator of commercial vehicles that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) An applicant seeking approval to provide transportation shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), (D)(1), (D)(3), and (K) of that rule do not apply to operators of commercial vehicles.

(3) An applicant seeking approval to provide transportation as an independent provider shall present his or her driving record prepared by the bureau of motor vehicles no earlier than fourteen days prior to the date of his or her application for initial or renewal provider certification. A person having six or more points on his or her driving record is prohibited from providing transportation.

(4) An independent provider of transportation shall:

(a) Hold a valid driver's license as specified by Ohio law.

(b) Have valid liability insurance as specified by Ohio law.

(c) Immediately notify the department, in writing, if he or she accumulates six or more points on his or her driving record or if his or her driver's license is suspended or revoked.

(5) An agency provider of transportation shall:

(a) Ensure that each driver holds a valid driver's license as specified by Ohio law.

(b) Have or ensure that each driver has valid liability insurance as specified by Ohio law.

(c) Obtain, for each driver, a driving record prepared by the bureau of motor vehicles no earlier than fourteen days prior to the date of initial employment as a driver and at least once every three years thereafter. A person having six or more points on his or her driving record is prohibited from providing transportation.

(d) Require each driver to immediately notify the agency provider, in writing, if the driver accumulates six or more points on his or her driving record or if his or her driver's license is suspended or revoked.

(e) Develop and maintain written policies and procedures regarding the requirements of its drivers.

(6) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in the denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Transportation shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code or paragraph (H) of rule 5101:3-42-01 of the Administrative Code, as applicable.

(2) Transportation services extend to those times when the individual is not physically present and the provider is performing transportation on behalf of the individual.

(E) Documentation of services

Service documentation for transportation shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Name of individual receiving service.

(4) Medicaid identification number of individual receiving service.

(5) Name of provider.

(6) Provider identifier/contract number.

(7) Origination and destination points of transportation provided.

(8) Total number of miles of transportation provided.

(9) Group size in which transportation is provided.

(10) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(11) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for transportation are contained in the appendix to this rule.

(2) Payment rates are established on a per person basis depending on the group size in which transportation is provided. When more than one individual is receiving transportation, the number of individuals in the group shall be determined by totaling the number of individuals, regardless of funding source, for whom transportation is being provided.

(3) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, residential respite, and transportation, alone or in combination, shall not exceed five thousand dollars per waiver eligibility span.

Click to view Appendix

Effective: 01/01/2014
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5123.045 , 5123.049 , 5123.16 , 5166.21 , 5166.23
Rule Amplifies: 5123.04 , 5123.045 , 5123.049 , 5123.16 , 5166.21 , 5166.23
Prior Effective Dates: 04/28/2003, 07/01/2006, 01/01/2007, 03/19/2012, 09/01/2013

5123:2-9-25 Home and community-based services waivers - specialized medical equipment and supplies under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to define specialized medical equipment and supplies and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Environmental accessibility adaptations" has the same meaning as in rule 5123:2-9-23 of the Administrative Code.

(5) "Home-delivered meals" has the same meaning as in rule 5123:2-9-29 of the Administrative Code.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Personal emergency response systems" has the same meaning as in rule 5123:2-9-26 of the Administrative Code.

(10) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(11) "Remote monitoring equipment" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Specialized medical equipment and supplies" means adaptive and assistive equipment and other specialized medical equipment and supplies such as devices, controls, or appliances, specified in the individual service plan, which enable an individual to increase his or her ability to perform activities of daily living, or to perceive, control, or communicate with the environment in which he or she lives. This service also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the medicaid state plan. To the extent that such equipment and supplies are available under the medicaid state plan or could be covered under the provisions of 1905(r) of the Social Security Act, 42 U.S.C. 1396d as in effect on the effective date of this rule, they will not be covered as home and community-based services for waiver participants less than twenty-one years of age. Excluded are items that are not of direct medical or remedial benefit to the individual. All items shall meet applicable standards of manufacture, design, and installation.

(14) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(15) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Specialized medical equipment and supplies shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide specialized medical equipment and supplies only when no other certified provider is willing and able.

(3) An applicant seeking approval to provide specialized medical equipment and supplies shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) An applicant seeking approval to provide specialized medical equipment and supplies shall submit to the department documentation verifying the applicant's experience in providing specialized medical equipment and supplies.

(5) A veterinarian who is providing services to support animals shall be licensed to engage in the practice of veterinary medicine in accordance with Chapter 4741. of the Revised Code.

(6) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Specialized medical equipment and supplies shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code or paragraph (H) of rule 5101:3-42-01 of the Administrative Code, as applicable.

(2) The provider of specialized medical equipment and supplies shall:

(a) Ensure proper installation of equipment, if required;

(b) Provide training to the individual, family, and other persons, as applicable, in the proper utilization of equipment;

(c) Properly maintain rental equipment, if required;

(d) Repair equipment as authorized by the county board representative; and

(e) Assume full liability for equipment improperly installed or maintained.

(E) Documentation of services

Service documentation for specialized medical equipment and supplies shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for specialized medical equipment and supplies are contained in the appendix to this rule.

(2) Under the level one waiver, payment for environmental accessibility adaptations, home-delivered meals, personal emergency response systems, remote monitoring, remote monitoring equipment, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012

5123:2-9-26 Home and community-based services waivers - personal emergency response systems under the level one waiver.

(A) Purpose

The purpose of this rule is to define personal emergency response systems and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Environmental accessibility adaptations" has the same meaning as in rule 5123:2-9-23 of the Administrative Code.

(5) "Home-delivered meals" has the same meaning as in rule 5123:2-9-29 of the Administrative Code.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Personal emergency response systems" means an electronic device which enables an individual at high risk of institutionalization to secure help in an emergency and may include a portable "help" button to allow for mobility. The system is connected to the individual's phone and programmed to signal a response center staffed by trained professionals once a "help" button is activated. Personal emergency response systems is available only to individuals who live alone or who are alone for significant parts of the day and have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision.

(10) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(11) "Remote monitoring equipment" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Specialized medical equipment and supplies" has the same meaning as in rule 5123:2-9-25 of the Administrative Code.

(14) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(15) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Personal emergency response systems shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) Personal emergency response systems shall not be provided by an independent provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) An applicant seeking approval to provide personal emergency response systems shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) An applicant seeking approval to provide personal emergency response systems shall submit to the department documentation verifying the applicant's experience in providing personal emergency response systems.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Personal emergency response systems shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-42-01 of the Administrative Code.

(2) The provider of personal emergency response systems shall:

(a) Comply with all federal, state, and local regulations that apply to the operation of the provider's business or trade;

(b) Provide response center coverage twenty-four hours per day, seven days per week;

(c) Have an effective system for notifying emergency personnel such as police, fire, emergency medical services, and psychiatric crisis response entities;

(d) Ensure that its equipment is in operating order, conduct preventive maintenance checks to ensure the operational integrity of the equipment, and test the equipment on at least a quarterly basis; and

(e) Provide an individual who receives personal emergency response systems with initial and ongoing training on how to use the personal emergency response systems as specified in the individual service plan.

(E) Documentation of services

Service documentation for personal emergency response systems shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) A record of the provider's notification to emergency personnel such as police, fire, emergency medical services, and psychiatric crisis response entities.

(11) A record of preventive maintenance checks and quarterly testing of the provider's equipment as required by paragraph (D)(2)(d) of this rule.

(12) A record of training provided to the individual who receives personal emergency response systems as required by paragraph (D)(2)(e) of this rule.

(F) Payment standards

(1) The billing units, service codes, and payment rates for personal emergency response systems are contained in the appendix to this rule.

(2) Under the level one waiver, payment for environmental accessibility adaptations, home-delivered meals, personal emergency response systems, remote monitoring, remote monitoring equipment, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012

5123:2-9-27 Home and community-based services waivers - emergency assistance under the level one waiver.

(A) Purpose

The purpose of this rule is to set forth the coverage and eligibility for emergency assistance under the level one waiver.

(B) Definitions

(1) "County board" means a county board of developmental disabilities.

(2) "Department" means the Ohio department of developmental disabilities.

(3) "Emergency assistance" means an increased amount of environmental accessibility adaptations, homemaker/personal care, informal respite, personal emergency response systems, remote monitoring, remote monitoring equipment, residential respite, specialized medical equipment and supplies, or transportation necessary to support an individual in an emergency situation.

(4) "Environmental accessibility adaptations" has the same meaning as in rule 5123:2-9-23 of the Administrative Code.

(5) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(9) "Personal emergency response systems" has the same meaning as in rule 5123:2-9-26 of the Administrative Code.

(10) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(11) "Remote monitoring equipment" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(12) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(13) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(14) "Specialized medical equipment and supplies" has the same meaning as in rule 5123:2-9-25 of the Administrative Code.

(15) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(16) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(17) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Eligibility for emergency assistance

(1) An individual enrolled in the level one waiver shall be eligible for emergency assistance if he or she:

(a) Has lost his or her present residence for any reason including legal action;

(b) Has lost his or her present caregiver for any reason, including death of caregiver or change in caregiver's mental or physical status resulting in the caregiver's inability to perform effectively for the individual;

(c) Has been the victim of abuse, neglect, or exploitation;

(d) Has health and welfare conditions that pose a serious risk to the individual of immediate harm or death; or

(e) Has significant changes in his or her emotional or physical condition that necessitate substantial, expanded accommodations that cannot be reasonably provided by the individual's present caregiver.

(2) Eligibility for emergency assistance shall be determined through the individual service plan development process.

(3) If the individual is determined to be eligible for emergency assistance, the service and support administrator, through the individual service plan development process, shall recommend emergency assistance funds in an amount not to exceed eight thousand dollars within a three-year period.

(4) If the individual's request is denied, the county board shall give the individual notice of the individual's due process and hearing rights under section 5101.35 of the Revised Code and Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(D) Requirements for service delivery

(1) Emergency assistance shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-42-01 of the Administrative Code.

(2) Emergency assistance shall only be used to support an individual on an interim basis until nonrecurring circumstances that present a threat to the individual's health and welfare are resolved.

(3) Environmental accessibility adaptations, homemaker/personal care, informal respite, personal emergency response systems, remote monitoring, remote monitoring equipment, residential respite, specialized medical equipment and supplies, or transportation provided as emergency assistance shall be provided in accordance with Chapter 5123:2-9 of the Administrative Code.

(E) Payment standards

(1) The service codes to be used for environmental accessibility adaptations, homemaker/personal care, informal respite, personal emergency response systems, remote monitoring, remote monitoring equipment, residential respite, specialized medical equipment and supplies, and transportation when these services are provided as emergency assistance are contained in the appendix to this rule.

(2) Emergency assistance shall not exceed eight thousand dollars within a three-year period.

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012

5123:2-9-28 Home and community-based services waivers - nutrition services under the individual options waiver.

(A) Purpose

The purpose of this rule is to define nutrition services and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code.

(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(7) "Nutrition services" means a nutritional assessment and intervention for individuals who are identified as being at nutritional risk and includes development of a nutrition care plan, including appropriate means of nutrition intervention (i.e., nutrition required, feeding modality, nutrition education, and nutrition counseling). Nutrition services shall not supplant existing services provided by the federal women, infants, and children program.

(8) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services.

(C) Provider qualifications

(1) Nutrition services shall be provided by a dietician licensed by the state pursuant to section 4759.06 of the Revised Code who is either an independent provider or the employee of an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Nutrition services shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) An applicant seeking approval to provide nutrition services shall meet the requirements of this rule and complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Nutrition services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code.

(2) The provider shall:

(a) Perform nutritional assessments and evaluations in accordance with the individual service plan;

(b) Develop dietary programs, if indicated by the nutritional assessment and the individual service plan; and

(c) Train the individual, family members, professionals, paraprofessionals, direct care workers, habilitation specialists, and vocational/school staff regarding the dietary program.

(E) Documentation of services

(1) The requirements of paragraph (B) of rule 5123:2-9-05 of the Administrative Code do not apply to service documentation for nutrition services.

(2) Service documentation for nutrition services shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(i) Group size in which the service was provided.

(j) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(k) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(l) Begin and end time of the delivered service.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for nutrition services are contained in appendix A to this rule.

(2) Payment rates for nutrition services include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(3) Payment rates for nutrition services are established separately for services provided by independent providers and services provided through agency providers.

(4) Payment rates for nutrition services are based on the number of individuals receiving services.

Click to view Appendix

Click to view Appendix

Effective: 11/03/2011
R.C. 119.032 review dates: 11/03/2016
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-29 Home and community-based services waivers - home-delivered meals under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to define home-delivered meals and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Environmental accessibility adaptations" has the same meaning as in rule 5123:2-9-23 of the Administrative Code.

(5) "Home-delivered meals" means the preparation, packaging, and delivery of one or more meals to individuals who are unable to prepare or obtain nourishing meals. A maximum of two meals per day shall be provided under the individual options or level one waivers.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Personal emergency response systems" has the same meaning as in rule 5123:2-9-26 of the Administrative Code.

(10) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(11) "Remote monitoring equipment" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Specialized medical equipment and supplies" has the same meaning as in rule 5123:2-9-25 of the Administrative Code.

(14) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(C) Provider qualifications

(1) Home-delivered meals shall be provided by an independent provider or an agency provider that meets all applicable regulatory requirements for the preparation, packaging, and delivery of home-delivered meals as defined by the Ohio department of aging and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) Home-delivered meals shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) An applicant seeking approval to provide home-delivered meals shall meet the requirements of this rule and complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(4) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Home-delivered meals shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code or paragraph (H) of rule 5101:3-42-01 of the Administrative Code, as applicable.

(2) The provider shall:

(a) Be able to provide two meals per day, seven days per week;

(b) Be able to provide special diets, including but not limited to, low sodium and low sugar;

(c) Ensure that each meal contains at least one-third of the daily recommended dietary allowance as established by the food and nutrition board of the national academy of sciences national research council;

(d) Ensure that a licensed dietitian approves and signs all menus and develops all special menus in accordance with the individual service plan;

(e) Maintain a roster of delivery drivers who are trained and have available backup staff for scheduled meal deliveries; and

(f) Initiate new orders for home-delivered meals within seventy-two hours of referral or as otherwise specified in the individual service plan.

(3) The provider shall prepare and deliver a noontime and/or evening meal as specified in the individual service plan.

(a) Noontime meals shall be delivered within one hour of noon.

(b) Evening meals shall be delivered within one hour of five-thirty p.m. or, on condition that appropriate methods exist to ensure proper and safe handling by the provider and safe consumption by the individual, may be delivered with the noontime meals.

(c) Notwithstanding paragraphs (D)(3)(a) and (D)(3)(b) of this rule, if frozen meals are used, all meals for a week may be delivered at one time during the week on condition that appropriate methods exist to ensure proper and safe handling by the provider and safe consumption by the individual. Each frozen meal shall be individually packaged and labeled with the words, "use before," followed by the month, day, and year by which the meal is to be used.

(4) The provider shall not:

(a) Leave food un-refrigerated or unattended; or

(b) Leave food at a residence unless the individual or his or her representative is there to receive the food.

(E) Documentation of services

Service documentation for home-delivered meals shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) Number of meals delivered.

(11) Time that meals were delivered.

(12) Name of person accepting delivery of meals.

(F) Payment standards

(1) The billing unit, service codes, and payment rate for home-delivered meals are contained in the appendix to this rule.

(2) Under the level one waiver, payment for environmental accessibility adaptations, home-delivered meals, personal emergency response systems, remote monitoring, remote monitoring equipment, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 11/03/2016
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 11/03/2011

5123:2-9-30 Home and community-based services waivers - homemaker/ personal care under the individual options and level one waivers.

(A) Purpose

The purpose of this rule is to define homemaker/personal care and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(2) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(3) "Community respite" has the same meaning as in rule 5123:2-9-22 of the Administrative Code.

(4) "County board" means a county board of developmental disabilities.

(5) "Department" means the Ohio department of developmental disabilities.

(6) "Developmental center" means a state-operated intermediate care facility.

(7) "Direct contact" means exercising supervision over an individual enrolled in a waiver and for whom a provider will be providing homemaker/personal care.

(8) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(9) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123:2-9-06 of the Administrative Code to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(10) "Group size" means the number of individuals who are sharing services, regardless of the funding source for those services.

(11) "Homemaker/personal care" means the coordinated provision of a variety of services, supports, and supervision necessary for the health and welfare of an individual which enables the individual to live in the community. These are tasks directed at increasing the independence of the individual within his or her home or community. The service includes tasks directed at the individual's immediate environment that are necessitated by his or her physical or mental (including emotional and/or behavioral) condition and are of a supportive or maintenance type. Homemaker/personal care helps the individual meet daily living needs, and without the service, alone or in combination with other waiver services, the individual would require institutionalization.

(a) The homemaker/personal care provider performs such tasks as assisting the individual with activities of daily living, personal hygiene, dressing, feeding, transfer, and ambulatory needs or skills development. Skills development is intervention that focuses on both preventing the loss of skills and enhancing skills that are already present that will lead to greater independence within the residence or the community. The provider may also perform homemaking tasks for the individual. These tasks may include cooking, cleaning, laundry, money management, and shopping, among others. Homemaking and personal tasks are combined into a single service titled homemaker/personal care because, in actual practice, a provider performs both services and does so as part of the natural flow of the day.

(b) Examples of supports that may be provided as a component of homemaker/personal care include the following:

(i) Basic personal care and grooming, including bathing, care of the hair, and assistance with clothing;

(ii) Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom or assisting the individual with bedpan routines;

(iii) Assisting the individual with self-medication or provision of medication administration for prescribed medications and assisting the individual with, or performing, health care activities;

(iv) Performing household services essential to the individual's health and comfort in the home (e.g., necessary changing of bed linens or rearranging of furniture to enable the individual to move about more easily in his or her home);

(v) Assessing, monitoring, and supervising the individual to ensure the individual's safety, health, and welfare;

(vi) Light cleaning tasks in areas of the home used by the individual;

(vii) Preparation of a shopping list appropriate to the individual's dietary needs and financial circumstances, performance of grocery shopping activities as necessary, and preparation of meals;

(viii) Personal laundry; and

(ix) Incidental neighborhood errands as necessary, including accompanying the individual to medical and other appropriate appointments and accompanying individual for walks outside the home.

(12) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(13) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(14) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(15) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(16) "Intermediate care facility" means an intermediate care facility for individuals with intellectual disabilities as defined in rule 5123:2-7-01 of the Administrative Code.

(17) "Non-medical transportation" has the same meaning as in rule 5123:2-9-18 of the Administrative Code.

(18) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(19) "On-site/on-call" means a rate paid when no need for supervision or supports is anticipated and a provider must be on-site and available to provide homemaker/personal care but is not required to remain awake.

(20) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(21) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(22) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(23) "Supported employment-community" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(24) "Supported employment-enclave" has the same meaning as in rule 5123:2-9-16 of the Administrative Code.

(25) "Team" has the same meaning as in rule 5123:2-1-11 of the Administrative Code.

(26) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(27) "Vocational habilitation" has the same meaning as in rule 5123:2-9-14 of the Administrative Code.

(28) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Homemaker/personal care shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) Homemaker/personal care shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards except that the Lorain county board may continue to provide or subcontract to provide homemaker/personal care for no more than the number of individuals enrolled in the individual options waiver it served on July 1, 2005.

