5123:2-9-57 Home and community-based services waivers - supplemental adaptive and assistive devices under the transitions developmental disabilities waiver.

(A) Purpose

The purpose of this rule is to define supplemental adaptive and assistive devices 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) "Independent provider" means a non-agency, self-employed person approved by the Ohio office of medical assistance to provide services who does not employ, either directly or through contract, anyone else to provide the services.

(4) "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.

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

(6) "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.

(7) "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.

(8) "Supplemental adaptive and assistive devices" means medical equipment, supplies, and devices and vehicle modifications to a vehicle owned by the individual, the individual's family member, or someone who resides in the same household as the individual, that are not otherwise available through any other funding source and that enable an individual to function with greater independence, avoid institutionalization, and reduce the need for human assistance. Supplemental adaptive and assistive devices shall not include:

(a) Items considered by the federal food and drug administration to be experimental or investigational;

(b) Funding of down payments toward the purchase or lease of equipment or devices;

(c) Equipment, supplies, or services furnished in excess of what is approved pursuant to, and as specified in, the individual service plan;

(d) New equipment or supplies or repair of previously-approved equipment or supplies that have been damaged as the result of confirmed misuse, abuse, or negligence; or

(e) Activities described in paragraph (B)(9)(b) of this rule.

(9) "Vehicle modifications" means operating aids, raised and lowered floors, raised doors, raised roofs, wheelchair tie-downs, scooter/wheelchair handling devices, transfer seats, remote devices, lifts, equipment repair and/or replacement, and transfers of equipment from one vehicle to another for use by the same individual.

(a) Vehicle modifications may include the itemized cost and separate invoicing of vehicle adaptations associated with the purchase of a vehicle that has not been pre-owned or pre-leased.

(b) Vehicle modifications shall not include:

(i) Payment toward the purchase or lease of a vehicle except as set forth in paragraph (B)(9)(a) of this rule;

(ii) Routine care and maintenance of vehicle equipment and devices;

(iii) Permanent modification of leased vehicles;

(iv) Vehicle inspection costs;

(v) Vehicle insurance costs; or

(vi) New vehicle modifications or repairs of previously-approved modifications that have been damaged as a result of confirmed misuse, abuse, or negligence.

(C) Provider qualifications

(1) Supplemental adaptive and assistive devices shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio office of medical assistance.

(2) Supplemental adaptive and assistive devices 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.

(D) Requirements for service delivery

(1) Supplemental adaptive and assistive devices 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) A provider of supplemental adaptive and assistive devices shall be identified and have specified in the individual service plan the supplemental adaptive and assistive devices the provider is authorized to furnish to the individual.

(3) All supplemental adaptive and assistive devices shall be prior-authorized by the service and support administrator.

(a) The service and support administrator shall approve only the lowest cost alternative that meets the individual's needs as determined during the assessment process.

(b) The service and support administrator shall not approve the same type of medical equipment, supplies, and devices for the same individual within the same calendar year unless there is a documented need for ongoing medical equipment, supplies, or devices as documented by a licensed healthcare professional, or a documented change in the individual's medical or physical condition requiring the replacement.

(c) The service and support administrator shall not approve the same type of vehicle modification for the same individual within the same three-year period, unless there is a documented change in the individual's medical or physical condition requiring the replacement.

(4) Prior to authorization of a vehicle modification, the individual and if applicable, any other person who will operate the vehicle, shall provide the service and support administrator with documentation of:

(a) A valid driver's license, with appropriate restrictions, and if requested by the service and support administrator, evidence of successful completion of driver training from a qualified driver rehabilitation specialist, or a written statement from a qualified driver rehabilitation specialist attesting to the driving ability and competency of the individual and/or other person operating the vehicle;

(b) Proof of ownership of the vehicle being modified;

(c) Evidence of the vehicle owner's collision and liability insurance for the vehicle being modified; and

(d) A written statement from a certified mechanic stating the vehicle is in good operating condition.

(5) Providers of supplemental adaptive and assistive devices shall ensure that supplemental adaptive and assistive devices are tested and are in proper working order and subject to warranty in accordance with industry standards.

(E) Documentation of services

(1) Providers of supplemental adaptive and assistive devices shall maintain service documentation for each individual served in a manner that protects the confidentiality of the individual's records. Service documentation shall be maintained at the provider's place of business. For purposes of this rule, the place of business must be a location other than the individual's residence.

(2) Service documentation for supplemental adaptive and assistive devices 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) Name of individual's treating physician;

(c) A copy of all individual service plans in effect when the provider provides services; and

(d) Documentation that clearly shows the date supplemental adaptive and assistive devices was provided.

(F) Payment standards

(1) The billing unit, service code, and payment rate for supplemental adaptive and assistive devices are contained in the appendix to this rule.

(2) Providers shall submit claims for payment for supplemental adaptive and assistive devices to the Ohio office of medical assistance in accordance with rule 5101:3-41-22 of the Administrative Code.

(3) Providers of supplemental adaptive and assistive devices shall ensure that the amount of all manufacturers' rebates have been deducted from claims for payment for supplemental adaptive and assistive devices.

(4) Payment for supplemental adaptive and assistive devices shall not exceed ten thousand dollars within a rolling twelve-month period.

Replaces: Part of 5101:3-47-04

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