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