(3) An applicant seeking approval to provide homemaker/personal care shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx [File Link Not Available]) and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(4) Providers licensed under section 5123.19 of the Revised Code seeking to provide homemaker/personal care shall:

(a) Meet all of the requirements set forth in and maintain a license issued under section 5123.19 of the Revised Code.

(b) Maintain a current medicaid provider agreement with the Ohio department of medicaid.

(c) Provide to the department written assurance to arrange for substitute coverage, if necessary, only from a provider certified by the department and as identified in the individual service plan; notify the individual or legally responsible person in the event that substitute coverage is necessary; and notify the person identified in the individual service plan when substitute coverage is not available to allow such person to make other arrangements.

(5) Each independent provider and each employee, contractor, and employee of a contractor of an agency provider who has direct contact with individuals receiving homemaker/personal care shall annually complete at least eight hours of training, in accordance with standards established by the department.

(a) The training shall enhance the skills and competencies of the independent provider or employee/contractor of the agency provider relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code including a review of health and welfare alerts issued by the department since the previous year's training.

(iii) The requirements relative to the independent provider's or employee's/contractor's role in providing behavior support to the individuals he or she serves.

(iv) Principles of positive intervention culture.

(v) Self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(c) The provider shall maintain a written record, which may include an electronic record, of training. This information shall be presented upon request by the Ohio department of medicaid, the department, or the county board. Documentation shall include the name of the person receiving the training, date of training, training topic, duration of training, instructor's name if applicable, and a brief description of the training.

(6) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(7) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(D) Requirements for service delivery

(1) Homemaker/personal care shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 of the Administrative Code. Providers shall participate in individual service plan development meetings when a request for their participation is made by the individual.

(2) Homemaker/personal care shall not be provided to an individual at the same time as residential respite.

(3) Homemaker/personal care services extend to those times when the individual is not physically present and the provider is performing homemaker activities on behalf of the individual.

(4) Homemaker/personal care services involving direct contact with an individual receiving the services shall not be provided at the same time the individual is receiving adult day support, supported employment-community, supported employment-enclave, or vocational habilitation.

(5) A provider shall not bill for homemaker/personal care provided by the driver during the same time non-medical transportation is provided.

(E) Documentation of services

Service documentation for homemaker/personal care shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Group size in which the service was provided.

(10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(11) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(12) Begin and end times of the delivered service.

(F) Payment standards

(1) The billing units, service codes, and payment rates for homemaker/personal care are contained in appendix A to this rule. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business category for an individual is the category assigned to the county in which the service is actually provided for the preponderance of time. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) Payment rates for homemaker/personal care are established separately for services provided by independent providers and services provided through agency providers.

(3) The base rate paid to a provider of homemaker/personal care shall be adjusted to reflect the number of individuals sharing services.

(a) If two individuals receive service from one staff member, the base rate shall be one hundred seven per cent of the base rate for one-to-one service. If three individuals share the service, the base rate shall be one hundred seventeen per cent of the base rate of one-to-one service. If four or more individuals share the service, the base rate shall be one hundred thirty per cent of the base rate for one-to-one service.

(b) The base rate established is divided by the number of individuals sharing the service to determine the rate paid per individual.

(4) Payment rates for routine homemaker/personal care may be modified to reflect the needs of individuals requiring behavior support and/or medical assistance in accordance with paragraphs (F)(4)(a) and (F)(4)(b) of this rule. Upon determination by the county board that the individual meets the criteria, the county board shall recommend and implement rate modifications for behavior support and/or medical assistance. Rate modifications are subject to review by the department. The duration of approval for behavior support and/or medical assistance rate modifications shall be limited to the individual's waiver eligibility span, may be determined needed or no longer needed within that waiver eligibility span, and may be renewed annually. A modification to the homemaker/personal care rate shall be applied for each individual in a congregate setting meeting the criteria and shall be included in the payment rates of only those individuals meeting the criteria.

(a) The behavior support rate modification is applicable to routine homemaker/personal care only and shall be paid during all times when routine homemaker/personal care is provided to an individual who qualifies for the modification. The amount of the behavior support rate modification for each fifteen-minute billing unit of service is contained in appendix A to this rule.

(i) The purpose of the behavior support rate modification is to provide funding for the implementation of behavior support plans by staff who have the level of training necessary to implement the plans and who are working under the direction of licensed or certified personnel or other professionals who have specialized training or experience implementing behavior support plans.

(ii) In order for an individual to receive the behavior support rate modification, the following conditions shall be met:

(a) The individual has been assessed within the last twelve months to present a danger to self or others or have the potential to present a danger to self or others; and

(b) A behavior support plan that is a component of the individual service plan has been developed in accordance with the requirements in rules established by the department; and

(c) The individual receives ongoing behavior support services from a licensed, certified, or other specially trained professional to address the identified behavior; and

(d) The individual either:

(i) Has a response of "yes" to at least four items in question thirty-two of the behavior domain of the Ohio developmental disabilities profile; or

(ii) Requires a structured environment that, if removed, will result in the individual's engagement in behavior destructive to self or others.

(iii) When determined through the individual service plan development process that the conditions specified in paragraph (F)(4)(a)(ii) of this rule have been met, the county board shall apply the behavior support rate modification for routine homemaker/personal care. The department retains the right to review and validate the qualifications of any provider of ongoing behavior support services identified in accordance with paragraph (F)(4)(a)(ii)(c) of this rule.

(b) The medical assistance rate modification is applicable to routine homemaker/personal care only and shall be paid during all times when routine homemaker/personal care is provided to an individual who qualifies for the modification. The amount of the medical assistance rate modification for each fifteen-minute billing unit of service is contained in appendix A to this rule. The county board shall apply the medical assistance rate modification when the following criteria have been met:

(i) An individual requires routine feeding and/or the administration of prescribed medications through gastrostomy and/or jejunostomy tubes, and/or requires the administration of routine doses of insulin through subcutaneous injections and insulin pumps; or

(ii) An individual requires oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) An individual requires a nursing procedure or nursing task that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code, which is provided in accordance with section 5123.42 of the Revised Code, and when such procedure or nursing task is not the administration of oral or topical medication or a health-related activity as defined in rule 5123:2-6-01 of the Administrative Code.

(5) Payment rates for routine homemaker/personal care may be modified to reflect the needs of individuals enrolled in the individual options waiver who formerly resided at developmental centers when the following conditions are met:

(a) The individual was a resident of a developmental center immediately prior to enrollment in the individual options waiver;

(b) Homemaker/personal care is identified in the individual service plan as a service to be delivered and the individual begins receiving the service on or after July 1, 2011; and

(c) The director of the department determines that the rate modification is warranted due to time-limited cost increases experienced when individuals move from institutional settings to community-based settings.

(6) Payment rates for routine homemaker/personal care may be modified to reflect the needs of individuals enrolled in the individual options waiver who formerly resided at intermediate care facilities when the following conditions are met:

(a) The individual was a resident of an intermediate care facility immediately prior to enrollment in the individual options waiver;

(b) As a result of the individual enrolling in the individual options waiver, the intermediate care facility has reduced its medicaid-certified capacity;

(c) Homemaker/personal care is identified in the individual service plan as a service to be delivered and the individual begins receiving the service on or after April 1, 2013; and

(d) The director of the department determines that the rate modification is warranted due to time-limited cost increases experienced when individuals move from institutional settings to community-based settings.

(7) The amount of the payment rate modifications set forth in paragraphs (F)(5) and (F)(6) of this rule shall be limited to fifty-two cents for each fifteen-minute billing unit of routine homemaker/personal care provided to the individual during the first year of the individual's enrollment in the individual options waiver.

(8) The team shall assess and document in the individual service plan when on-site/on-call may be appropriate.

(a) In making the assessment, the team shall consider all of the following:

(i) Medical or psychiatric condition which requires supervision or supports throughout the night;

(ii) Behavioral needs which require supervision or supports throughout the night;

(iii) Sensory or motor function limitations during sleep hours which require supervision or supports throughout the night;

(iv) Special dietary needs, restrictions, or interventions which require supervision or supports throughout the night;

(v) Other safety considerations which require supervision or supports throughout the night; and

(vi) Emergency action needed to keep the individual safe.

(b) A provider shall be paid at the on-site/on-call rate for homemaker/personal care contained in appendix A to this rule when:

(i) Based upon assessed and documented need, the individual service plan indicates the days of the week and the beginning and ending times each day when it is anticipated that an individual will require on-site/on-call; and

(ii) The individual is asleep and requires staff to be available to provide homemaker/personal care; and

(iii) The needs of the individual require staff to be on-site but not to remain awake; and

(iv) On-site/on-call does not exceed eight hours for the individual in any twenty-four-hour period.

(c) A provider shall be paid the routine homemaker/personal care rate instead of the on-site/on-call rate when an individual receives supervision or supports during the night. In these instances, the provider shall document the date and begin and end times during which supervision or supports were provided to the individual.

(d) The payment rate modifications set forth in paragraphs (F)(4), (F)(5), and (F)(6) of this rule are not applicable to the on-site/on-call payment rates for homemaker/personal care.

(9) Payment for homemaker/personal care does not include room and board, items of comfort and convenience, or costs for the maintenance, upkeep, and improvement of the home.

(10) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, residential respite, and transportation, alone or in combination, shall not exceed five thousand dollars per waiver eligibility span.

Click to view Appendix

Click to view Appendix

Effective: 07/01/2014
R.C. 119.032 review dates: 04/19/2017
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5123.045 , 5123.049 , 5123.16 , 5166.21 , 5166.23
Rule Amplifies: 5123.04 , 5123.045 , 5123.049 , 5123.16 , 5166.21 , 5166.23
Prior Effective Dates: 07/24/1995, 04/28/2003, 07/01/2005, 04/20/2006, 07/01/2006, 07/01/2007, 12/12/2007 (Emer.), 03/20/2008, 07/01/2010, 04/19/2012, 09/01/2013, 01/01/2014

5123:2-9-31 Home and community-based services waivers - homemaker/ personal care daily billing unit for sites where individuals enrolled on the individual options waiver share services.

(A) Purpose

The purpose of this rule is to establish the payment process for homemaker/personal care (HPC) when individuals share the services of the same provider at the same site as part of the home and community-based services (HCBS) individual options waiver administered by the Ohio department of developmental disabilities (the department). This rule establishes a daily billing unit for individuals/sites that qualify, which shall be used instead of the fifteen-minute billing unit established in rule 5123:2-9-06 of the Administrative Code. All other requirements of rule 5123:2-9-06 of the Administrative Code apply to the HPC daily billing unit.

(B) Definitions

(1) "Cost projection tool" means the web-based analytical tool, developed and administered by the department, used to project the cost of HCBS waiver services identified in the individual service plans (ISPs) of individuals enrolled on individual options and level one HCBS waivers. The department shall publish any changes to the cost projection tool thirty days prior to implementation.

(2) "Daily billing unit" means the amount of a provider's payment that is apportioned to each individual who lives at the site and shares HPC services with others. The daily billing unit is determined via the daily rate application in accordance with planning information entered by the county board of developmental disabilities (county board) and actual service information entered by the provider of HPC services.

(3) "Daily rate application" means the web-based analytical tool, developed and administered by the department, used by county boards to apportion the cost of HPC services identified in the ISPs of individuals who share the services of the same provider at the same site as part of the HCBS individual options waiver.

(4) "Direct service hours" means the direct staff time spent delivering HPC services. A direct service hour is comprised of four fifteen-minute billing units.

(5) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time.

(6) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraphs (F)(2)(a) to (F)(2)(h) of this rule to validate payment for medicaid services.

(7) "Site span" means a period of time where there are no changes to the estimated total costs or estimated total direct service hours for a site where individuals share HPC services of a provider. An individual may have one or more site spans during one waiver span.

(C) Circumstances excluded from the daily billing unit approach

(1) Individuals who receive HPC services and supports in adult foster care settings shall do so in accordance with rule 5123:2-13-06 of the Administrative Code. A daily billing unit for HPC shall not be billed on the same day as adult foster care.

(2) Individuals who do not share the HPC services of the same provider at the same site shall remain on the fifteen-minute billing unit approach established in rule 5123:2-9-06 of the Administrative Code.

(3) Individuals who share occasional or time-limited services of a provider in addition to their primary residential provider shall remain on the fifteen-minute billing unit approach established in rule 5123:2-9-06 of the Administrative Code for the occasional or time-limited HPC services of their non-residential provider. Examples include but are not limited to:

(a) Individuals who live together and share HPC services of a provider and who use a second HPC provider for recreational activities; and

(b) Individuals who live in different homes who travel with a provider who is not their residential provider to a recreational event such as bowling, respite, or camp on a monthly or weekly basis.

(4) Individuals who live alone and share services with a neighbor or other eligible person.

(D) Calculation of the individual daily billing unit

(1) The process for assigning a funding range, determining an individual funding level, establishing behavior support and/or medical assistance HPC rate modifications, and projecting the cost of an individual's services, set forth in rule 5123:2-9-06 of the Administrative Code, shall be followed.

(2) For situations where there is at least one staff person serving more than one individual during sleep hours and of those individuals, at least one individual's ISP calls for routine HPC during the sleep hours, while at the same time at least one other individual has a need for on-site/on-call (OSOC), the provider shall be paid at the routine HPC rate as set forth in rule 5123:2-9-06 of the Administrative Code, which shall be determined by the number of awake staff and the number of individuals who are receiving routine HPC. The cost of that rate shall be apportioned so that the individuals receiving OSOC shall be charged the OSOC rate as set forth in rule 5123:2-9-06 of the Administrative Code and the individuals receiving routine HPC shall be charged an equal share of the remainder of the cost. The following examples are provided to illustrate how the rates are determined and how the cost of those rates is apportioned. The examples utilize rates in rule 5123:2-9-06 of the Administrative Code for cost-of-doing-business category one.

(a) Example 1. Four individuals live together and have one staff person during sleep hours. One individual receives routine HPC and the other three individuals receive OSOC.

image: oh/admin/2014/5123$2-9-31_ph_ff_n_ru_20100621_0958-1.png

(b) Example 2. Five individuals live together and have one staff person during sleep hours. Two individuals receive routine HPC and the other three individuals receive OSOC.

image: oh/admin/2014/5123$2-9-31_ph_ff_n_ru_20100621_0958-2.png

image: oh/admin/2014/5123$2-9-31_ph_ff_n_ru_20100621_0958-3.png

(3) Using the cost projection tool, the service and support administrator or other county board designee, with input from members of the individual's team, shall project the service utilization for the individuals who share services based on factors including but not limited to: a typical usage pattern and identified waiver span; adjustments based on past history, holidays, day service site closings, and weekends; and other anticipated changes to direct service hours. The result shall include total planned HPC costs based on ISPs for the site and a total projected number of service hours for the site. These projections include any individual's prior authorization requests that have been approved pursuant to rule 5101:3-41-12 of the Administrative Code.

(4) The daily rate application shall include:

(a) Total planned HPC costs for the site based on ISPs for individuals who are sharing HPC services of the same provider at the site;

(b) Total estimated HPC hours for the site to be provided; and (c) Each individual's authorized funding for HPC services.

(5) After HPC services are provided at the site, the provider shall enter into the daily rate application, the number of direct service hours rendered for all individuals for a specific seven-day time span, or up to a fourteen-day time span if the daily billing unit is expected to exceed the maximum medicaid payment rate for the seven-day time span, and the specific dates that each individual received HPC services at the site. Using the results from the cost projection tool, the daily rate application determines the provider's direct service hourly rate for that site. The daily rate application then calculates the maximum HPC payment to the provider for that period. The daily rate application then determines how the total payment to that provider for that period shall be apportioned to each individual's authorized budget, resulting in a daily billing unit for each individual for each day that services were provided. The provider then uses that information to prepare a claim for payment.

(6) When changes occur at the site that affect the total estimated direct service hours, total planned HPC costs based on ISPs, or an individual's predicted ongoing participation at the site, the county board shall enter changes into the cost projection tool for a new, prospective site span. These changes shall be made with any necessary changes to the ISP and the cost projection and payment authorization for the individual(s) living at the site who will be affected by these changes.

(a) If, during a site span, there is a change of service needs for an individual that may impact the total estimated direct service hours, total planned HPC costs based on ISPs, or an individual's predicted ongoing participation at the site, the provider shall notify the county board. The provider and the county board shall work together to identify potential solutions.

(b) If the individual/guardian, county board, or provider wishes to convene a meeting to discuss a change of service needs for an individual during a site span, that meeting shall occur within ten working days of the day the request was made. Discussion shall occur in accordance with paragraph (C)(6) of rule 5123:2-9-06 of the Administrative Code.

(E) The director of the department reserves the right to allow a provider of HPC services to continue to use the fifteen-minute billing unit in the event of a unique and/or extenuating circumstance. This right shall be exercised in consultation with the Ohio department of job and family services (ODJFS) as the single state medicaid agency.

(F) Service documentation requirements

(1) The requirements of paragraph (B) of rule 5123:2-9-05 of the Administrative Code do not apply to service documentation for HPC when individuals share the services of the same provider at the same site.

(2) The service documentation for HPC when individuals share the services of the same provider at the same site shall include each of the following to validate payment for medicaid services:

(a) Date of service.

(b) Place of service.

(c) Name of individual(s) receiving services each day.

(d) Description and details of the services delivered that directly relate to the services specified on the individual's approved ISP as the services to be provided.

(e) Medicaid identification number of the individual(s) receiving services.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider, or an electronic process approved by the department.

(G) Payment standards

(1) The billing process and payment for HPC services when individuals share the services of the same provider at the same site shall be at the daily billing unit for each individual based on that individual's apportioned share of the services rendered at the site and the number of days each person receives services pursuant to the daily rate application. The service codes for the HPC daily billing unit are contained in the appendix to this rule.

(2) Providers shall be paid at the lower of the provider's usual and customary rate or the statewide HPC rates established in appendix A to rule 5123:2-9-06 of the Administrative Code.

(3) Agency providers of HPC may bill for each day the individual receives HPC through the agency.

(4) Independent providers of HPC may bill for each day the HPC service is delivered by the provider.

(5) Payment for HPC does not include room and board, items of comfort or convenience, or costs for the maintenance, upkeep, and improvement of the home.

(6) ODJFS retains the final authority to establish payment rates for all waiver services included in HCBS waivers administered by the department.

(H) Monitoring

(1) Providers, county boards, and the department shall have access to both utilization reports and reports generated by the daily rate application in order to monitor estimated services and actual services provided at each specific site. This information shall be made available to ODJFS upon request.

(2) The department shall monitor the ongoing progress of the daily billing unit approach through a series of fiscal control and quality assurance procedures including: validation of total expenditures and total hours that are entered by the county board into the cost projection tool; verification that daily billing units are supported by appropriate documentation; and verification that provider service hours rendered are reported appropriately. Each type of procedural monitoring shall take place in each region of the state and shall be summarized in a report to ODJFS every six months.

(3) ODJFS reserves the right to perform independent oversight reviews as part of its general oversight functions, in addition to the department's monitoring activities described in paragraph (H)(2) of this rule.

(I) Due process rights and responsibilities

(1) Any recipient or applicant for waiver services administered by the department may utilize the process set forth in section 5101.35 of the Revised Code, in accordance with division 5101:6 of the Administrative Code, for any purpose authorized by that statute and the rules implementing the statute. The process set forth in section 5101.35 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives. Providers shall have no standing in an appeal under this section.

