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

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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