(2) Applicants for and recipients of waiver services administered by the department shall use the process set forth in section 5101.35 of the Revised Code for any challenge related to the administration and/or scoring of the ODDP or to the type, amount/level, scope, or duration of services included on or excluded from an ISP or individual behavior plan addendum. A change in staff to waiver recipient service ratios does not automatically result in a change in the level of services received by an individual.

Replaces: 5123:2-13-07

Click to view Appendix

Effective: 07/01/2010
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5111.871 , 5111.873
Rule Amplifies: 5123.04 , 5111.871 , 5111.873
Prior Effective Dates: 12/21/2007 (Emer.), 03/20/2008

5123:2-9-32 Home and community-based services waivers - adult family living under the individual options waiver.

(A) Purpose

The purpose of this rule is to define adult family living and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Adult" means an individual eighteen years of age or older.

(2) "Adult family living" means personal care and support services provided to an adult by a caregiver who is related to and lives with the individual receiving the services. Adult family living is provided in conjunction with residing in the home and is part of the rhythm of life that naturally occurs when people live together as a family. Due to the environment provided by living together as a family, segregating these activities into discrete services is impractical. The supports that may be provided as a component of adult family living include the following:

(a) Basic personal care and grooming, including bathing, care of the hair, and assistance with clothing.

(b) Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom or assisting the individual with bedpan routines.

(c) Assisting the individual with self-medication or provision of medication administration for prescribed medications and assisting the individual with, or performing, health care activities.

(d) Performing household services essential to the individual's health and comfort in the home (e.g., necessary changing of bed linens or rearranging of furniture to enable the individual to move about more easily in his or her home).

(e) Assessing, monitoring, and supervising the individual to ensure the individual's safety, health, and welfare.

(f) Light cleaning tasks in areas of the home used by the individual.

(g) Preparation of a shopping list appropriate to the individual's dietary needs and financial circumstances, performance of grocery shopping activities as necessary, and preparation of meals.

(h) Personal laundry.

(i) Incidental neighborhood errands as necessary, including accompanying the individual to medical and other appropriate appointments and accompanying the individual for walks outside the home.

(j) Skill development to prevent the loss of skills and enhance skills that are already present that lead to greater independence and community integration.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(4) "Community respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Department" means the Ohio department of developmental disabilities.

(7) "Funding range" means one of the dollar ranges contained in appendix C to rule 5123:2-9-06 of the Administrative Code, to which individuals have been assigned for the purpose of funding services for individuals enrolled on the individual options waiver. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(8) "Group size" means the number of individuals who are sharing services, regardless of the funding source for those services.

(9) "Homemaker/personal care" has the same meaning as in rule 5123:2-13-04 of the Administrative Code.

(10) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(11) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code.

(12) "Individual funding level" has the same meaning as in rule 5123:2-9-06 of the Administrative Code.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(14) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled on the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(15) "Related to" means the caregiver is related to the individual receiving adult family living by blood, marriage, or adoption, but does not include the individual's spouse. This definition includes a caregiver who is the individual's:

(a) Parent or stepparent.

(b) Sibling or stepsibling.

(c) Grandparent.

(d) Aunt, uncle, nephew, or niece.

(e) Cousin.

(f) Child or stepchild.

(16) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(17) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(18) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraphs (F)(2) and (F)(3) of this rule, as applicable, to validate payment for medicaid services.

(19) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Adult family living shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Adult family living shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) An applicant seeking approval to provide adult family living shall meet the requirements of this rule and complete and submit an application and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(4) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(5) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(D) Requirements for service delivery

(1) Adult family living shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code.

(2) The total number of persons with developmental disabilities living in a home in which an individual receives adult family living shall not exceed four.

(3) A provider shall not provide both a residence and adult family living or other services to more than three persons with developmental disabilities living in a home unless the home is licensed under section 5123.19 of the Revised Code.

(4) An independent provider of adult family living shall reside in the home where the services are delivered and that home shall be the provider's primary, legal residence.

(5) An agency provider of adult family living shall employ or contract with another person to be the caregiver who shall reside in the home where the services are delivered and that home shall be the person's primary, legal residence. The person who is the caregiver shall be related to the individual receiving services.

(6) Except as provided in paragraphs (E) and (G) of this rule, an individual who receives supports under the individual options waiver that meet the definition of adult family living is not eligible to receive homemaker/personal care.

(E) Payment standards

(1) The billing units, service codes, and payment rates for adult family living are contained in appendix A to this rule. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(2) Individuals who receive adult family living shall choose either to have their services paid through a daily rate or a fifteen-minute rate.

(a) Daily rate option

(i) The daily rate shall be determined by an individual's Ohio developmental disabilities profile range and the county cost-of-doing-business category. For example, if an individual is in Ohio developmental disabilities profile range one and cost-of-doing-business category one, his or her daily rate is thirty-eight dollars and ninety-three cents; if an individual is in Ohio developmental disabilities profile range four and cost-of-doing-business category three, his or her daily rate is one hundred eighteen dollars and twenty-five cents.

(ii) An individual who chooses the daily rate option shall not receive homemaker/personal care except as provided in paragraph (E)(2)(a)(iv) of this rule.

(iii) An individual who chooses the daily rate option may have more than one adult family living provider, however, only one provider may bill for adult family living on a given day.

(iv) An individual who chooses the daily rate option may receive homemaker/personal care only if the services are provided on a day when the individual's adult family living provider does not bill for adult family living and either of the following apply:

(a) The services are provided outside the family living setting by a certified homemaker/personal care provider who is not related to the individual.

(b) The services are provided as substitute coverage in the individual's family living setting or in a community setting agreed to by the individual, by a certified homemaker/personal care provider who is not related to the individual, in circumstances where the adult family living provider is temporarily unavailable to provide services.

(v) Homemaker/personal care that meets the requirements of paragraph (E)(2)(a)(iv) of this rule is not considered adult family living and is not subject to the limitation in paragraph (E)(7) of this rule.

(b) Fifteen-minute rate option

(i) The fifteen-minute rate provides flexibility to an individual who utilizes multiple adult family living providers on a regular basis or chooses to receive adult family living and homemaker/personal care on the same or different days.

(ii) Under the fifteen-minute rate, the maximum payment for adult family living and homemaker/personal care in a waiver eligibility span is subject to the limitation specified in paragraph (E)(7) of this rule.

(3) The daily rate and the fifteen-minute rate shall be adjusted to reflect the group size as specified in appendix A to this rule.

(4) The daily rate and the fifteen-minute rate shall not be billed on the same day.

(5) An individual's service and support administrator shall explain the implications of the payment options (i.e., daily rate or fifteen-minute rate) to the individual. The individual's choice of payment option shall be identified in his or her individual service plan.

(6) If an individual requests a change in his or her payment option, the individual's service and support administrator shall identify the change and its effective date in the individual service plan. The change to the individual service plan shall be made prior to implementing the change in the payment option.

(7) Except as provided in paragraph (E)(2)(a)(iv) of this rule and regardless of which payment option an individual chooses or whether a change in payment option occurs, payment of an individual's adult family living and homemaker/personal care for a waiver eligibility span shall not exceed an amount determined by multiplying the daily rate for adult family living by the number of days in the span.

(8) Paragraphs (F), (G), and (H) of rule 5123:2-9-06 of the Administrative Code do not apply to payment for adult family living.

(9) Adult family living is subject to the funding ranges and individual funding levels as set forth in paragraph (C) of rule 5123:2-9-06 of the Administrative Code.

(10) An individual who receives adult family living may request prior authorization under rule 5101:3-41-12 of the Administrative Code for waiver services other than adult family living. Prior authorization may not be requested for the purpose of increasing an adult family living provider's rate.

(11) Payment for adult family living does not include room and board.

(12) Adult family living providers shall not bill homemaker/personal care for services to individuals for whom they provide adult family living.

(13) An individual who receives adult family living may receive residential respite or community respite under the individual options waiver because of an adult family living provider's short-term absence or need for relief. Adult family living shall not be billed during the period of time when residential respite or community respite is being provided.

(F) Documentation of services

(1) The requirements of paragraph (B) of rule 5123:2-9-05 of the Administrative Code do not apply to service documentation for adult family living.

(2) Service documentation for the adult family living daily rate shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(i) Group size in which the service was provided.

(j) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(3) Service documentation for the adult family living fifteen-minute rate shall include the items delineated in paragraph (F)(2) of this rule and each of the following to validate payment for medicaid services:

(a) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(b) Begin and end time of the delivered service.

(G) Applicability and exemptions

(1) Except as provided in paragraphs (G)(2) and (G)(3) of this rule, this rule applies to any individual who receives supports under the individual options waiver that meet the definition of adult family living.

(2) Individuals who, on the effective date of this rule, are receiving homemaker/personal care under the individual options waiver that meets the definition of adult family living are not eligible to receive adult family living unless both the individual and the county board agree otherwise.

(3) This rule does not apply to an individual for whom personal care and support services provided by a caregiver who is related to and lives with the individual constitute less than twenty per cent of his or her individual funding level.

Click to view Appendix

Click to view Appendix

Effective: 07/15/2011
R.C. 119.032 review dates: 07/15/2016
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-33 Home and community-based services waivers - adult foster care under the individual options waiver.

(A) Purpose

The purpose of this rule is to define adult foster care and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Adult" means an individual eighteen years of age or older.

(2) "Adult foster care" means personal care and support services provided to an adult by a caregiver who is not related to and lives with the individual receiving the services. Adult foster care is provided in conjunction with residing in the home and is part of the rhythm of life that naturally occurs when people live together in the same home. Due to the environment provided by living together in the same home, segregating these activities into discrete services is impractical. Examples of supports that may be provided as a component of adult foster care include:

(a) Basic personal care and grooming, including bathing, care of the hair, and assistance with clothing.

(b) Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom or assisting the individual with bedpan routines.

(c) Assisting the individual with self-medication or provision of medication administration for prescribed medications and assisting the individual with, or performing, health care activities.

(d) Performing household services essential to the individual's health and comfort in the home (e.g., necessary changing of bed linens or rearranging of furniture to enable the individual to move about more easily in his or her home).

(e) Assessing, monitoring, and supervising the individual to ensure the individual's safety, health, and welfare.

(f) Light cleaning tasks in areas of the home used by the individual.

(g) Preparation of a shopping list appropriate to the individual's dietary needs and financial circumstances, performance of grocery shopping activities as necessary, and preparation of meals.

(h) Personal laundry.

(i) Incidental neighborhood errands as necessary, including accompanying the individual to medical and other appropriate appointments and accompanying the individual for walks outside the home.

(j) Skill development to prevent the loss of skills and enhance skills that are already present that lead to greater independence and community integration.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(4) "Community respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Department" means the Ohio department of developmental disabilities.

(7) "Group size" means the number of individuals who are sharing services, regardless of the funding source for those services.

(8) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(9) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through a contract, anyone else to provide the services.

(10) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code.

(11) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(12) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(13) "Related to" means the caregiver is related to the individual by blood, marriage, or adoption. This definition includes a caregiver who is the individual's:

(a) Parent or stepparent.

(b) Sibling or stepsibling.

(c) Grandparent.

(d) Aunt, uncle, nephew, or niece.

(e) Cousin.

(f) Child or stepchild.

(14) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(15) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(16) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(C) Provider qualifications

(1) Adult foster care shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Adult foster care shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) An applicant seeking approval to provide adult foster care shall meet the requirements of this rule and complete and submit an application and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(4) Providers of adult foster care shall not be related to an individual for whom they provide adult foster care.

(5) Providers of adult foster care shall not be the guardian of an individual for whom they provide adult foster care.

(6) Providers licensed under section 5123.19 of the Revised Code seeking to provide adult foster care shall:

(a) Meet all of the requirements set forth in and maintain a license issued under section 5123.19 of the Revised Code.

(b) Maintain a current medicaid provider agreement with the Ohio department of job and family services.

(c) Provide to the department written assurance to arrange for substitute coverage, if necessary, only from a provider certified by the department and as identified in the individual service plan; notify the individual or legally responsible person in the event that substitute coverage is necessary; and notify the person identified in the individual service plan when substitute coverage is not available to allow such person to make other arrangements.

(7) Each independent provider and each employee, contractor, and employee of a contractor of an agency provider who has direct contact with individuals receiving adult foster care shall annually complete at least eight hours of training, in accordance with standards established by the department.

(a) The training shall enhance the skills and competencies of the independent provider or employee/contractor of the agency provider relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training.

(iii) The requirements relative to the independent provider's or employee's/contractor's role in providing behavior support to the individuals he or she serves.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/ programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(c) The provider shall maintain a written record, which may include an electronic record, of training. This information shall be presented upon request by the Ohio department of job and family services, the department, or the county board. Documentation shall include the name of the person receiving the training, date of training, training topic, duration of training, instructor's name if applicable, and a brief description of the training.

(8) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(9) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(D) Requirements for service delivery

(1) Adult foster care shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code.

(2) The total number of persons with developmental disabilities living in a home in which an individual receives adult foster care shall not exceed four.

(3) A provider shall not provide both a residence and adult foster care or other services to more than three persons with developmental disabilities living in a home unless the home is licensed under section 5123.19 of the Revised Code.

(4) An independent provider of adult foster care shall reside in the home where the services are delivered and that home shall be the provider's primary, legal residence.

(5) An agency provider of adult foster care shall employ or contract with another person to be the caregiver who shall reside in the home where the services are delivered and that home shall be the person's primary, legal residence.

(a) Caregivers of adult foster care shall not be related to an individual for whom they provide adult foster care.

(b) Caregivers of adult foster care shall not be the guardian of an individual for whom they provide adult foster care.

(6) Individuals who choose to receive personal care services and supports in adult foster care settings shall receive adult foster care in lieu of homemaker/personal care except as provided in paragraph (D)(8) of this rule.The service and support administrator shall explain the implications of this choice to the individual.

(7) Adult foster care is not available to individuals who are eligible to receive reimbursement for foster care under Title IV-E as amended by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. No. 104-193, and the Balanced Budget Act of 1997, Pub. L. No. 105-33.

(8) Individuals may receive homemaker/personal care when the individuals choose services that take place outside the adult foster care setting and the services are provided by a certified provider of homemaker/personal care.

(a) An agency provider may contract for these services. If the agency provider opts to contract, the daily rate for adult foster care may be billed by the adult foster care provider for that day.

(b) In situations where an agency provider does not contract for these services or in situations where an individual served by an independent provider seeks homemaker/personal care services outside of the adult foster care setting, the adult foster care provider shall not bill for adult foster care on a day when homemaker/personal care is rendered. This prohibition exists regardless of whether claims for homemaker/personal care are submitted to the department for the entire twenty-four-hour period or for a lesser amount of time that day.

(c) In circumstances where a caregiver of adult foster care is temporarily unavailable to provide services, substitute coverage may be provided as follows:

(i) In the individual's adult foster care setting or in another community setting agreed to by the individual.

(ii) For independent providers, a certified provider of homemaker/personal care is arranged to deliver substitute coverage and the service is billed as homemaker/personal care. Independent providers shall work with the individual's service and support administrator to arrange for substitute coverage when needed.

(iii) For agency providers, an adult foster care provider is arranged to deliver substitute coverage and the service is billed as adult foster care.

(d) Homemaker/personal care shall not be billed on the same day as adult foster care.

(e) Independent providers of adult foster care shall not bill homemaker/personal care for services to individuals for whom they provide adult foster care.

(9) An individual who receives adult foster care may also choose to use community respite or residential respite during a short-term absence or need for relief of the caregiver.

(E) Documentation of services

Service documentation for adult foster care shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Group size in which the service was provided.

(10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for adult foster care are contained in appendix A to this rule.

(2) Payment for adult foster care shall be at a daily rate. Payment rates include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(3) Payment rates for adult foster care are established separately for services provided by independent providers and services provided through agency providers.

(4) The rate paid to a provider of adult foster care shall be adjusted to reflect the group size:

(a) Payment for one individual shall be at one hundred per cent of the daily rate for the range assigned by the Ohio developmental disabilities profile.

(b) Payment for a group size of two shall be at eighty-five per cent of the daily rate for the range for each individual.

(c) Payment for a group size of three shall be at seventy-five per cent of the daily rate for the range for each individual.

(d) Payment for a group size of four shall be at sixty-five per cent of the daily rate for the range for each individual.

(5) Agency providers of adult foster care may bill for each day the individual receives adult foster care through the agency.

(6) Independent providers of adult foster care may bill for each day adult foster care is delivered. Adult foster care shall not be billed on the same day as homemaker/personal care.

(7) An individual who receives adult foster care may request prior authorization in accordance with rule 5101:3-41-12 of the Administrative Code. In no instance shall prior authorization result in a per diem rate in excess of the highest rate within the applicable cost-of-doing-business category as set forth in appendix A to this rule.

(8) Payment for adult foster care does not include room and board, items of comfort or convenience, or costs for the maintenance, upkeep, and improvement of the foster home.

Replaces: 5123:2-13-06

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Effective: 03/19/2012
R.C. 119.032 review dates: 03/19/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 10/01/2007

5123:2-9-34 Home and community-based services waivers - residential respite under the individual options, level one, and self-empowered life funding waivers.

(A) Purpose

The purpose of this rule is to define residential respite and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the services.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "Community inclusion" has the same meaning as in rule 5123:2-9-42 of the Administrative Code.

(3) "Community respite" has the same meaning as in rule 5123:2-9-22 of the Administrative Code.

(4) "County board" means a county board of developmental disabilities.

(5) "Department" means the Ohio department of developmental disabilities.

(6) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123:2-9-06 of the Administrative Code, to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(7) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(8) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(9) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(10) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(11) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(12) "Intermediate care facility" means an intermediate care facility for individuals with intellectual disabilities as defined in rule 5123:2-7-01 of the Administrative Code.

(13) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(14) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(15) "Residential respite" means services provided to individuals unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individuals. Residential respite shall only be provided in the following locations:

(a) An intermediate care facility;

(b) A residential facility, other than an intermediate care facility, licensed by the department under section 5123.19 of the Revised Code; or

(c) A residence, other than an intermediate care facility or a facility licensed by the department under section 5123.19 of the Revised Code, where residential respite is provided by an agency provider.

(16) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(17) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(18) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Residential respite shall be provided by one of the following entities that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid:

(a) An intermediate care facility;

(b) A residential facility licensed by the department under section 5123.19 of the Revised Code; or

(c) An agency provider that is approved to provide residential respite in accordance with this rule.

(2) An applicant seeking approval to provide residential respite shall complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(3) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(4) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(D) Requirements for service delivery

(1) Residential respite shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable.

(2) The individual service plan shall address all emergency and replacement coverage should the individual unexpectedly need to leave the residential respite service delivery location.

(3) When residential respite is provided in a residence other than an intermediate care facility or a residential facility licensed by the department under section 5123.19 of the Revised Code, each individual who receives homemaker/personal care or community inclusion and permanently resides at the residence shall consent to the provision of residential respite in the residence.

(4) When residential respite is provided at a residence other than an intermediate care facility or a residential facility licensed by the department under section 5123.19 of the Revised Code, the total number of persons with developmental disabilities being served at the residence shall not exceed four.

(5) Residential respite is limited to ninety calendar days of service per waiver eligibility span.

(6) Residential respite shall not be provided to an individual at the same time as homemaker/personal care or community inclusion.

(E) Documentation of services

Service documentation for residential respite shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing units, service codes, and payment rates for residential respite are contained in the appendix to this rule.

(2) Only one provider shall bill residential respite for the same individual on any given day.

(3) Residential respite provided to individuals enrolled in the individual options waiver is subject to the funding ranges and individual funding levels set forth in paragraph (C) of rule 5123:2-9-06 of the Administrative Code.

(4) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, residential respite, and transportation, alone or in combination, shall not exceed five thousand dollars per waiver eligibility span.

(5) Under the self-empowered life funding waiver, payment for community inclusion, community respite, remote monitoring, and residential respite, alone or in combination, shall not exceed twenty-five thousand dollars per waiver eligibility span.

(6) Payment for residential respite shall not include payment for room and board or transportation.

Replaces: Part of 5123:2-9-34

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Effective: 09/01/2013
R.C. 119.032 review dates: 09/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 07/15/2011, 07/01/2012

5123:2-9-35 Home and community-based services waivers - remote monitoring and remote monitoring equipment under the individual options, level one, and self-empowered life-funding waivers.

(A) Purpose

The purpose of this rule is to define remote monitoring and remote monitoring equipment and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the services.

(B) Definitions

(1) "Acquisition costs" means the cost of any attachments, accessories, or auxiliary apparatus necessary to make the equipment usable; taxes; duty; protective in-transit insurance; and freight charges.

(2) "Actual price" means the actual price that the provider of remote monitoring equipment is charged to purchase an item of equipment by the seller and that fully and accurately reflects any discount or rebate the provider receives. The provider shall maintain documentation of the actual price in the form of an invoice from the seller that gives details of date, price, quantity, and type of equipment or other documentation approved by the department.

(3) "Adult family living" has the same meaning as in rule 5123:2-9-32 of the Administrative Code.

(4) "Adult foster care" has the same meaning as in rule 5123:2-9-33 of the Administrative Code.

(5) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(6) "Backup support person" means the person who is responsible for responding in the event of an emergency or when an individual receiving remote monitoring otherwise needs assistance or the remote monitoring equipment stops working for any reason. Backup support may be provided on an unpaid basis by a family member, friend, or other person selected by the individual or on a paid basis by an agency provider of homemaker/personal care or community inclusion, as applicable.

(7) "Community inclusion" has the same meaning as in rule 5123:2-9-42 of the Administrative Code.

(8) "Community respite" has the same meaning as in rule 5123:2-9-22 of the Administrative Code.

(9) "County board" means a county board of developmental disabilities.

(10) "Department" means the Ohio department of developmental disabilities.

(11) "Environmental accessibility adaptations" has the same meaning as in rule 5123:2-9-23 of the Administrative Code.

(12) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123:2-9-06 of the Administrative Code, to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, non-medical transportation, supported employment-community, supported employment-enclave, and vocational habilitation. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool.

(13) "Group size" means the number of individuals who are sharing services, regardless of the funding source for those services.

(14) "Home-delivered meals" has the same meaning as in rule 5123:2-9-29 of the Administrative Code.

(15) "Homemaker/personal care" has the same meaning as in rule 5123:2-9-30 of the Administrative Code.

(16) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(17) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(18) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(19) "Manufacturer's suggested retail price" means the current retail price of an item of remote monitoring equipment that is recommended by the product's manufacturer. If a provider of remote monitoring equipment is also the manufacturer, the provider may establish a suggested retail price provided that the price is equal to or less than the suggested retail price for the same or a comparable item of equipment recommended by one or more other manufacturers.

(20) "Monitoring base" means the location from which the remote monitoring staff monitor an individual.

(21) "Ohio developmental disabilities profile" means the standardized instrument utilized by the department to assess the relative needs and circumstances of an individual enrolled in the individual options waiver compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department.

(22) "Personal emergency response systems" has the same meaning as in rule 5123:2-9-26 of the Administrative Code.

(23) "Remote monitoring" means the monitoring of an individual in his or her residence by staff using one or more of the following systems: live video feed, live audio feed, motion sensing system, radio frequency identification, web-based monitoring system, or other device approved by the department. The system shall include devices to engage in live two-way communication with the individual being monitored as described in the individual service plan.

(24) "Remote monitoring equipment" means the equipment used to operate systems such as live video feed, live audio feed, motion sensing system, radio frequency identification, web-based monitoring system, or other device approved by the department. It also means the equipment used to engage in live two-way communication with the individual being monitored.

(25) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(26) "Sensor" means equipment used to notify the remote monitoring staff of a situation that requires attention. Examples include, but are not limited to, seizure mats, door sensors, floor sensors, and smoke detectors.

(27) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(28) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraphs (D)(3) and (E)(3) of this rule, as applicable, to validate payment for medicaid services.

(29) "Specialized medical equipment and supplies" has the same meaning as in rule 5123:2-9-25 of the Administrative Code.

(30) "Team" has the same meaning as in rule 5123:2-1-11 of the Administrative Code.

(31) "Three-year period" means the three-year period beginning with the individual's initial enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(32) "Useful life" means three years.

(33) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) General provisions for remote monitoring and remote monitoring equipment

(1) Provider qualifications

(a) An applicant seeking approval to provide remote monitoring or remote monitoring equipment shall meet the requirements of this rule and complete and submit an application through the department's provider portal (https://doddportal.dodd.ohio.gov/PRV/certification/Pages/default.aspx) and adhere to the requirements of either rule 5123:2-2-01 or 5123:2-3-19 of the Administrative Code, as applicable.

(b) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(c) Failure of a licensed provider to comply with this rule and Chapter 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license.

(2) Requirements for service delivery

(a) The individual's service and support administrator, in consultation with the individual and the individual's team, shall assess whether remote monitoring is sufficient to ensure the individual's health and welfare.

(b) Remote monitoring and remote monitoring equipment shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code, paragraph (H) of rule 5101:3-42-01 of the Administrative Code, or paragraph (K) of rule 5123:2-9-40 of the Administrative Code, as applicable.

(3) Payment standards

(a) The billing units, service codes, and payment rates for remote monitoring and remote monitoring equipment are contained in the appendix to this rule.

(b) Remote monitoring and remote monitoring equipment provided to individuals enrolled in the individual options waiver are subject to the funding ranges and individual funding levels set forth in paragraph (C) of rule 5123:2-9-06 of the Administrative Code.

(D) Specific provisions for remote monitoring

(1) Provider qualifications

(a) Remote monitoring shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(b) Remote monitoring shall not be provided by an independent provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(c) The requirements of paragraphs (C)(3)(a) and (C)(3)(b) of rule 5123:2-2-01 of the Administrative Code do not apply to an applicant for certification to provide remote monitoring.

(d) Staff of agency providers and entities under contract with agency providers who monitor individuals from the monitoring base shall complete the training specified in paragraph (C)(3)(c) of rule 5123:2-2-01 of the Administrative Code.

(2) Requirements for service delivery

(a) Remote monitoring is intended to ensure an individual's health and welfare and shall only be used to reduce or replace the amount of homemaker/personal care or community inclusion, as applicable, an individual needs.

(b) Remote monitoring shall be done in real time, not via a recording, by awake staff at a monitoring base using the appropriate connection. While remote monitoring is being provided, the remote monitoring staff shall not have duties other than remote monitoring.

(c) Remote monitoring shall not be provided in adult foster care, adult family living, or non-residential settings.

(d) When remote monitoring involves the use of audio and/or video equipment that permits remote monitoring staff to view activities and/or listen to conversations in the residence, both of the following requirements shall be met:

(i) The individual who receives the service and each person who lives with the individual shall consent in writing after being fully informed of what remote monitoring entails including, but not limited to, that the remote monitoring staff will observe their activities and/or listen to their conversations in the residence, where in the residence the remote monitoring will take place, and whether or not recordings will be made. If the individual or a person who lives with the individual has a guardian, the guardian shall consent in writing. The individual's service and support administrator shall keep a copy of each signed consent form with the individual service plan.

(ii) A notice shall be prominently displayed within the residence that advises that the residence is equipped with audio and/or video equipment that permits others to view activities and/or listen to conversations within the residence.

(e) The provider of remote monitoring shall provide initial and ongoing training to its staff to ensure they know how to use the remote monitoring system.

(f) The provider of remote monitoring shall have a backup power system (such as battery power and/or generator) in place at the monitoring base in the event of electrical outages. The provider shall have other backup systems and additional safeguards in place which shall include, but are not limited to, contacting the backup support person in the event the remote monitoring system stops working for any reason.

(g) The provider of remote monitoring shall comply with all federal, state, and local regulations that apply to the operation of its business or trade, including but not limited to, 18 U.S.C. section 2510 to section 2522 as in effect on the effective date of this rule and section 2933.52 of the Revised Code.

(h) The provider of remote monitoring shall have an effective system for notifying emergency personnel such as police, fire, emergency medical services, and psychiatric crisis response entities.

(i) The provider of remote monitoring shall provide an individual who receives remote monitoring with initial and ongoing training on how to use the remote monitoring system as specified in the individual service plan.

(j) The provider of remote monitoring shall disclose to the individual and the individual's team during the provider selection process its current ratio of monitoring staff to individuals receiving remote monitoring. The provider shall update this information as needed, but no less than once a year.

(k) If an emergency arises at an individual's residence, the remote monitoring staff shall immediately assess the situation and call emergency personnel first, if that is deemed necessary, and then contact the backup support person. The remote monitoring staff shall stay engaged with the individual during an emergency until emergency personnel or the backup support person arrives.

(i) The backup support person shall verbally acknowledge receipt of a request for assistance from the remote monitoring staff.

(ii) The backup support person shall arrive at the individual's residence within a reasonable amount of time (to be specified in the individual service plan) when a request for in-person assistance is made.

(l) If an individual needs assistance but the situation is not an emergency, the remote monitoring staff shall address the situation as specified in the individual service plan.

(m) The remote monitoring staff shall have detailed and current written protocols for responding to an individual's needs as specified in the individual service plan and/or the behavior support plan, including contact information for the backup support person to provide assistance at the individual's residence when necessary.

(n) If an individual indicates he or she wants the remote monitoring system turned off, the following protocol shall be implemented:

(i) The remote monitoring staff shall contact the backup support person and request in-person assistance at the individual's residence.

(ii) The remote monitoring system shall remain in operation until the backup support person arrives.

(iii) If no one else at the residence is receiving remote monitoring, the remote monitoring staff shall turn off the system once the backup support person arrives at the residence and is briefed on the situation.

(iv) The remote monitoring staff shall contact the individual's service and support administrator who shall confirm whether the individual/guardian chooses to continue to receive the service.

(o) A monitoring base shall not be located at the residence of an individual who receives remote monitoring.

(p) A secure network system requiring authentication, authorization, and encryption of data that complies with 45 C.F.R. section 164.102 to section 164.534 as in effect on the effective date of this rule shall be in place to ensure that access to computer, video, audio, sensor, and written information is limited to authorized persons.

(q) If an unusual incident or a major unusual incident as defined in rule 5123:2-17-02 of the Administrative Code occurs while an individual is being monitored, the remote monitoring provider shall retain or ensure the retention of any video and/or audio recordings and any sensor and written information pertaining to the incident for at least seven years from the date of the incident.

(3) Documentation of services

Service documentation for remote monitoring shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Begin and end time of the remote monitoring service when the backup support person is needed on site.

(i) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(j) Number of units of the delivered service.

(k) Group size in which the service was provided.

(l) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(m) A notation made at least monthly indicating the individual's response to services delivered.

(4) Payment standards

(a) The payment rates for remote monitoring are intended as payment for providing remote monitoring for all individuals in the residence who receive the service.

(b) There are two payment rates for remote monitoring, which differ depending on whether an individual is receiving remote monitoring with unpaid backup support or paid backup support.

(c) When an individual receives remote monitoring with unpaid backup support, the agency provider of the remote monitoring shall bill for the remote monitoring. When two or more individuals share remote monitoring with unpaid backup support, the rate shall be divided equally among those sharing the service, regardless of funding source.

(d) When an individual receives remote monitoring with paid backup support, the homemaker/personal care or community inclusion provider, as applicable, that is providing the backup support shall bill for the remote monitoring and provide the remote monitoring directly or through a contract with an agency provider of remote monitoring that meets the requirements of this rule. When two or more individuals share remote monitoring with paid backup support, the rate shall be divided equally among those sharing the service, regardless of funding source.

(e) The homemaker/personal care or community inclusion provider, as applicable, shall be paid for backup support until the remote monitoring staff contacts the backup support person and requests emergency or in-person assistance. Once contact is made, the backup support person's time shall be billed as homemaker/personal care or community inclusion, as applicable.

(f) Under the level one waiver, payment for environmental accessibility adaptations, home-delivered meals, personal emergency response systems, remote monitoring, remote monitoring equipment, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

(g) Under the self-empowered life funding waiver, payment for community inclusion, community respite, remote monitoring, and residential respite, alone or in combination, shall not exceed twenty-five thousand dollars per waiver eligibility span.

(E) Specific provisions for remote monitoring equipment

(1) Provider qualifications

(a) Remote monitoring equipment shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(b) The requirements of paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of rule 5123:2-2-01 of the Administrative Code do not apply to an applicant for certification to provide remote monitoring equipment.

(2) Requirements for service delivery

(a) Remote monitoring equipment shall include an indicator to the individual being monitored that the equipment is on and operating. The indicator shall be appropriate to meet the individual's needs.

(b) Remote monitoring equipment shall be designed so that it can be turned off only by the person(s) indicated in the individual service plan.

(c) The provider of remote monitoring equipment shall be responsible for all of the following:

(i) Delivery of the equipment to the individual's residence and, when necessary, to the room or area of the home in which the equipment will be used;

(ii) Installation of the equipment, including assembling the equipment or parts used for the assembly of the equipment;

(iii) Adjustments and/or modifications of the equipment;

(iv) Conducting monthly testing of the equipment to ensure proper operation;

(v) Maintenance and necessary repairs to the equipment; and

(vi) Replacing equipment that needs to be replaced prior to the expiration of the equipment's useful life for any reason other than misuse or damage by an individual.

(3) Documentation of services

Service documentation for remote monitoring equipment shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(i) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(j) Group size in which the service was provided.

(4) Payment standards

(a) If the provider of remote monitoring equipment purchases the equipment, the monthly rate billed to the department for the item of equipment shall be the lesser of the provider's usual and customary charge or the actual price plus acquisition costs of the item both of which shall be pro rated over the useful life of the equipment plus a reasonable percentage adequate to cover the cost of the provider's responsibilities as set forth in paragraph (E)(2)(c) of this rule.

(b) If the provider of remote monitoring equipment leases or manufactures the equipment, the monthly rate billed to the department for the item of equipment shall be the lesser of the provider's usual and customary charge or the manufacturer's suggested retail price pro rated over the useful life of the equipment plus a reasonable percentage adequate to cover the cost of the provider's responsibilities as set forth in paragraph (E)(2)(c) of this rule.

(c) When two or more individuals share the equipment, the rate shall be divided equally among those sharing the equipment, regardless of funding source.

(d) The monthly rate shall be recalculated in accordance with paragraph (E)(4)(a) or (E)(4)(b) of this rule, as applicable, when an item of equipment needs to be replaced after the expiration of the equipment's useful life or due to misuse or damage by an individual, when additional equipment is added, and when existing equipment is eliminated.

(e) Payment for an item of equipment includes the manufacturer's and seller's warranties.

(f) Payment for an item of equipment shall start at the beginning of the month in which an individual at the residence begins using the equipment as specified in his or her individual service plan. Payment shall stop at the end of the month in which no individual in the residence is using the equipment as specified in his or her individual service plan.

Click to view Appendix

Effective: 09/01/2013
R.C. 119.032 review dates: 07/15/2016
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 07/15/2011, 07/01/2012

5123:2-9-36 Home and community-based services waivers - interpreter services under the individual options waiver.

(A) Purpose

The purpose of this rule is to define interpreter services and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code.

(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(7) "Interpreter services" means the process by which one person's message is conveyed to another in a manner that incorporates both the message and attitude of the communicator.

(8) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services.

(C) Provider qualifications

(1) Interpreter services shall be provided by a person who:

(a) Is certified by the registry of interpreters for the deaf;

(b) Is either an independent provider or the employee of an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Meets one of the following standards:

(i) Has graduated from an interpreter training program (of a minimum of two-years) and has at least one year of documented experience providing interpreter services;

(ii) Has successfully completed a written test administered by the registry of interpreters for the deaf and has at least one year of documented experience providing interpreter services; or

(iii) Has at least two years of documented experience providing interpreter services.

(2) An applicant seeking approval to provide interpreter services shall meet the requirements of this rule and complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(3) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Interpreter services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code.

(2) The provider shall:

(a) Maintain a role of facilitator of communication rather than the initiator of communication; and

(b) Render the message faithfully, always conveying the content and spirit of the individual being served, using language most readily understood by the individual.

(3) The provider shall not counsel, advise, or interject his or her personal opinions.

(E) Documentation of services

(1) The requirements of paragraph (B) of rule 5123:2-9-05 of the Administrative Code do not apply to service documentation for interpreter services.

(2) Service documentation for interpreter services shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(i) Group size in which the service was provided.

(j) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(k) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(l) Begin and end time of the delivered service.

(F) Payment standards

(1) The billing unit, service code, and payment rates for interpreter services are contained in appendix A to this rule.

(2) Payment rates for interpreter services include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(3) Payment rates for interpreter services are established separately for services provided by independent providers and services provided through agency providers.

(4) Payment rates for interpreter services are based on the number of individuals receiving services.

Click to view Appendix

Click to view Appendix

Effective: 11/03/2011
R.C. 119.032 review dates: 11/03/2016
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-38 Home and community-based services waivers - social work under the individual options waiver.

(A) Purpose

The purpose of this rule is to define social work and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be certified under rules adopted by the department.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(5) "Independent provider" means a self-employed person who provides services for which he or she must be certified under rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

(6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(9) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services.

(10) "Social work" means the application of specialized knowledge of human development and behavior as well as social, economic, and cultural systems.This knowledge is used to assist individuals and their families to improve and/or restore their capacity for social functioning. Social work includes the provision of counseling and active participation in problem-solving with individuals and family members; counseling to meet the psychosocial needs of individuals; collaboration with healthcare professionals and other providers to assist them to understand and support the social and emotional needs and problems experienced by individuals and their families; advocacy; referral to community-based and specialized services; development of social work/counseling plans of treatment; and assisting providers of services and family members to understand and implement activities related to implementation of the plan of treatment. Social work is not intended to duplicate the efforts of the service and support administrator.

(C) Provider qualifications

(1) Social work shall be provided by one of the following who is either an independent provider or the employee of an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services:

(a) An independent social worker licensed by the state pursuant to section 4757.27 of the Revised Code;

(b) A social worker licensed by the state pursuant to section 4757.28 of the Revised Code;

(c) A professional clinical counselor licensed by the state pursuant to section 4757.22 of the Revised Code; or

(d) A professional counselor licensed by the state pursuant to section 4757.23 of the Revised Code.

(2) Social work shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(3) Social work shall not be provided to an individual by his or her family member.

(4) An applicant seeking approval to provide social work shall meet the requirements of this rule and complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Social work shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (H) of rule 5101:3-40-01 of the Administrative Code.

(2) The provider shall:

(a) Document the individual's social needs and develop a social work/counseling plan of treatment;

(b) Provide direct service in the form of counseling and actively participate in resolving problems;

(c) Counsel the individual and involved family members with regard to the individual's psychosocial needs;

(d) Collaborate with the individual's physician and assist various providers of services in understanding emotional and social needs of the individual being served;

(e) Recognize the social needs of the individual and caregiver and take appropriate therapeutic intervention;

(f) Act as an advocate for the individual's social needs;

(g) Assist the individual, staff, and family to resolve challenges which prevent the individual's adjustment or any other challenges which affect the individual's ability to benefit from medical treatment;

(h) Assist the individual to develop self-help, social, and adaptive skills that enable the individual to remain functional within his or her community;

(i) Arrange individual and caregiver counseling and other supportive services to alleviate the pressures of estrangement from social support systems such as family, employment, and residential placement; and

(j) Refer individuals/families to the service and support administrator for financial matters or interagency collaboration and follow-up.

(E) Documentation of services

(1) The requirements of paragraph (B) of rule 5123:2-9-05 of the Administrative Code do not apply to service documentation for social work.

(2) Service documentation for social work shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(i) Group size in which the service was provided.

(j) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(k) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(l) Begin and end time of the delivered service.

(F) Payment standards

(1) The billing unit, service codes, and payment rates for social work are contained in appendix A to this rule.

(2) Payment rates for social work include an adjustment based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule.

(3) Payment rates for social work are established separately for services provided by independent providers and services provided through agency providers.

(4) Payment rates for social work are based on the number of individuals receiving services.

Click to view Appendix

Click to view Appendix

Effective: 11/03/2011
R.C. 119.032 review dates: 11/03/2016
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-40 Home and community-based services waivers - administration of the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to implement the self-empowered life funding waiver, a component of the medicaid home and community-based services program administered by the department pursuant to section 5111.871 of the Revised Code. Individuals enrolled in the self-empowered life funding waiver exercise participant direction through budget authority and/or employer authority.

(B) Definitions

(1) "Adult" means an individual who is at least twenty-two years old or an individual who is under twenty-two years old and eligible for adult day support, integrated employment, supported employment-enclave, or vocational habilitation.

(2) "Agency with choice" means an agency provider that acts as a co-employer with an individual. Under this arrangement, the individual acts as the "managing employer" and is responsible for hiring, managing, and dismissing staff. The agency with choice enables the individual to exercise choice and control over services while relieving him or her of the burden of carrying out financial matters and other legal responsibilities associated with the employment of workers. The agency with choice is considered the employer of staff who are selected, hired, and trained by the individual and assumes responsibility for:

(a) Employing and paying staff who have been selected by the individual;

(b) Reimbursing allowable services;

(c) Withholding, filing, and paying federal, state, and local income and employment taxes; and

(d) Providing other supports to the individual as described in the individual service plan.

(3) "Budget authority" means the individual has the authority and responsibility to manage his or her budget. This authority supports the individual in determining the budgeted dollar amount for each waiver service that will be provided to the individual and making decisions about the acquisition of waiver services that are authorized in the individual service plan (e.g., negotiating payment rates to providers within the applicable range as specified in rules adopted by the department).

(4) "Child" means an individual who is under twenty-two years old and is not eligible for adult day support, integrated employment, supported employment-enclave, or vocational habilitation.

(5) "Co-employer" means either an agency with choice or a financial management services entity under contract with the state that functions as the employer of staff recruited by the individual. The individual directs the staff and is considered their co-employer (also known as "managing employer"). The co-employer conducts all necessary payroll functions and is legally responsible for discharging the employment-related functions and duties for individual-selected staff with the individual based on the roles and responsibilities identified in the individual service plan for the two co-employers. The co-employer may function solely to support the individual's employment of workers or it may provide other employer-related supports to the individual, including providing traditional agency-based staff.

(6) "Common law employer" means the individual is the legally responsible and liable employer of staff selected by the individual. The individual hires, supervises, and discharges staff. The individual is liable for the performance of necessary employment-related tasks and uses a financial management services entity under contract with the state to perform necessary payroll and other employment-related functions as the individual's agent in order to ensure that the employer-related legal obligations are fulfilled.

(7) "County board" means a county board of developmental disabilities.

(8) "Department" means the Ohio department of developmental disabilities.

(9) "Employer authority" means the individual has the authority to recruit, hire, supervise, and direct the staff who furnish supports. The individual functions as the common law employer or the co-employer of these staff.

(10) "Financial management services" means services provided to an individual who directs some or all of his or her waiver services. When used in conjunction with budget authority, financial management services includes, but is not limited to, paying invoices for waiver goods and services and tracking expenditures against the individual's budget. When used in conjunction with employer authority, financial management services includes, but is not limited to, operating a payroll service for individual-employed staff and making required payroll withholdings. Financial management services also includes acting as the employer of staff on behalf of an individual under the co-employer model of employer authority.

(11) "Home and community-based services" means any federally approved medicaid waiver service provided to an individual enrolled in a waiver as an alternative to institutional care under Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C. 1396n , as amended, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(12) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(14) "Participant direction" means the individual has authority to make decisions about some or all of his or her waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and employer authority as set forth in paragraph (I) of this rule.

(15) "Provider" means a person or agency certified or licensed by the department that has met the provider qualification requirements to provide the specific self-empowered life funding waiver service as specified in paragraph (M)(1) of this rule and holds a valid medicaid provider agreement in accordance with paragraph (M)(2) of this rule.

(16) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(17) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(18) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility redetermination date.

(C) Financial management services entity

The state shall contract with an entity to provide financial management services to individuals enrolled in the self-empowered life funding waiver.

(D) Application for the self-empowered life funding waiver

(1) Individuals enrolling in the self-empowered life funding waiver must complete the Ohio department of job and family services form 02399, "Request for Medicaid Home and Community-Based Services" (revised January 2012). Forms are to be used in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(2) The county board is responsible for explaining to individuals requesting home and community-based services the services available through the self-empowered life funding waiver benefit package including the amount, scope, and duration of services and any applicable benefit package limitations.

(E) Criteria for enrolling in the self-empowered life funding waiver

(1) The individual enrolling in the self-empowered life funding waiver must be determined to require the level of care provided in an intermediate care facility and be eligible for intermediate care facility services upon initial enrollment and no later than every twelve months thereafter, as specified in rules 5101:3-3-07 and 5123:2-9-01 of the Administrative Code and in accordance with the process set forth in rule 5101:3-3-15.5 of the Administrative Code; and

(2) The individual's medicaid eligibility has been established in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code; and

(3) The individual's health and welfare needs can be met through the utilization of self-empowered life funding waiver services at or below the federally-approved cost limitation and other formal and informal supports regardless of funding source; and

(4) The individual must require, at a minimum, one waiver service, as described in paragraph (H) of this rule, to be considered eligible for this waiver; and

(5) The individual or the individual's guardian or the individual's designee must be willing and able to perform the duties associated with participant-direction (i.e., development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services); and

(6) The individual or the individual's guardian or the individual's designee is required to exercise budget authority or employer authority, in accordance with paragraph (I)(1) or (I)(2) of this rule, for at least one service the individual receives under the waiver.

(F) Reserved capacity for children with intensive behavioral needs

The department shall reserve capacity under the self-empowered life funding waiver for children with intensive behavioral needs who qualify based on an assessment approved by the department.

(G) Self-empowered life funding waiver enrollment, continued enrollment, and disenrollment

(1) An individual who meets the criteria specified in paragraph (E) of this rule or the individual's guardian or the individual's designee, as applicable, shall be informed by the county board of the following:

(a) All services available under the self-empowered life funding waiver, as delineated in paragraph (H) of this rule, and any choices that the individual may make regarding those services;

(b) Any feasible alternative to the waiver; and

(c) The right to choose either institutional or home and community-based services.

(2) The department shall allocate waivers to the county board in accordance with section 5111.872 of the Revised Code.

(3) The county board shall offer available self-empowered life funding waivers to eligible individuals in accordance with applicable waiting list requirements set forth in rules 5101:3-41-05 and 5123:2-1-08 of the Administrative Code.

(4) An individual's continued enrollment in the self-empowered life funding waiver shall be redetermined no less frequently than every twelve months beginning with the individual's initial enrollment date or subsequent redetermination date. Individuals must continue to meet the criteria specified in paragraph (E) of this rule to continue enrollment in the waiver.

(5) The maximum number of individuals that can be enrolled in the self-empowered life funding waiver statewide shall not exceed the allowable number specified in the federally-approved waiver document.

(6) The individual must require at least one waiver service monthly, or, if less than monthly as described in the individual service plan, require monthly monitoring of the individual's health and welfare. If no services are planned to be delivered in a month, monthly monitoring of the individual's health and welfare must be required in the individual service plan, as designated in paragraph (K) of this rule, and must include at least periodic face-to-face monitoring.

(7) The county board shall be responsible for providing notification to an individual's support broker under the following circumstances:

(a) When the individual is enrolled in the waiver;

(b) When the individual is disenrolled or potentially disenrolled from the waiver; and

(c) For all other situations where the individual's enrollment status may be jeopardized.

(8) An individual enrolled in the self-empowered life funding waiver who is recommended for disenrollment from the waiver and the individual's support broker shall be given notification of hearing rights as established in paragraph (P) of this rule.

(H) Self-empowered life funding waiver benefit package

The self-empowered life funding waiver benefit package is comprised of the following services:

(1) Adult day support in accordance with rule 5123:2-9-17 of the Administrative Code;

(2) Clinical/therapeutic intervention in accordance with rule 5123:2-9-41 of the Administrative Code;

(3) Community inclusion in accordance with rule 5123:2-9-42 of the Administrative Code;

(4) Community respite in accordance with rule 5123:2-9-34 of the Administrative Code;

(5) Functional behavioral assessment in accordance with rule 5123:2-9-43 of the Administrative Code;

(6) Integrated employment in accordance with rule 5123:2-9-44 of the Administrative Code;

(7) Non-medical transportation in accordance with rule 5123:2-9-18 of the Administrative Code;

(8) Participant-directed goods and services in accordance with rule 5123:2-9-45 of the Administrative Code;

(9) Participant/family stability assistance in accordance with rule 5123:2-9-46 of the Administrative Code;

(10) Remote monitoring in accordance with rule 5123:2-9-35 of the Administrative Code;

(11) Remote monitoring equipment in accordance with rule 5123:2-9-35 of the Administrative Code;

(12) Residential respite in accordance with rule 5123:2-9-34 of the Administrative Code;

(13) Support brokerage in accordance with rule 5123:2-9-47 of the Administrative Code;

(14) Supported employment-enclave in accordance with rule 5123:2-9-16 of the Administrative Code; and

(15) Vocational habilitation in accordance with rule 5123:2-9-14 of the Administrative Code.

(I) Participant direction

The self-empowered life funding waiver is designed to support individuals who want to direct their services through exercise of budget authority and/or employer authority.

(1) Individuals enrolled in the self-empowered life funding waiver may exercise budget authority for:

(a) Clinical/therapeutic intervention;

(b) Community inclusion;

(c) Community respite;

(d) Functional behavioral assessment;

(e) Integrated employment;

(f) Participant-directed goods and services;

(g) Participant/family stability assistance;

(h) Remote monitoring;

(i) Remote monitoring equipment;

(j) Residential respite; and

(k) Support brokerage.

(2) Individuals enrolled in the self-empowered life funding waiver may exercise employer authority for:

(a) Community inclusion;

(b) Integrated employment;

(c) Participant-directed goods and services;

(d) Participant/family stability assistance; and

(e) Support brokerage.

(3) Individuals enrolled in the self-empowered life funding waiver may not exercise either budget authority or employment authority for:

(a) Adult day support;

(b) Non-medical transportation;

(c) Supported employment-enclave; and

(d) Vocational habilitation.

(J) Benefit limitations

(1) The cost of services available under the self-empowered life funding waiver shall not exceed the following overall benefit limitations:

(a) Adult -- forty thousand dollars per waiver eligibility span.

(b) Child -- twenty-five thousand dollars per waiver eligibility span.

(2) The following services are subject to specific benefit limitations:

(a) Payment for community inclusion, community respite, remote monitoring, and residential respite, alone or in combination, shall not exceed twenty-five thousand dollars per waiver eligibility span.

(b) Payment for support brokerage shall not exceed eight thousand dollars per waiver eligibility span.

(c) An individual may receive only one functional behavioral assessment per waiver eligibility span, the cost of which shall not exceed one thousand five hundred dollars.

(3) The benefit limitations in rule 5123:2-9-19 of the Administrative Code apply to adult day support, non-medical transportation, supported employment-enclave, and vocational habilitation provided under the self-empowered life funding waiver.

(K) Individual service plan requirements

(1) All services shall be provided to an individual enrolled in the self-empowered life funding waiver pursuant to a written individual service plan.

(2) The service and support administrator shall ensure that the individual service plan is developed with the active participation of the individual, the support broker, the individual's guardian or representative, as applicable, and other persons selected by the individual including, but not limited to, family members and providers.

(a) The individual service plan shall list the self-empowered life funding waiver services and the non-waiver services, regardless of funding source, that are necessary to ensure the individual's health and welfare.

(b) The individual service plan shall contain the following medicaid required elements:

(i) Type of service to be provided;

(ii) Amount of service to be provided;

(iii) Frequency and duration of each service to be provided; and

(iv) Type of provider to furnish each service.

(c) The individual service plan shall be developed on at least an annual basis consistent with the individual's eligibility redetermination as indicated in paragraph (G)(4) of this rule or as the individual's needs change and in accordance with division 5123:2 of the Administrative Code.

(d) The individual service plan shall be developed to include only waiver services which are consistent with efficiency, economy, and quality of care. When combined with non-waiver services, waiver services must ensure the health and welfare for the individual for whom the individual service plan is developed.

(e) When adult day support and/or vocational habilitation are identified in the individual service plan as the service or services to be provided, the individual service plan shall include a justification as to why these services are more appropriate than supported employment-enclave and/or integrated employment.

(f) The individual service plan is subject to approval by the department and the Ohio department of job and family services pursuant to section 5111.871 of the Revised Code. Notwithstanding the procedures set forth in this rule, the Ohio department of job and family services may in its sole discretion, and in accordance with section 5111.852 of the Revised Code, direct the department or the county board to amend individual service plans for individuals if the Ohio department of job and family services determines that such services are medically necessary and the procedures set forth in division 5101:3 of the Administrative Code would not accommodate a request for such medically necessary services.

(L) Free choice of provider

Individuals enrolled in the self-empowered life funding waiver shall be given free choice of qualified self-empowered life funding waiver providers in accordance with Chapters 5101:3-41 and 5123:2-9 of the Administrative Code. Providers are qualified if they meet the standards established in paragraph (M) of this rule.

(M) Provision of self-empowered life funding waiver services

(1) Self-empowered life funding waiver services shall be provided by persons or agencies that are certified or licensed in accordance with section 5123.045 of the Revised Code and rules adopted by the department.

(2) Self-empowered life funding waiver services shall be provided by persons or agencies that have a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(3) Self-empowered life funding waiver services shall be provided only to individuals who have met the criteria specified in paragraph (E) of this rule and are enrolled in the self-empowered life funding waiver at the time of service delivery.

(N) Service documentation

(1) Services under the self-empowered life funding waiver shall not be considered delivered unless the provider maintains service documentation.

(2) A provider shall maintain all service documentation in an accessible location. The service documentation shall be available, upon request, for review by the centers for medicare and medicaid services, the Ohio department of job and family services, the department, a county board or regional council of governments that submits to the department payment authorization for the service, and those designated or assigned authority by the Ohio department of job and family services or the department to review service documentation.

(3) A provider shall maintain all service documentation for a period of six years from the date of receipt of payment for the service or until an initiated audit is resolved, whichever is longer.

(4) If a provider discontinues operations, the provider shall, within seven days of discontinuance, notify the county boards for the counties in which individuals to whom the provider has provided services reside, of the location where the service documentation will be stored, and provide each such county board with the name and telephone number of the person responsible for maintaining the records.

(5) Claims for payment a provider submits for services delivered shall not be considered service documentation. Any information contained on the submitted claim shall not be substituted for any required service documentation information that the provider is required to maintain to validate payment for medicaid services.

(O) Payment standards

(1) Services provided under the self-empowered life funding waiver shall be subject to the payment standards set forth in rules adopted by the department.

(2) Rule 5123:2-9-06 of the Administrative Code does not apply to services provided under the self-empowered life funding waiver.

(3) Payment for services constitutes payment in full. Payment shall be made when:

(a) The service is identified in an approved individual service plan;

(b) The service is recommended for payment through the payment authorization process; and

(c) The service is provided by a provider selected by an individual enrolled in the self-empowered life funding waiver.

(4) Payment for services shall not exceed amounts authorized through the payment authorization process for the individual's corresponding waiver eligibility span.

(5) When a service is also available on the state plan, state plan services shall be billed first. Only services in excess of what is covered under the state plan shall be authorized.

(6) Claims for payment shall be submitted to the department or the financial management services entity in the format prescribed by the department. The department or the financial management services entity, as applicable, shall inform county boards of the billing information submitted by providers in a manner and at the frequency necessary to assist the county boards to manage the waiver expenditures being authorized.

(7) Claims for payment shall be submitted within three hundred thirty days after the service is provided. Payment shall be made in accordance with the requirements of rule 5101:3-1-19.7 of the Administrative Code. Claims for payment shall include the number of units of service.

(8) Providers shall take reasonable measures to identify any third-party health care coverage available to the individual and file a claim with that third party in accordance with the requirements of rule 5101:3-1-08 of the Administrative Code.

(9) For individuals with a monthly patient liability for the cost of self-empowered life funding waiver services, as defined in rule 5101:1-39-95 of the Administrative Code, and determined by the county department of job and family services for the county in which the individual resides, payment is available only for the waiver services delivered to the individual that exceed the amount of the individual's monthly patient liability. Verification that patient liability has been satisfied shall be accomplished as follows:

(a) The department shall provide notification to the appropriate county board identifying each individual who has a patient liability for waiver services and the monthly amount of the patient liability.

(b) The county board shall assign the waiver services to which each individual's patient liability shall be applied and assign the corresponding monthly patient liability amount to the provider that provides the preponderance of waiver services. The county board shall notify each individual and waiver service provider, in writing, of this assignment.

(c) Upon submission of a claim for payment, the designated waiver service provider shall report the waiver service to which the patient liability was assigned and the applicable patient liability amount on the claim for payment using the format prescribed by the department.

(10) The department, the Ohio department of job and family services, the centers for medicare and medicaid services, and/or the auditor of state may audit any funds a provider receives pursuant to this rule, including any source documentation supporting the claiming and/or receipt of such funds.

(11) Overpayments, duplicate payments, payments for services not rendered, payments for which there is no documentation of services delivered or the documentation does not include all the required items as set forth in rules adopted by the department, or payments for services not in accordance with an approved individual service plan are recoverable by the department, the Ohio department of job and family services, the auditor of state, or the office of the attorney general. All recoverable amounts are subject to the application of interest in accordance with rules 5101:3-1-25 and 5101:6-51-03 of the Administrative Code.

(P) Due process rights and responsibilities

(1) Any applicant for or recipient of self-empowered life funding waiver services may utilize the process set forth in section 5101.35 of the Revised Code, in accordance with division 5101:6 of the Administrative Code, for any purpose authorized by that statute and the rules implementing the statute. The process set forth in section 5101.35 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives. Providers shall have no standing in an appeal under this section.

(2) Applicants for and recipients of self-empowered life funding waiver services shall use the process set forth in section 5101.35 of the Revised Code for any challenge related to the type, amount/level, scope, or duration of services included in or excluded from an individual service plan.

(Q) Ohio department of job and family services authority

The Ohio department of job and family services retains final authority to establish payment rates for self-empowered life funding waiver services; to review and approve each service identified in an individual service plan that is funded through the self-empowered life funding waiver and the payment rate for the service; and to authorize the provision of and payment for waiver services through the payment authorization process.

(R) Monitoring, compliance, and quality assurance

The Ohio department of job and family services shall conduct periodic monitoring and compliance reviews related to the self-empowered life funding waiver in accordance with Chapter 5111. of the Revised Code. Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided and interviews of providers, recipients, and administrators of waiver services. A financial management services entity under contract with the state, self-empowered life funding waiver providers, the department, and county board shall furnish to the Ohio department of job and family services, the centers for medicare and medicaid services, and the medicaid fraud control unit or their designees any records related to the administration and/or provision of self-empowered life funding waiver services. Individuals enrolled in the self-empowered life funding waiver shall cooperate with all monitoring, compliance, and quality assurance reviews conducted by the Ohio department of job and family services, the department, the county board, the centers for medicare and medicaid services, and the medicaid fraud control unit or their designees.

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-41 Home and community-based services waivers - clinical/therapeutic intervention under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define clinical/therapeutic intervention and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "Clinical/therapeutic intervention" means services that are necessary to reduce an individual's intensive behaviors and to improve the individual's independence and inclusion in his or her community and that are not otherwise available under the state medicaid program. Clinical/therapeutic intervention includes consultation activities that are provided by professionals in psychology, counseling, special education, and behavior management. The service includes the development of a treatment/support plan, training and technical assistance to assist unpaid caregivers and/or paid support staff in carrying out the plan, delivery of the services described in the plan, and monitoring of the individual and the provider in the implementation of the plan. Clinical/therapeutic intervention may be delivered in the individual's home or in the community as described in the individual service plan. Clinical/therapeutic intervention must be determined necessary to reduce an individual's intensive behaviors by a functional behavioral assessment conducted by one of the following: licensed psychologist, licensed professional clinical counselor, licensed professional counselor, licensed independent social worker, or licensed social worker working under the supervision of a licensed independent social worker. Experimental treatments are prohibited.

(3) "County board" means a county board of developmental disabilities.

(4) "Department" means the Ohio department of developmental disabilities.

(5) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(6) "Functional behavioral assessment" means an assessment not otherwise available under the state medicaid program to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. Functional behavioral assessments describe the relationship between a skill or performance problem and the variables that contribute to its occurrence. Functional behavioral assessments can provide information to develop a hypothesis as to why the individual engages in the behavior, when the individual is most likely to demonstrate the behavior, and situations in which the behavior is least likely to occur.

(7) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(8) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either.

(9) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(10) "Medicaid program" has the same meaning as in section 5111.01 of the Revised Code.

(11) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(12) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(13) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(14) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Provider qualifications

(1) Clinical/therapeutic intervention shall be provided by an independent provider or an agency provider that:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Has completed and submitted an application and adheres to the requirements of rule 5123:2-2-01 of the Administrative Code, except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of that rule do not apply to providers of clinical/therapeutic intervention.

(2) Clinical/therapeutic intervention shall be provided by senior level specialized clinical/therapeutic interventionists, specialized clinical/therapeutic interventionists, and clinical/therapeutic interventionists.

(a) A senior level specialized clinical/therapeutic interventionist shall have a doctoral degree in psychology, special education, medicine, or a related discipline; be licensed under the laws of the state to practice in his or her field; and have at least three months of experience and/or training in the implementation and oversight of comprehensive interventions for individuals with developmental disabilities who need significant behaviorally-focused interventions.

(b) A specialized clinical/therapeutic interventionist shall:

(i) Have a master's degree in psychology, special education, or a related discipline and be licensed under the laws of the state to practice in his or her field or be registered with the state board of psychology as an aide or a psychology aide working under psychological work supervision in accordance with rule 4732-13-03 of the Administrative Code; and

(ii) Have at least three months of experience and/or training in the implementation and oversight of comprehensive interventions for individuals with developmental disabilities who need significant behaviorally-focused interventions.

(c) A clinical/therapeutic interventionist shall work under the supervision of a senior level specialized clinical/therapeutic interventionist or a specialized clinical/therapeutic interventionist and shall either:

(i) Have experience providing one-to-one care for an individual with developmental disabilities who needs significant behaviorally-focused interventions; or

(ii) Have undergone two monitored sessions with an individual with developmental disabilities who needs significant behaviorally-focused interventions.

(3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide clinical/therapeutic intervention by senior level specialized clinical/therapeutic interventionists only when no other certified provider is willing and able. Neither a county board nor a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards shall provide clinical/therapeutic intervention by specialized clinical/therapeutic interventionists or clinical/therapeutic interventionists.

(4) Clinical/therapeutic intervention shall not be provided to an individual by his or her family member.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

Clinical/therapeutic intervention shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(E) Documentation of services

Service documentation for clinical/therapeutic intervention shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided and details of the individual's response to the services, including progress toward achieving outcomes specified in the individual service plan.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Times the delivered service started and stopped.

(F) Payment standards

(1) The billing units, service codes, and payment rates for clinical/therapeutic intervention are contained in the appendix to this rule.

(2) The payment rates for clinical/therapeutic intervention provided by independent providers shall be negotiated by the individual and the provider subject to the minimum and maximum payment rates contained in the appendix to this rule and shall be identified in the individual service plan.

(3) The payment rates for clinical/therapeutic intervention provided by agency providers shall be the lesser of the provider's usual and customary charge or the statewide payment rates contained in the appendix to this rule.

Click to view Appendix

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-42 Home and community-based services waivers - community inclusion under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define community inclusion and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "Commercial vehicles" means buses, light rail transit, livery vehicles, and taxicabs that are available for public use.

(3) "Community inclusion" means supports that promote an individual's full participation in his or her community, but does not include services that are otherwise available under the state medicaid program or experimental or prohibited treatments. Community inclusion includes, but is not limited to, such developmental and other supportive services as may be required to assist an individual with a developmental disability. Community inclusion also includes opportunities and experiences that focus on socialization and/or therapeutic recreational activities as well as personal growth, peer support activities, and organization and participation in self-advocacy events. Community inclusion is comprised of two components:

(a) Personal assistance in the home and/or the community with life activities.

(b) Transportation including, but not limited to, transportation in a modified vehicle; transportation provided by operators of commercial vehicles; and mileage reimbursement for up to the federal reimbursable mileage rate.

(4) "Community respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(5) "County board" means a county board of developmental disabilities.

(6) "Department" means the Ohio department of developmental disabilities.

(7) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(8) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(9) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either.

(10) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(11) "Medicaid program" has the same meaning as in section 5111.01 of the Revised Code.

(12) "Modified vehicle" means a motor vehicle that has been designed, constructed, or fabricated and equipped to be used upon public streets and/or highways for transportation of persons who require use of a wheelchair.

(13) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(14) "Residential respite" has the same meaning as in rule 5123:2-9-34 of the Administrative Code.

(15) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(16) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraphs (F)(1) and (F)(2) of this rule, as applicable, to validate payment for medicaid services.

(17) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(18) "Usual and customary charge" means the amount charged to other persons for the same service.

(19) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility redetermination date.

(C) Provider qualifications for community inclusion-personal assistance

(1) Community inclusion-personal assistance shall be provided by an independent provider or an agency provider that:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Has completed and submitted an application and adheres to the requirements of rule 5123:2-2-01 of the Administrative Code.

(2) The individual may determine additional qualifications for a provider of community inclusion-personal assistance; additional qualifications determined by the individual shall be recorded in the individual service plan.

(3) Neither a county board nor a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards shall provide community inclusion-personal assistance.

(4) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Provider qualifications for community inclusion-transportation

(1) Community inclusion-transportation shall be provided by an independent provider, an agency provider, or an operator of commercial vehicles that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) Neither a county board nor a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards shall provide community inclusion-transportation.

(3) An applicant seeking approval to provide community inclusion-transportation shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), (D)(1), (D)(3), and (K) of that rule do not apply to operators of commercial vehicles.

(4) An applicant seeking approval to provide community inclusion-transportation as an independent provider shall present his or her driving record prepared by the bureau of motor vehicles no earlier than fourteen days prior to the date of his or her application for initial or renewal provider certification. A person having six or more points on his or her driving record is prohibited from providing community inclusion-transportation.

(5) An independent provider of community inclusion-transportation shall:

(a) Hold a valid driver's license as specified by Ohio law.

(b) Have valid liability insurance as specified by Ohio law.

(c) Immediately notify the department, in writing, if he or she accumulates six or more points on his or her driving record or if his or her driver's license is suspended or revoked.

(6) An agency provider of community inclusion-transportation shall:

(a) Ensure that each driver holds a valid driver's license as specified by Ohio law.

(b) Have or ensure that each driver has valid liability insurance as specified by Ohio law.

(c) Obtain, for each driver, a driving record prepared by the bureau of motor vehicles no earlier than fourteen days prior to the date of initial employment as a driver and at least once every three years thereafter. A person having six or more points on his or her driving record is prohibited from providing community inclusion-transportation.

(d) Require each driver to immediately notify the agency provider, in writing, if the driver accumulates six or more points on his or her driving record or if his or her driver's license is suspended or revoked.

(e) Develop and maintain written policies and procedures regarding the requirements of its drivers.

(7) Operators of commercial vehicles that provide community inclusion-transportation shall comply with federal, state, and local laws and regulations pertaining to the maintenance and operation of the commercial vehicles.

(8) The individual may determine additional qualifications for a provider of community inclusion-transportation; additional qualifications determined by the individual shall be recorded in the individual service plan.

(9) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(E) Requirements for service delivery Community inclusion shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(F) Documentation of services

(1) Service documentation for community inclusion-personal assistance shall include each of the following to validate payment for medicaid services:

(a) Type of service.

(b) Date of service.

(c) Place of service.

(d) Name of individual receiving service.

(e) Medicaid identification number of individual receiving service.

(f) Name of provider.

(g) Provider identifier/contract number.

(h) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(i) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(j) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(k) Times the delivered service started and stopped.

(2) Service documentation for community inclusion-transportation shall include each of the following to validate payment for medicaid services:

(a) Mode of transportation provided (e.g., modified vehicle, bus, light rail transit, livery vehicle, taxicab, or transportation mileage).

(b) Date of service, or in the case of purchase of bus fares, taxicab tokens, or similar types of travel vouchers to be used on more than one date, date of purchase.

(c) Name of individual receiving service.

(d) Medicaid identification number of individual receiving service.

(e) Name of provider.

(f) Provider identifier/contract number.

(g) If seeking mileage reimbursement, number of miles traveled.

(G) Payment standards

(1) The billing units, service codes, and payment rates for community inclusion are contained in the appendix to this rule.

(2) The payment rates for community inclusion-personal assistance provided by independent providers shall be negotiated by the individual and the provider subject to the minimum and maximum payment rates contained in the appendix to this rule and shall be identified in the individual service plan.

(3) The payment rates for community inclusion-personal assistance provided by agency providers shall be the lesser of the provider's usual and customary charge or the statewide payment rate contained in the appendix to this rule.

(4) Providers of community inclusion-transportation shall be paid no more than their usual and customary charge for the service.

(5) Providers of community inclusion-transportation may be paid mileage reimbursement up to the federal reimbursable mileage rate.

(6) Payment for community inclusion, community respite, remote monitoring, and residential respite, alone or in combination, shall not exceed twenty-five thousand dollars per waiver eligibility span.

Click to view Appendix

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Effective: 11/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Prior Effective Dates: 07/01/2012

5123:2-9-43 Home and community-based services waivers - functional behavioral assessment under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define functional behavioral assessment and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(5) "Functional behavioral assessment" means an assessment not otherwise available under the state medicaid program to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. Functional behavioral assessments describe the relationship between a skill or performance problem and the variables that contribute to its occurrence. Functional behavioral assessments can provide information to develop a hypothesis as to why the individual engages in the behavior, when the individual is most likely to demonstrate the behavior, and situations in which the behavior is least likely to occur.

(6) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Medicaid program" has the same meaning as in section 5111.01 of the Revised Code.

(10) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(11) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(12) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(13) "Usual and customary charge" means the amount charged to other persons for the same service.

(14) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility redetermination date.

(C) Provider qualifications

(1) Functional behavioral assessment shall be provided by an independent provider or an agency provider that:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Has completed and submitted an application and adheres to the requirements of paragraph (C)(2) of rule 5123:2-2-01 of the Administrative Code. The remainder of rule 5123:2-2-01 of the Administrative Code does not apply to providers of functional behavioral assessment.

(2) Functional behavioral assessment shall be provided by persons who have the experience necessary to perform psychometric tests that assess an individual's functional behavioral level and who are one of the following:

(a) Psychologist licensed by the state pursuant to Chapter 4732. of the Revised Code;

(b) Professional clinical counselor licensed by the state pursuant to section 4757.22 of the Revised Code;

(c) Professional counselor licensed by the state pursuant to section 4757.23 of the Revised Code;

(d) Independent social worker licensed by the state pursuant to section 4757.27 of the Revised Code; or

(e) Social worker licensed by the state pursuant to section 4757.28 of the Revised Code working under the supervision of a licensed independent social worker.

(3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide functional behavioral assessment only when no other certified provider is willing and able.

(4) Functional behavioral assessment shall not be provided to an individual by his or her family member.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code, as applicable, may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

Functional behavioral assessment shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(E) Documentation of services

Service documentation for functional behavioral assessment shall include each of the following to validate payment for medicaid service:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(F) Payment standards

(1) The billing unit, service code, and payment rate for functional behavioral assessment are contained in the appendix to this rule.

(2) Providers of functional behavioral assessment shall be paid no more than their usual and customary charge for the service.

(3) An individual may receive only one functional behavioral assessment in a waiver eligibility span, the cost of which shall not exceed one thousand five hundred dollars.

(4) Providers of functional behavioral assessment are prohibited from submitting claims under both the self-empowered life funding waiver and the state medicaid program for the same functional behavioral assessment.

Click to view Appendix

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-44 Home and community-based services waivers - integrated employment under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define integrated employment and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either.

(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(7) "Integrated employment" means the initial and ongoing supports an individual needs to acquire and maintain a job in the general workforce at or above the state's minimum wage. The intended outcome of this service is sustained paid employment in an integrated setting in the general workforce and a job that meets the individual's personal and career goals. Integrated employment may be provided by a coworker or other worksite personnel as long as the services that are furnished are not part of that person's regular duties for which he or she is compensated by the employer and the person meets the qualifications established in this rule for independent providers. Integrated employment does not include sheltered work or other types of vocational services furnished in specialized facilities. Integrated employment is individual-specific and shall not be provided to two or more individuals working in an enclave. Integrated employment is comprised of two distinct components:

(a) Initial supports necessary for an individual to acquire a job in the general workforce, provided in advance of the individual securing a job in the general workforce, related to career planning, placement, and training including:

(i) Person-centered employment planning, job development, and job placement;

(ii) Training and systematic instruction;

(iii) Supports an individual needs to acquire an internship or apprenticeship of limited duration; and

(iv) Supports an individual needs to achieve self-employment through the operation of a business, but not including funding for start-up costs or ongoing business operation expenses.

(b) Retention supports necessary for an individual to maintain a job in the general workforce including:

(i) Periodic contact with the individual to ensure the job match remains successful;

(ii) Ongoing assistance navigating the work environment (e.g., problem-solving issues with coworkers and/or supervisors, interpreting social cues, understanding office/organizational policies and practices);

(iii) Job coaching (i.e., one-on-one instruction that helps an individual adjust to the work environment and/or to learn specific job tasks); and

(iv) Advocacy coaching (e.g., assistance developing and practicing a script to request a reasonable accommodation).

(8) "Mentor" means a person with experience providing direct services to persons with developmental disabilities who is available on a regular basis to provide guidance to new direct support staff regarding techniques and practices that enhance the effectiveness of the direct provision of integrated employment.

(9) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(11) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(C) Provider qualifications

(1) Integrated employment shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of job and family services.

(2) An applicant seeking approval to provide integrated employment shall complete and submit an application and adhere to the requirements of rule 5123:2-2-01 of the Administrative Code except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of that rule do not apply to an independent provider who is the individual's coworker or otherwise employed at the worksite.

(3) Integrated employment shall be provided by a person who is:

(a) An independent provider who is the individual's coworker or otherwise employed at the worksite as long as the services that are furnished are not part of that person's regular duties for which he or she is compensated by the employer;

(b) An independent provider, other than an independent provider who is the individual's coworker or otherwise employed at the worksite, who has at least one year of full-time, paid work experience or thirty hours of formal training related to supporting individuals to acquire and maintain jobs in the general workforce; or

(c) An employee or contractor of an agency provider.

(4) An independent provider who is the individual's coworker or otherwise employed at the worksite shall annually complete training in:

(a) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training.

(5) An independent provider, other than an independent provider who is the individual's coworker or otherwise employed at the worksite, shall annually complete at least eight hours of training that enhances his or her skills and competencies relevant to the services he or she provides which shall include, but is not limited to:

(a) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training; and

(c) Services that comprise integrated employment as it is defined in paragraph (B)(7) of this rule.

(6) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of integrated employment successfully completes, within ninety days of employment or contract, either:

(a) The "Ohio Alliance of Direct Support Professionals Professional Advancement Through Training and Education in Human Services (PATHS) Certificate of Initial Proficiency" program; or

(b) An orientation program of at least eight hours that addresses, but is not limited to:

(i) Organizational background of the agency provider, including:

(a) Mission, vision, values, principles, and goals;

(b) Organizational structure;

(c) Key policies, procedures, and work rules;

(d) Ethical and professional conduct and practice;

(e) Avoiding conflicts of interest; and

(f)Working effectively with individuals, families, and other team members.

(ii) Components of quality care for individuals served, including:

(a) Interpersonal relationships and trust;

(b) Cultural and personal sensitivity;

(c) Effective communication;

(d) Person-centered philosophy and practice;

(e) Development of individual service plans;

(f) Roles and responsibilities of team members; and

(g)Recordkeeping including progress notes and incident/accident reports.

(iii) Health and safety, including:

(a) Signs and symptoms of illness or injury and procedure for response;

(b) Building/site-specific emergency response plans; and

(c)Program-specific transportation safety.

(iv) Positive behavior support, including:

(a) Principles of positive intervention culture;

(b) Role of direct service staff in creating a positive culture;

(c) General requirements for behavior support plans and intervention strategies and direct service staff role including documentation;

(d) Behavior support review and human rights committees; and

(e) Crisis intervention techniques.

(v) Services that comprise integrated employment as it is defined in paragraph (B)(7) of this rule.

(7) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of integrated employment, during the first year of employment or contract with the agency provider:

(a) Is assigned and has access to a mentor employed by the agency provider or contractor.

(b) Successfully completes on-the-job training specific to each individual he or she serves that includes, but is not limited to:

(i) Requirements set forth in the individual service plan including skill development goals, service/support activities, behavior support plan, planned interventions, and related documentation requirements;

(ii) The individual's preferences and strengths;

(iii) The individual's diagnoses and related needs;

(iv) The individual's care needs including nutrition, diet and mealtime support, restroom assistance, mobility needs, lifting, and general supervision/support requirements;

(v) Medication administration and delegated nursing, as applicable;

(vi) Teaching techniques and related documentation requirements; and

(vii) The employee's or contractor's role regarding management of the individual's funds and related documentation requirements.

(c) Successfully completes at least eight hours of training specific to the provision of integrated employment that includes, but is not limited to:

(i) Skill building in vocational assessment, job development and placement, job training/coaching, ongoing job supports, worksite accessibility, developing natural supports, personal adjustment, work adjustment, and vocational planning; and

(ii) Self-determination which includes assisting the individual to develop self-advocacy skills, to exercise his or her civil rights, to exercise control and responsibility over the services he or she receives, and to acquire skills that enable him or her to become more independent, productive, and integrated within the community.

(8) An agency provider shall develop and implement a written plan identifying training priorities for employees, contractors, and employees of a contractor who are engaged in direct provision of integrated employment. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish employees' and contractors' competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(9) An agency provider shall ensure that each employee, contractor, and employee of a contractor who is engaged in direct provision of integrated employment, commencing in the second year of employment or contract with the agency provider, annually completes at least eight hours of training, in accordance with the written plan of training priorities.

(a) The training shall enhance the skills and competencies of the employee or contractor relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The provisions governing rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(ii) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department since the previous year's training;

(iii) The requirements relative to the employee's or contractor's role in providing behavior support to the individuals he or she serves; and

(iv) Best practices related to the provision of integrated employment.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other facilities/services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(10) An agency provider shall ensure that a written record of training completed for each employee, contractor, and employee of a contractor who is engaged in direct provision of integrated employment is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(11) The individual may determine additional qualifications for a provider of integrated employment; additional qualifications determined by the individual shall be recorded in the individual service plan.

(12) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

(1) Integrated employment shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(2) The service and support administrator shall ensure that documentation is maintained to demonstrate that the service provided as integrated employment to an individual enrolled in a self-empowered life funding waiver is not otherwise available as vocational rehabilitation services funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 730 , or as special education or related services as those terms are defined in section 602 of the Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1401 .

(3) An independent provider or appropriate staff of an agency provider shall be knowledgeable in benefits, work incentives, and employer tax credits for individuals with developmental disabilities and ensure that individuals served receive this information.

(E) Documentation of services

Service documentation for integrated employment shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified and the goals established in the approved individual service plan, including:

(a) Results of formal and informal assessments (e.g., vocational evaluation, situational assessment, discovery process, and resource exploration);

(b) Progress notes relative to the individual's goals, job-seeking activities, and/or work performance (e.g., punctuality, attendance, hygiene, resume writing, and interview skills);

(c) Career exploration and employment planning activities and outcomes (e.g., job tryouts, interviews, volunteer opportunities, employers contacted, and job offers received);

(d) Job coaching/follow-along reports (e.g., goals addressed, skills developed, and natural supports identified or utilized); and

(e) Other outcomes (e.g., job placement, promotion, or change in duties).

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Times the delivered service started and stopped.

(12) As applicable, the name of the individual's employer, the number of hours worked by the individual, and the hourly wage earned by the individual.

(F) Payment standards

(1) The billing units, service codes, and payment rates for integrated employment are contained in the appendix to this rule.

(2) Payment rates for integrated employment are established separately for the two distinct components of the service (i.e., initial supports and retention supports).

(3) The payment rates for integrated employment provided by independent providers shall be negotiated by the individual and the provider subject to the minimum and maximum payment rates contained in the appendix to this rule and shall be identified in the individual service plan.

(4) The payment rates for integrated employment provided by agency providers shall be the lesser of the provider's usual and customary charge or the statewide payment rates contained in the appendix to this rule.

(G) Data reporting and analysis

(1) The department shall develop a system that shall be used by providers, other than an independent provider who is an individual's coworker or otherwise employed at the worksite, to submit on a monthly basis, data regarding the provision and outcomes of integrated employment, including but not limited to:

(a) Job placement rates;

(b) Duration of job placements;

(c) Hours worked by individuals; and

(d) Wages earned by individuals.

(2) The department shall make available reports generated from the data submitted.

(3) By January 1, 2014 and periodically thereafter, the department shall review the collected data and develop any changes necessary to ensure that the service as implemented is advancing employment outcomes for individuals served and that provider payment is consistent with efficiency, economy, and quality of care.

Click to view Appendix

Effective: 08/23/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-45 Home and community-based services waivers - participant-directed goods and services under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define participant-directed goods and services and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(5) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(6) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor or either.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "Medicaid program" has the same meaning as in section 5111.01 of the Revised Code.

(9) "Participant-directed goods and services" means services, equipment, or supplies not otherwise provided through the self-empowered life funding waiver or through the state's medicaid program that address a need identified in the individual service plan (including maintaining and improving an individual's opportunities for full membership in the community) and meet the following requirements:

(a) The services, equipment, or supplies:

(i) Decrease the need for other medicaid services;

(ii) Promote inclusion in the community; or

(iii) Increase the individual's safety in his or her home.

(b) The services, equipment, or supplies are not illegal or otherwise prohibited by federal or state statutes or regulations;

(c) The individual does not have funds to purchase the services, equipment, or supplies, and they are not available through another resource; and

(d) The services, equipment, or supplies are required to meet the needs and outcomes identified in the individual service plan; assure the health and welfare of the individual; are the least costly alternative that reasonably meets the individual's assessed needs; and are for the direct benefit of the individual in achieving at least one of the following outcomes:

(i) Improving cognitive, social, or behavioral functioning;

(ii) Maintaining the ability of the individual to remain in the community;

(iii) Enhancing community inclusion and family member involvement;

(iv) Developing or maintaining personal, social, or physical skills;

(v) Decreasing dependency on formal support services; or

(vi) Increasing independence of the individual.

(10) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(11) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services.

(12) "Specialized services" means any program or service designed and operated to serve primarily a person with a developmental disability, including a program or service provided by an entity licensed or certified by the department. Programs or services available to the general public are not specialized services.

(13) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(14) "Usual and customary charge" means the amount charged to other persons for the same service.

(C) Provider qualifications

(1) Rule 5123:2-2-01 of the Administrative Code does not apply to providers of participant-directed goods and services.

(2) Paragraphs (M)(1) and (M)(2) of rule 5123:2-9-40 of the Administrative Code do not apply to participant-directed goods and services.

(3) Participant-directed goods and services shall be provided by an independent provider or an agency provider that meets the requirements of this rule.

(4) The financial management services entity and/or support broker may purchase items for the individual as specified in the individual's approved individual service plan.

(5) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide participant-directed goods or services only when no other certified provider is willing and able.

(D) Requirements for service delivery

(1) Participant-directed goods and services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(2) Participant-directed goods and services shall not be specialized services. If there is a question as to whether participant-directed goods and services are specialized services, the director of the department may make a determination. The director's determination is final.

(3) Participant-directed goods and services shall not include the following which are prohibited from being paid for under the self-empowered life funding waiver:

(a) Experimental treatments;

(b) Items used solely for entertainment or recreational purposes; and

(c) Tobacco products or alcohol.

(E) Documentation of services

(1) Paragraph (N) of rule 5123:2-9-40 of the Administrative Code does not apply to participant-directed goods and services.

(2) Service documentation for participant-directed goods and services shall consist of a written invoice that contains the individual's name and medicaid identification number, a description of the item or service provided, the provider's name, the date the item or service was provided, and the provider's charge for the item or service.

(3) The financial management services entity shall maintain all service documentation for a period of six years from the date of receipt of payment for the service or until an initiated audit is resolved, whichever is longer.

(F) Payment standards

(1) The billing unit, service code, and payment rate for participant-directed goods and services are contained in the appendix to this rule.

(2) Providers of participant-directed goods and services shall be paid no more than their usual and customary charge for the services, equipment, or supplies provided.

Click to view Appendix

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-46 Home and community-based services waivers - participant/family stability assistance under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define participant/family stability assistance and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for these services.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(5) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(6) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor or either.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "Participant/family stability assistance" means training (including education and instruction) and counseling (including consultation) that enhance an individual's ability to direct his or her own services and/or enable an individual and/or family members who reside with the individual to understand how best to support the individual in order that the individual and his or her family members may live as much like other families as possible and to prevent or delay unwanted out-of-home placement.

(a) Participant/family stability assistance may be utilized only by the individual and family members who reside with the individual and shall be outcome-based, meaning that there shall be a specific goal for the service which is recorded in the individual service plan.

(b) Participant/family stability assistance includes training and counseling related to accommodating the individual's disability in the home, accessing supports offered in the community, effectively supporting the individual so that he or she may be fully engaged in the life of the family, and supporting the unique needs of the individual.

(c) Participant/family stability assistance includes the cost of enrollment fees and materials, but does not cover travel expenses or experimental and prohibited treatments.

(9) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (F) of this rule to validate payment for medicaid services.

(11) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(12) "Usual and customary charge" means the amount charged to other persons for the same service.

(C) Provider qualifications for participant/family stability assistance-training

(1) Participant/family stability assistance-training shall be provided by an independent provider or an agency provider that:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Has completed and submitted an application and adheres to the requirements of rule 5123:2-2-01 of the Administrative Code, except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of that rule do not apply to providers of participant/family assistance-training.

(2) The individual may determine additional qualifications for a provider of participant/family stability assistance-training; additional qualifications determined by the individual shall be recorded in the individual service plan.

(3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide participant/family stability assistance-training only when no other provider is willing and able.

(4) Participant/family stability assistance-training shall not be provided to an individual by his or her family member.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code, as applicable, may result in denial, suspension, or revocation of the provider's certification.

(D) Provider qualifications for participant/family stability assistance-counseling

(1) Participant/family stability assistance-counseling shall be provided by an independent provider or an agency provider that:

(a) Meets the requirements of this rule;

(b) Has a medicaid provider agreement with the Ohio department of job and family services; and

(c) Has completed and submitted an application and adheres to the requirements of paragraph (C)(2) of rule 5123:2-2-01 of the Administrative Code. The remainder of rule 5123:2-2-01 of the Administrative Code does not apply to providers of participant/family assistance-counseling.

(2) Participant/family stability assistance-counseling shall be provided by persons who are one of the following:

(a) Psychologist licensed by the state pursuant to Chapter 4732. of the Revised Code;

(b) Professional clinical counselor licensed by the state pursuant to section 4757.22 of the Revised Code;

(c) Professional counselor licensed by the state pursuant to section 4757.23 of the Revised Code;

(d) Independent social worker licensed by the state pursuant to section 4757.27 of the Revised Code;

(e) Social worker licensed by the state pursuant to section 4757.28 of the Revised Code working under the supervision of a licensed independent social worker; or

(f) Marriage and family therapist licensed by the state pursuant to section 4757.30 of the Revised Code.

(3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide participant/family stability assistance-counseling only when no other provider is willing and able.

(4) Participant/family stability assistance-counseling shall not be provided to an individual by his or her family member.

(5) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code, as applicable, may result in denial, suspension, or revocation of the provider's certification.

(E) Requirements for service delivery

Participant/family stability assistance shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(F) Documentation of services

Service documentation for participant/family stability assistance shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Times the delivered service started and stopped.

(G) Payment standards

(1) The billing units, service codes, and payment rates for participant/family stability assistance are contained in the appendix to this rule.

(2) Providers of participant/family stability assistance shall be paid no more than their usual and customary charge for the service.

Click to view Appendix

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-47 Home and community-based services waivers - support brokerage under the self-empowered life funding waiver.

(A) Purpose

The purpose of this rule is to define support brokerage and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Family member" means a person who is related to the individual by blood, marriage, or adoption.

(5) "Independent provider" means a person who provides services and does not employ, either directly or through contract, anyone else to provide the services.

(6) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual who is his or her own guardian may designate another person to assist the individual with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor or either.

(7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(8) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(9) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services.

(10) "Support broker" means a person who is responsible, on a continuing basis, for providing an individual with representation, advocacy, advice, and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the individual service plan. The support broker assists the individual with the individual's responsibilities regarding participant direction, including understanding employer authority and budget authority, locating and selecting providers, negotiating payment rates, and keeping the focus of the services and support delivery on the individual and his or her desired outcomes. The support broker, working in conjunction with the service and support administrator, assists the individual with creating the individual service plan, developing the waiver budget, and doing day-to-day monitoring of the provision of services as specified in the individual service plan.

(11) "Support brokerage" means the services of a support broker.

(12) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility redetermination date.

(C) Provider qualifications

(1) Support brokerage shall be provided by one of the following:

(a) An independent provider or an agency provider that:

(i) Meets the requirements of this rule;

(ii) Has a medicaid provider agreement with the Ohio department of job and family services; and

(iii) Has completed and submitted an application and adheres to the requirements of rule 5123:2-2-01 of the Administrative Code, except that paragraphs (C)(3)(a), (C)(3)(b), (C)(3)(c), and (K) of that rule do not apply to providers of support brokerage.

(b) An unpaid volunteer who has the qualifications specified in paragraph (C)(2) of this rule.

(2) Support brokerage shall be provided by persons who:

(a) Have at least an associate's degree from an accredited college or university or at least two years of experience providing one-to-one support for a person with a developmental disability; and

(b) Prior to providing support brokerage, have successfully completed the support broker training established by the department.

(3) The individual may determine additional qualifications for a provider of support brokerage; additional qualifications determined by the individual shall be recorded in the individual service plan.

(4) The following persons or entities shall not provide support brokerage:

(a) A county board.

(b) An employee of a county board.

(c) A housing or adult services nonprofit corporation affiliated with a county board.

(d) An employee of a housing or adult services nonprofit corporation affiliated with a county board.

(e) A regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(f) An employee of a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards.

(g) A certified provider of any other self-empowered life funding waiver service.

(h) A related entity affiliated with a certified provider of any other self-empowered life funding waiver service including, but not limited to, contractors of the provider.

(5) Support brokerage shall not be provided on a paid basis by the parents of a minor child (under age eighteen) or an individual's spouse, guardian, or family member if the family member resides with the individual.

(6) Failure to comply with this rule and rule 5123:2-2-01 of the Administrative Code, as applicable, may result in the denial, suspension, or revocation of the provider's certification.

(D) Requirements for service delivery

Support brokerage shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (K) of rule 5123:2-9-40 of the Administrative Code.

(E) Documentation of services

Service documentation for support brokerage shall include each of the following to validate payment for medicaid services:

(1) Type of service.

(2) Date of service.

(3) Place of service.

(4) Name of individual receiving service.

(5) Medicaid identification number of individual receiving service.

(6) Name of provider.

(7) Provider identifier/contract number.

(8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider.

(9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided.

(10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided.

(11) Times the delivered service started and stopped.

(F) Payment standards

(1) The billing units, service codes, and payment rates for support brokerage are contained in the appendix to this rule.

(2) Payment for support brokerage shall not exceed eight thousand dollars per waiver eligibility span.

Click to view Appendix

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16
Rule Amplifies: 5111.871 , 5111.873 , 5123.04 , 5123.045 , 5123.049 , 5123.16

5123:2-9-50 Home and community-based services waivers - administration of the transitions developmental disabilities waiver.

(A) Purpose

The purpose of this rule is to implement the transitions developmental disabilities waiver, a component of the medicaid home and community-based services program administered by the department pursuant to section 5166.21 of the Revised Code.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be approved by the Ohio department of medicaid.

(2) "Alternative services" has the same meaning as in rule 5123:2-1-08 of the Administrative Code.

(3) "County board" means a county board of developmental disabilities.

(4) "Department" means the Ohio department of developmental disabilities.

(5) "Foster caregiver" means a person having a valid foster home certificate issued under section 5103.03 of the Revised Code.

(6) "Home and community-based services" means any federally approved medicaid waiver service provided to an individual enrolled in a waiver as an alternative to institutional care under Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C.A. 1396n as in effect on the effective date of this rule, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(7) "Independent provider" means a non-agency, self-employed person approved by the Ohio department of medicaid to provide services who does not employ, either directly or through contract, anyone else to provide the services.

(8) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(9) "Individual cost cap" means the monthly cost of services that is approved by the department for an individual enrolled in the transitions developmental disabilities waiver. The department, as the designee of the Ohio department of medicaid, oversees that the cost of covered services does not exceed the individual cost cap, determines when an increase or decrease in the individual cost cap is required, and, taking into consideration a recommendation from a county board, approves an increase or decrease in the individual cost cap in accordance with paragraph (H) of this rule.

(10) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(11) "Intermediate care facility" means an intermediate care facility for individuals with intellectual disabilities as defined in rule 5123:2-7-01 of the Administrative Code.

(12) "Natural supports" means the personal associations and relationships typically developed in the community that enhance the quality of life for individuals. Natural supports may include family members, friends, neighbors, and others in the community or organizations that serve the general public who provide voluntary support to help an individual achieve agreed upon outcomes through the individual service plan development process.

(13) "Plan of care" means the medical treatment plan that is established, approved, and signed by the treating physician. The plan of care must be signed and dated by the treating physician prior to requesting payment for a service. The plan of care is not the same as the individual service plan.

(14) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(15) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in service-specific rules in Chapter 5123:2-9 of the Administrative Code to validate payment for medicaid services.

(16) "Significant change" means a change experienced by an individual that includes, but is not limited to, a change in health status, caregiver status, or location/residence; referral to or active involvement on the part of a protective services agency; or institutionalization.

(C) Department waiting list for the transitions developmental disabilities waiver

The department shall establish a waiting list for the transitions developmental disabilities waiver for eligible individuals when capacity and appropriations are not available. Enrollment in the transitions developmental disabilities waiver shall be based upon the date of application for the transitions developmental disabilities waiver. In the event an individual is placed on the waiting list for the transitions developmental disabilities waiver, the department shall notify the county board.

(1) The county board shall assist an individual placed on the waiting list for the transitions developmental disabilities waiver in identifying and obtaining alternative services that are available to meet the individual's immediate needs.

(2) Due process shall be made available to an individual aggrieved by the establishment or maintenance of, placement on, the failure to offer services in accordance with, or removal from the waiting list for the transitions developmental disabilities waiver.

(D) Benefit package

The transitions developmental disabilities waiver benefit package is comprised of the following services:

(1) Adult day health center services in accordance with rule 5123:2-9-51 of the Administrative Code;

(2) Emergency response services in accordance with rule 5123:2-9-52 of the Administrative Code;

(3) Home-delivered meals in accordance with rule 5123:2-9-53 of the Administrative Code;

(4) Home modification services in accordance with rule 5123:2-9-54 of the Administrative Code;

(5) Out-of-home respite in accordance with rule 5123:2-9-55 of the Administrative Code;

(6) Personal care aide services in accordance with rule 5123:2-9-56 of the Administrative Code;

(7) Supplemental adaptive and assistive devices in accordance with rule 5123:2-9-57 of the Administrative Code;

(8) Supplemental transportation in accordance with rule 5123:2-9-58 of the Administrative Code; and

(9) Waiver nursing services in accordance with rule 5123:2-9-59 of the Administrative Code.

(E) Individual choice and control

(1) Individuals enrolled in the transitions developmental disabilities waiver exercise choice and control over the arrangement and provision of home and community-based waiver services including selection and direction of approved providers of waiver services.

(2) An individual may choose to receive waiver services:

(a) Exclusively from independent providers;

(b) Exclusively from agency providers; or

(c) From a combination of independent providers and agency providers.

(3) The service and support administrator shall ensure that individuals have the authority to choose transitions developmental disabilities waiver service providers as outlined in paragraph (E)(2) of this rule.

(4) An individual enrolled in the transitions developmental disabilities waiver shall:

(a) Participate in the development of the individual service plan and all plans of care.

(b) Decide whether anyone besides the service and support administrator will participate in the face-to-face development of the individual service plan and plans of care.

(c) Authorize the service and support administrator to exchange information for development of the individual service plan with all of the individual's providers.

(d) Participate in the development and maintenance of service back-up plans that meet the needs of the individual.

(e) Communicate, as applicable, to the independent provider and/or assigned staff of the agency provider and the agency provider management staff, personal preferences about the duties, tasks, and procedures to be performed.

(f) Work with the service and support administrator and, as applicable, the independent provider and/or the agency provider to identify and secure orientation and training for the independent provider and/or assigned staff of the agency provider within the provider's scope of practice in order to meet the individual's specific needs.

(g) Report to the service and support administrator and, as applicable, the agency provider, in accordance with rule 5123:2-17-02 of the Administrative Code, incidents that may impact the health and welfare of the individual.

(h) Communicate to the service and support administrator any significant change that may affect the provision of services or result in a need for more or fewer hours of service.

(i) Provide verification that services have been furnished or approve independent provider or agency provider staff time sheets only after services have been furnished to the individual. An individual shall not approve blank time sheets or time sheets that have been completed before services have been furnished to the individual.

(j) Participate in the recruitment, selection, and dismissal of providers.

(k) Notify the provider if the individual is going to miss a scheduled visit.

(l) Notify the agency provider if the assigned staff of the agency provider misses a scheduled visit.

(m) Notify the service and support administrator if the independent provider misses a scheduled visit.

(n) Notify the service and support administrator when the individual wishes to select a different provider. Notification shall include the end date of the former provider and the start date of the new provider.

(o) Participate in the monitoring of performance of providers.

(p) If he or she chooses to receive waiver services from an independent provider:

(i) Designate a location in the individual's home in which the individual and the independent provider can safely store a copy of the individual's service documentation in a manner that protects the confidentiality of the individual's records and information, and for the purpose of contributing to the continuity of the individual's care; and

(ii) Make the individual's service documentation available upon request by the service and support administrator, the department, or the Ohio department of medicaid.

(5) If the service and support administrator determines that the individual cannot fulfill the requirements regarding the individual's role and responsibilities regarding provision of services by independent providers as set forth in paragraph (E)(4) of this rule and/or the health and welfare of the individual receiving services from an independent provider cannot be assured, the service and support administrator may require that the individual receive services exclusively from agency providers. In that event, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(F) Individual service plan requirements

(1) All services shall be provided to an individual enrolled in the transitions developmental disabilities waiver pursuant to an individual service plan.

(2) The service and support administrator shall ensure that the individual service plan is developed in accordance with rule 5123:2-1-11 of the Administrative Code.

(a) The individual service plan shall list the transitions developmental disabilities waiver services, the medicaid state plan services, and the non-medicaid services, regardless of funding source, that are necessary to ensure the individual's health and welfare.

(b) The individual service plan shall be developed to include waiver services which are consistent with efficiency, economy, quality of care, and the health and welfare of the individual.

(c) The individual service plan shall contain the following medicaid required elements:

(i) Type of service to be provided;

(ii) Amount of service to be provided;

(iii) Frequency and duration of each service to be provided; and

(iv) Type of provider to furnish each service.

(d) The individual service plan is subject to approval by the department. Notwithstanding the procedures set forth in this rule, the Ohio department of medicaid may in its sole discretion, and in accordance with section 5166.05 of the Revised Code, direct the department or the county board to amend individual service plans for individuals if the Ohio department of medicaid determines that such services are medically necessary.

(G) Provider qualifications

(1) Independent providers and agency providers of transitions developmental disabilities waiver services shall receive approval from the Ohio department of medicaid before providing services to an individual enrolled in the transitions developmental disabilities waiver. Services provided before the Ohio department of medicaid issues such approval shall not be reimbursable.

(2) Rule 5123:2-2-01 of the Administrative Code does not apply to providers of transitions developmental disabilities waiver services.

(3) An independent provider and each employee, contractor, and employee of a contractor of an agency provider who is engaged in direct provision of transitions developmental disabilities waiver services shall:

(a) Be at least eighteen years of age.

(b) Have a valid social security number and one of the following forms of identification:

(i) State of Ohio identification;

(ii) A valid driver's license; or

(iii) Other government-issued photo identification.

(c) Be able to read, write, and understand English at a level sufficient to comply with all requirements set forth in administrative rules governing the services provided.

(d) Be able to effectively communicate with the individual receiving services.

(4) The following standards of practice apply to each independent provider and to each agency provider and its employees, contractors, and employees of contractors:

(a) Providing services only to individuals whose needs he or she can meet.

(b) Implementing services in accordance with the individual service plan and plans of care.

(c) Taking all reasonable steps necessary to prevent the occurrence or recurrence of incidents adversely affecting health and safety of individuals served.

(d) Complying with the requirements of behavior supports established under rules adopted by the department and ensuring that anyone responsible for implementing a behavior support plan receives training in the plan components prior to implementation of the plan.

(e) Arranging for substitute coverage, if necessary, only from a provider approved by the Ohio department of medicaid and as identified in the individual service plan, notifying the individual or legally responsible person in the event that substitute coverage is necessary, and notifying the person identified in the individual service plan when substitute coverage is not available to allow such person to make other arrangements.

(f) Notifying, in writing, the individual or the individual's guardian and the individual's service and support administrator in the event that the provider intends to cease providing services to the individual no less than thirty calendar days prior to termination of services. If, however, an independent provider intends to cease providing services to an individual because the health or safety of the independent provider is at serious and immediate risk, the provider shall immediately notify the county board by calling the county board's twenty-four-hour emergency telephone number; once the county board has been notified, the independent provider may cease providing services.

(g) Complying with monitoring conducted by the service and support administrator in accordance with rule 5123:2-1-11 of the Administrative Code.

(h) Complying with paragraph (C) of rule 5160-45-10 of the Administrative Code.

(5) An independent provider or an employee, contractor, or employee of a contractor of an agency provider of transitions developmental disabilities waiver services shall not:

(a) Provide services to his or her minor (under age eighteen) child unless he or she is providing waiver nursing services as an employee of an agency provider of waiver nursing services;

(b) Provide services to his or her spouse unless he or she is providing waiver nursing services as an employee of an agency provider of waiver nursing services;

(c) Provide services to an individual for whom he or she is the foster caregiver;

(d) Engage in sexual conduct or have sexual contact with an individual for whom he or she is providing care; or

(e) Administer any medication to or perform health care tasks for individuals who receive services unless he or she meets the applicable requirements of Chapter 4723. of the Revised Code.

(H) Service authorization

(1) Effective January 1, 2013, a baseline funding amount shall be assigned to each individual receiving services under the transitions developmental disabilities waiver. The baseline amount shall be the annualized cost of services determined by the Ohio department of medicaid for the individual for fiscal year 2012.

(2) A service and support administrator shall submit a proposed service authorization for each individual receiving services under the transitions developmental disabilities waiver to the department for review and approval at least annually and upon identification of a significant change that affects a service authorization. The annual service authorization submission to the department shall contain a monthly breakout of the cost of covered services which shall not exceed the proposed annual service authorization amount except as provided in paragraph (H)(3) of this rule.

(3) When reviewing a proposed service authorization, the department shall determine whether the waiver services for which authorization is requested are medically necessary unless the requested services have been determined by the Ohio department of medicaid not to be medically necessary within a twelve-month period immediately preceding the service authorization request, in which case a medical necessity review under this paragraph shall not be required. The department shall determine the services to be medically necessary if the services:

(a) Are appropriate for the individual's health and welfare needs, living arrangement, circumstances, and expected outcomes; and

(b) Are of an appropriate type, amount, duration, scope, and intensity; and

(c) Are the most efficient, effective, and lowest cost alternative that, when combined with non-waiver services, ensure the health and welfare of the individual receiving the services; and

(d) Protect the individual from substantial harm expected to occur if the requested services are not authorized.

(4) Notwithstanding the procedures set forth in this rule, the department may approve a proposed service authorization in its entirety or may partially approve a proposed service authorization if it determines that the services set forth in paragraph (D) of this rule are medically necessary. At no time shall an approved service authorization exceed the funding limitations specified in the transitions developmental disabilities waiver.

(5) The individual shall be afforded notice and hearing rights regarding service authorizations in accordance with division 5101:6 of the Administrative Code.

(a) Providers shall have no standing in appeals under this section.

(b) A change in staff-to-waiver-recipient service ratios does not necessarily result in a change in the level of services received by an individual which would affect the annual service authorization.

(I) Service documentation

(1) A provider of services shall maintain service documentation in accordance with this rule and service-specific rules in Chapter 5123:2-9 of the Administrative Code. Services shall not be considered delivered unless the provider maintains service documentation.

(2) Claims for payment a provider of services submits to the Ohio department of medicaid for services delivered shall not be considered service documentation. Any information contained in the submitted claim may not and shall not be substituted for any required service documentation information that a provider of services is required to maintain to validate payment for medicaid services.

(3) A provider of services shall maintain all service documentation in an accessible location. The service documentation shall be available, upon request, for review by the centers for medicare and medicaid services, the Ohio department of medicaid, the department, a county board or regional council of governments that submits to the department payment authorization for the service, and those designated or assigned authority by the Ohio department of medicaid or the department to review service documentation.

(4) A provider of services shall maintain service documentation for a period of six years from the date of receipt of payment for the service or until an initiated audit is resolved, whichever is longer.

(5) If a provider of services discontinues operations, the provider shall, within seven days of discontinuance, notify the county boards for the counties in which individuals to whom the provider has provided services reside, of the location where the service documentation will be stored, and provide each such county board with the name and telephone number of the person responsible for maintaining the records.

(J) Payment and billing procedures

(1) Rule 5123:2-9-06 of the Administrative Code does not apply to services provided under the transitions developmental disabilities waiver.

(2) In order for a provider to be paid for services delivered to an individual enrolled in the transitions developmental disabilities waiver, the services must be delivered in accordance with Chapter 5123:2-9 of the Administrative Code.

(3) Providers shall submit claims for payment to the Ohio department of medicaid in accordance with rule 5160-41-22 of the Administrative Code.

(4) The amount of payment for a service shall be the lesser of the provider's billed charge or the medicaid maximum rate.

(5) Providers of services shall take reasonable measures to identify any third-party health care coverage available to the individual and file a claim with that third party in accordance with the requirements of rule 5160-1-08 of the Administrative Code.

(6) For individuals with a monthly patient liability for the cost of transitions developmental disabilities waiver services and determined by the county department of job and family services for the county in which the individual resides, payment is available only for waiver services delivered to the individual that exceeds the amount of the individual's monthly patient liability. Verification that patient liability has been satisfied shall be accomplished as follows:

(a) The department shall provide notification to the appropriate county board identifying each individual who has a patient liability for waiver services and the monthly amount of the patient liability.

(b) The county board shall assign the waiver services to which each individual's patient liability shall be applied and assign the corresponding monthly patient liability amount to the waiver service provider that provides the preponderance of waiver services. The county board shall notify each individual and waiver service provider, in writing, of this assignment.

(c) Upon submission of a claim for payment, the designated waiver service provider shall report the waiver services to which the patient liability was assigned and the applicable patient liability amount on the claim for payment using the format prescribed by the department.

(7) The department, the Ohio department of medicaid, the centers for medicare and medicaid services, and/or the auditor of state may audit any funds a provider of transitions developmental disabilities waiver services receives pursuant to this rule, including any source documentation supporting the claiming and/or receipt of such funds.

(8) Overpayments, duplicate payments, payments for services not rendered, payments for which there is no documentation of services delivered or for which the documentation does not include all of the items required in service-specific rules in Chapter 5123:2-9 of the Administrative Code, or payments for services not in accordance with an approved individual service plan are recoverable by the department, the Ohio department of medicaid, the auditor of state, or the office of the attorney general. All recoverable amounts are subject to the application of interest in accordance with rules 5160-1-25 and 5101:6-51-03 of the Administrative Code, as applicable.

(9) A county board shall be responsible for monitoring the utilization of services furnished pursuant to this rule based on quarterly service utilization reports provided by the department.

Effective: 07/01/2014
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5166.21
Rule Amplifies: 5123.04 , 5166.21
Prior Effective Dates: 01/01/2013, 11/22/2013

5123:2-9-51 Home and community-based services waivers - adult day health center services under the transitions developmental disabilities waiver.

(A) Purpose

The purpose of this rule is to define adult day health center services under the transitions developmental disabilities waiver and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Adult day health center" means a freestanding building or space within another building that shall not be used for any other purpose during the provision of adult day health center services. An adult day health center shall not be located in an intermediate care facility.

(2) "Adult day health center services" means regularly scheduled services delivered at an adult day health center to individuals age eighteen and older who have a need for the services as identified in their individual service plans.

(a) Adult day health center services shall include:

(i) Personal care aide services as set forth in rule 5123:2-9-56 of the Administrative Code or waiver nursing services as set forth in rule 5123:2-9-59 of the Administrative Code; and

(ii) Recreational and educational activities .

(b) Adult day health center services may include:

(i) Skilled therapies as set forth in rule 5160-12-01 of the Administrative Code; and

(ii) Transportation of the individual to and from adult day health center services.

(3) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be approved by the Ohio department of medicaid.

(4) "County board" means a county board of developmental disabilities.

(5) "Department" means the Ohio department of developmental disabilities.

(6) "Independent provider" means a non-agency, self-employed person approved by the Ohio department of medicaid to provide services who does not employ, either directly or through contract, anyone else to provide the services.

(7) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, his or her guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent.

(8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(9) "Intermediate care facility" means an intermediate care facility for individuals with intellectual disabilities as defined in rule 5123:2-7-01 of the Administrative Code.

(10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services.

(C) Provider qualifications

(1) Adult day health center services shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid.

(2) Adult day health center services shall not be provided by an independent provider.

(3) A provider of adult day health center services shall ensure that each employee who is engaged in the direct provision of adult day health center services completes training, in accordance with standards established by the department, prior to initially providing adult day health center services and at least annually thereafter, in:

(a) The provisions governing rights of individuals as set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(b) The requirements of rule 5123:2-17-02 of the Administrative Code relating to incidents adversely affecting health and safety including a review of health and safety alerts issued by the department.

(4) A provider of adult day health center services shall ensure that each non-licensed employee engaged in the direct provision of adult day health center services annually completes at least twelve hours of in-service training, excluding agency provider/program-specific orientation or training. Training completed pursuant to paragraph (C)(3) of this rule may be counted toward the twelve hours.

(D) Requirements for service delivery

(1) Adult day health center services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (F) of rule 5123:2-9-50 of the Administrative Code.

(2) Providers of adult day health center services shall:

(a) Be identified as the provider and have specified in the individual service plan the number of hours for which the provider is authorized to furnish adult day health center services to the individual;

(b) Operate the adult day health center in compliance with all federal, state, and local laws, rules, and regulations;

(c) Comply with applicable rules in Chapter 5123:2-9 of the Administrative Code;

(d) Provide for replacement coverage of an individual's loss due to theft and/or property damage, upon request provide documentation to the department or the Ohio department of medicaid or their designees verifying coverage, and maintain a written procedure identifying the steps an individual must take to file a liability claim;

(e) Ensure that any waiver nursing services are provided by a nurse who possesses a current, valid, and unrestricted license issued by the Ohio board of nursing as a registered nurse or a licensed practical nurse and who is providing nursing services within his or her scope of practice. A licensed practical nurse may provide waiver nursing services at the direction of a registered nurse;

(f) Provide task-based instruction to direct care staff providing adult day health center services as set forth in paragraph (B)(2) of this rule; and

(g) Maintain at all times a paid-direct-care-staff-to-individuals-served ratio of no less than one to six.

(E) Documentation of services

(1) Providers of adult day health center services shall maintain service documentation for each individual served in a manner that protects the confidentiality of the individual's records.

(2) Service documentation for adult day health center services shall include each of the following to validate payment for medicaid services:

(a) Individual-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) Individual's medical history;

(c) Name of individual's treating physician;

(d) A copy of all individual service plans in effect when the provider provides services;

(e) A copy of any advance directives including, but not limited to, a "do not resuscitate" order or medical power of attorney, if they exist;

(f) Documentation of drug and food interactions, allergies, and dietary restrictions;

(g) Documentation that clearly shows the date of adult day health center services delivery, including tasks performed or not performed, and the individual's arrival and departure times for each date;

(h) A discharge summary that includes information regarding progress made toward goal achievement and indicates any recommended follow-ups or referrals that is signed and dated by the adult day health center services provider, at the point the adult day health center services provider is no longer going to provide services to the individual or when the individual no longer needs adult day health center services; and

(i) Information specified in paragraph (E)(2) of rule 5123:2-9-59 of the Administrative Code when waiver nursing services or skilled therapy services are provided to the individual.

(F) Payment standards

(1) The billing units, service codes, and payment rates for adult day health center services are contained in the appendix to this rule.

(2) Providers shall submit claims for payment for adult day health center services to the Ohio department of medicaid in accordance with rule 5160-41-22 of the Administrative Code.

(3) The adult day health center services full day billing unit shall apply when adult day health center services are provided to an individual for five or more hours in one calendar day.

(4) The adult day health center services half day billing unit shall apply when adult day health center services are provided to an individual for less than five hours in one calendar day.

(5) The services set forth in paragraphs (B)(2)(a) and (B)(2)(b) of this rule and delivered by an adult day health center shall not be reimbursed as separate services.

Click to view Appendix

Effective: 07/01/2014
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5166.21
Rule Amplifies: 5123.04 , 5166.21
Prior Effective Dates: 03/30/1990 (Emer.), 06/29/1990, 07/01/1990, 03/12/1992 (Emer.), 06/01/1992, 07/31/1992 (Emer.), 10/30/1992, 07/01/1993 (Emer.), 07/30/1993, 09/01/1993, 01/01/1996, 07/01/1998, 07/01/2006, 07/01/2010, 01/01/2013

5123:2-9-52 Home and community-based services waivers - emergency response services under the transitions developmental disabilities waiver.

(A) Purpose

The purpose of this rule is to define emergency response services under the transitions developmental disabilities waiver and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be approved by the Ohio office of medical assistance.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Emergency response services" means emergency intervention comprised of telecommunications equipment (i.e., emergency response services equipment), an emergency response center, and a medium for two-way, hands-free communication between the individual being served and the emergency response center. Personnel at the emergency response center intervene in an emergency when the center receives an alarm signal from the emergency response services equipment. Emergency response services shall not include:

(a) Equipment such as a boundary alarm, a medication dispenser, a medication reminder, or any other equipment or home medical equipment or supplies, regardless of whether such equipment is connected to the emergency response services equipment;

(b) In-home communication connection systems used to supplant routine supervision of individuals under the age of eighteen;

(c) Remote monitoring services;

(d) Services performed in excess of what is approved pursuant to an individual service plan; or

(e) New equipment or repair of previously-approved equipment that has been damaged as a result of confirmed misuse, abuse, or negligence.

(5) "Emergency response services equipment" means a variety of remote or other specialty activation devices from which an individual can choose in accordance with his or her specific needs. All emergency response services equipment shall have an internal battery that provides at least twenty-four hours of power without recharging and sends notification to the emergency response center when the battery's level is low. Emergency response services equipment includes, but is not limited to: