Chapter 5123-9 Vocational Activities; Administration of Individuals' Funds; Behavior Modification

5123-9-02 Placement and discharge of individuals from developmental centers into nursing facilties.

(A) Purpose

The purpose of this rule is to establish procedures for placement and discharge of individuals from developmental centers into nursing faciuties as provided by the Sermak v. Brown consent decree, OBRA legislation, and Medicaid regulations.

(B) Provisions

The provisions of this rule shall be applicable to all developmental centers. The managing officer of each developmental center shall be responsible for designating an employee who shall ensure that all of the requirements of this rule are met.

(C) Definitions

The following definitions shall apply to this rule:

(1) "Active treatment" means a continuous program which includes aggressive, consistent implementation of a program of specialized and generic training, treatment and health services, and related services that is directed toward:

(a) The acquisition of the behaviors necessary for the individual to function with as much self-determ1nation and independence as possible; and

(b) The prevention or deceleration of regression or loss of current optimal functional status.

(2) "Comprehensive evaluation" means a study, including a sequence of observations and standardized examinations, of a person leading to conclusions and recommendations formulated jointly, with dissenting opinions, if any, by an interdisciplinary team, and which complies at a minimum with 42 C.F.R. 483.440(C)(3) of the Medicaid regulations.

(3) "DHS" means the Department of Human Services.

(4) "Individual Plan (IP)" means a written plan of interventions and specific objectives necessary to meet the individual's needs, developed by the interdisciplinary team including the individual and the legal guardian, if any. The individual shall be included in the development of the IP unless the individual chooses not to participate. The IP shall be based upon a comprehensive evaluation and shall identify sequential behavior objectives to increase the individual's level of social, physical, intellectual, emotional and vocational effectiveness. The IP shall be developed without regard to the actual availability of the services needed. The IP shall meet the requirements listed in 42 C.F.R. 483.440(C)(4) of the Medicaid regulations.

(5) "Interdisciplinary team" means a group of persons with special training and experience in the diagnosis and management of people with mental retardation and developmental disabilities, representing the professions, disciplines or service areas that are relevant to identifying the individual's needs and designing programs that meet the individual's needs. This team shall include a person who meets the qualifications of a qualified mental retardation specialist (QMRP) FOUND IN 42 C.F.R. 483.430. The QMRP shall be responsible for integrating, coordinating and monitoring the individual's active treatment program. Whenever possible, the team shall include a representative of the County Board of Mental Retardation and Developmental Disabilities and the nursing facility.

(6) "Nursing facility (NF)" as used in this rule, includes any long- term care facility

(excluding ICFs/MR) currently certified by the Ohio Department of Health as being in compliance with the nursing facility standards and conditions of participation.

(7) "OBRA" means the Omnibus Budget Reconciliation Act of 1987 and 1990.

(8) "ODMRDD" Means the Ohio Department of developmental disabilities.

(9) "OLRS" means the Ohio Legal Rights Service.

(10) "Qualified mental retardation professional (QMRP)" means a person who meets the requirements for education and experience as listed in 42 C.F.R. 483.430(a) of the Medicaid regulations.

(D) Placement of individuals from developmental centers into nursing facilities (NFS).

All potential placements of individuals from developmental centers directly into NFS shall be performed in compliance with this rule.

(1) Except as otherwise provided in this rule, no individual shall be placed or discharged from a developmental center into a NF.

(2) An individual shall be placed into a NF only when the individual has a medical condition which is determined to be unstable, extreme or complex and prevents the individual from participating in his/her health care programs.

(3) Placement of the individual shall be subject to medicaid regulations listed in 42 C.F.R 483.440(B)(4) and preadmission screening under OBRA as defined by federal statute and implementing regulations.

(4) Written notification of the proposed placement shall be made fifteen days prior to the intended placement date to OLRS.

(5) If the developmental center medical director or ODMRDD medical director determines that the individual is in a "medical crisis," which is defined as a situation in which the individual's medical condition presents an imminent threat or loss of life or serious physical harm in the absence of appropriate care, and the medical director believes that the medical crisis requires immediate placement into a NF. ODMRDD shall provide oral notification to OLRS within twenty-four hours of ODMRDD's awareness of such medical crisis, with written follow-up notification within three business days.

(6) Except when the individual is in medical crisis as defined in paragraph (D)(5) of this rule, the individual must have a current individual plan (IP), updated within thirty days prior to the proposed placement, which includes the individual's active treatment and health care needs as defined in 42 C.F.R. 483.440 of the Medicaid regulations. If the individual's active treatment needs or health care status have changed, the IP shall be updated to reflect these changes.

When an individual in a medical crisis as defined in paragraph (D)(5) of this rule has been placed into a NF the individual's active treatment needs shall be evaluated by ODMRDD within thirty days of the individual's placement.

(a) Whenever possible, development of the individual's IP, including the comprehensive evaluation and postinstitutional plan of care, will be done jointly by the NF and the developmental center.

(b) The individual shall be included in the development of the IP, including the comprehensive evaluation and post-institutional plan of care, unless the individual chooses not to participate.

(7) In no case shall the individual be placed unless the individual has stayed at least seventy-two continuous hours at the receiving facility and the team has met to consider information gathered during the stay.

(8) ODMRDD is responsible for ensuring that the individual's active treatment needs are provided for during the time the individual resides in the NF.

(9) ODMRDD shall ensure that the individual's continued need for services in the NF and active treatment needs are reviewed within the first one hundred twenty days. The review is to be conducted at least every one hundred eighty days thereafter.

(10) Any ind1vidual placed into a NF shall be maintained on the rolls of the developmental center for at least thirty days, after which time the individual may be discharged from the developmental center unless the individual has indicated, in any manner, dissatisfaction with the placement.

(11) Prior to discharge from the developmental center. the managing officer shall notify the county board of mental retardation and developmental disabilities of the individual's placement and service needs.

(E) Placement of an individual from a hospital directly into a NF

All potential placements of individuals from developmental centers who are hospitalized and for whom the hospital recommends placement into a NF shall be performed in compliance with this rule.

(1) Unless otherwise provided in this rule, no individual from a developmental center who has been hospitalized shall be placed from the hospital or discharged into a NF.

(2) Written notice shall be made to OLRS and to DHS of the hospital's recommendation to place the individual into a NF within three business days of ODMRDD'S awareness of such recommendation. This notice shall include the individual's diagnosis and medical needs as specified by the hospital medical staff. The notice shall also include the name of the receiving NF and the date of proposed placement.

(3) The individual shall be subject to preadmission screening under OBRA according to federal law and implementing regulation.

(4) The managing officer of the developmental center is responsible for ensuring that within thirty days of placement the individual's active treatment needs are evaluated.

(5) The individual must have a current individual plan (IP) updated within thirty days prior to the proposed placement, which includes the individual's active treatment and health care needs as defined in 42 C.F.R. 483.330 of the Medicaid regulations. If the individual's active treatment needs or health care status have changed, the IP shall be updated to reflect these changes.

(a) Whenever possible, development of the individual's IP, including the comprehensive evaluation and post institutional plan of care, will be done jointly by the NF and the developmental center.

(b) The individual shall be included in the development of the IP, including the comprehensive evaluation and post-institutional plan of care, unless the individual chooses not to participate.

(6) In no case shall the individual be placed unless the individual has stayed at least seventy-two continuous hours at the NF and the team has met to consider information gathered dur1ng the stay.

(7) ODMRDD is responsible for ensuring that the individual's active treatment needs are provided for during the time the individual resides in the NF.

(8) ODMRDD shall ensure that the individual's continued need for services in the NF and active treatment needs are reviewed within the first one hundred twenty days by the interdisciplinary team. A review will be conducted at least every one hundred eighty days thereafter, as long as the individual resides in the NF.

(9) If it is determined through the review process that discharge is appropriate, then written notice of the intent to discharge shall be given to OLRS.

(10) The individual will be maintained on the rolls of the developmental center unless discharge is deemed appropriate by ODMRDD. If the individual has indicated in any manner, dissatisfaction with the placement, the individual shall not be discharged.

(11) The county board of mental retardation and developmental disabilities where the individual is to reside shall be notified of the individual's placement and service needs prior to placement.

(F) Each developmental center shall designate an employee who shall be responsible for the following:

(1) Providing notice to OLRS and DHS;

(2) Coordinating joint development wherever possible by the NF and the developmental center of the individual's comprehensive evaluation and IP, including quarterly updates;

(3) Ensuring quarterly visits by appropriate developmental center staff to meet with and observe the individual; and

(4) Coordinating the return to the developmental center or subsequent placement and discharge from the NF.

Effective Date: April 27, 2000

5123-9-04 Home and community-based services waivers - waiting list.

(A) Purpose

This rule sets forth requirements for the waiting list established pursuant to section 5126.042 of the Revised Code when a county board determines that available resources are insufficient to enroll individuals who are assessed to need and who choose home and community-based services in department-administered home and community-based services waivers.

(B) Definitions

(1) "Adult" means an individual who is eighteen years of age or older.

(2) "Alternative services" means the various programs, funding mechanisms, services, and supports, other than home and community-based services, that exist as part of the developmental disabilities service system and other service systems. "Alternative services" includes, but is not limited to, services offered through Ohio's medicaid state plan such as home health services and services available at an intermediate care facility for individuals with intellectual disabilities.

(3) "Community-based alternative services" means alternative services in a setting other than a hospital, an intermediate care facility for individuals with intellectual disabilities, or a nursing facility.

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

(5) "Current need" means an unmet need for home and community-based services within twelve months, as determined by a county board based upon assessment of the individual using the waiting list assessment tool. Situations that give rise to current need include:

(a) An individual is likely to be at risk of substantial harm due to:

(i) The primary caregiver's declining or chronic physical or psychiatric condition that significantly limits his or her ability to care for the individual;

(ii) Insufficient availability of caregivers to provide necessary supports to the individual; or

(iii) The individual's declining skills resulting from a lack of supports.

(b) An individual has an ongoing need for limited or intermittent supports to address behavioral, physical, or medical needs, in order to sustain existing caregivers and maintain the viability of the individual's current living arrangement.

(c) An individual has an ongoing need for continuous supports to address significant behavioral, physical, or medical needs.

(d) An individual is aging out of or being emancipated from children's services and has needs that cannot be addressed through community-based alternative services.

(e) An individual requires waiver funding for adult day services or employment-related supports that are not otherwise available as vocational rehabilitation services funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 730, as in effect on the effective date of this rule, 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, as in effect on the effective date of this rule.

(6) "Date of request" means the earliest date and time of any written or otherwise documented request for home and community-based services made prior to the effective date of this rule.

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

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

(9) "Immediate need" means a situation that creates a risk of substantial harm to an individual, caregiver, or another person if action is not taken within thirty calendar days to reduce the risk. Situations that give rise to immediate need include:

(a) A resident of an intermediate care facility for individuals with intellectual disabilities has received notice of termination of services in accordance with rule 5123:2-3-05 of the Administrative Code.

(b) A resident of a nursing facility has received thirty-day notice of intent to discharge in accordance with Chapter 5160-3 of the Administrative Code.

(c) A resident of a nursing facility has received an adverse determination in accordance with rule 5123:2-14-01 of the Administrative Code.

(d) An adult is losing his or her primary caregiver due to the primary caregiver's declining or chronic physical or psychiatric condition or due to other unforeseen circumstances (such as military deployment or incarceration) that significantly limit the primary caregiver's ability to care for the individual when:

(i) Impending loss of the caregiver creates a risk of substantial harm to the individual; and

(ii) There are no other caregivers available to provide necessary supports to the individual.

(e) An adult or child is engaging in documented behavior that creates a risk of substantial harm to the individual, caregiver, or another person.

(f) There is impending risk of substantial harm to the individual or caregiver as a result of:

(i) The individual's significant care needs (i.e., bathing, lifting, high-demand, or twenty-four-hour care); or

(ii) The individual's significant or life-threatening medical needs.

(g) An adult has been subjected to abuse, neglect, or exploitation and requires additional supports to reduce a risk of substantial harm to the individual.

(10) Individual" means a person with a developmental disability.

(11) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.

(12) "Locally-funded home and community-based services waiver" means the county board pays the entire nonfederal share of medicaid expenditures in accordance with sections 5126.059 and 5126.0510 of the Revised Code.

(13) "Nursing facility" has the same meaning as in section 5165.01 of the Revised Code.

(14) "Service and support administration" means the duties performed by a service and support administrator pursuant to section 5126.15 of the Revised Code.

(15) "State-funded home and community-based services waiver" means the department pays, in whole or in part, the nonfederal share of medicaid expenditures associated with an individual's enrollment in the waiver.

(16) "Status date" means the date on which the individual is determined to have a current need based on completion of an assessment of the individual using the waiting list assessment tool.

(17) "Transitional list of individuals waiting for home and community-based services" means the list maintained in the department's web-based individual data system which shall include the name and date of request for each individual on a list of individuals waiting for home and community-based services on the day immediately prior to the effective date of this rule established in accordance with rule 5123:2-1-08 of the Administrative Code as that rule existed on the day immediately prior to the effective date of this rule.

(18) "Waiting list assessment tool" means the Ohio assessment for immediate need and current need contained in the appendix to this rule, which shall be used for purposes of making a determination of an individual's eligibility to be added to the waiting list for home and community-based services defined in paragraph (B)(20) of this rule and administered by persons who successfully complete training developed by the department.

(19) "Waiting list date" means, as applicable, either:

(a) The date of request for an individual whose name is included on the transitional list of individuals waiting for home and community-based services; or

(b) The earliest status date for an individual whose name is not included on the transitional list of individuals waiting for home and community-based services.

(20) "Waiting list for home and community-based services" means the list established by county boards and maintained in the department's web-based waiting list management system which shall include the name, status date, date of request (as applicable), waiting list date, and the criteria for current need by which an individual is eligible based on administration of the waiting list assessment tool, for each individual determined to have a current need on or after the effective date of this rule.

(C) Planning for locally-funded home and community-based services waivers

A county board shall, in conjunction with development of its plan described in section 5126.054 of the Revised Code and its strategic plan described in rule 5123-4-01 of the Administrative Code, identify how many individuals the county board plans to enroll in each type of locally-funded home and community-based services waiver during each calendar year, based on projected funds available to the county board to pay the nonfederal share of medicaid expenditures and the assessed needs of the county's residents on the waiting list for home and community-based services. This information shall be made available to any interested person upon request.

(D) Waiting list for home and community-based services

(1) An individual or the individual's guardian, as applicable, who thinks the individual has an immediate need or a current need may contact the county board in the individual's county of residence to request an assessment of the individual using the waiting list assessment tool. The county board shall initiate an assessment of the individual using the waiting list assessment tool within thirty calendar days. An individual or the individual's guardian, as applicable, shall have access to the individual's completed waiting list assessment tool maintained in the department's web-based waiting list management system and upon request, shall be provided a copy by the county board.

(2) The county board shall place an individual's name on the waiting list for home and community-based services when, based on assessment of the individual using the waiting list assessment tool, the individual:

(a) Has been determined to have a condition that is:

(i) Attributable to a mental or physical impairment or combination of mental and physical impairments, other than an impairment caused solely by mental illness;

(ii) Manifested before the individual is age twenty-two; and

(iii) Likely to continue indefinitely; and

(b) Has a current need which cannot be met by community-based alternative services in the county where the individual resides (including a situation in which an individual has a current need despite the individual's enrollment in a home and community-based services waiver).

(3) The county board shall not place an individual's name on the waiting list for home and community-based services when the individual:

(a) Is a child who is subject to a determination under section 121.38 of the Revised Code and requires home and community-based services; or

(b) Has an immediate need, in which case the county board shall take action necessary to ensure the immediate need is met. The county board shall provide the individual or the individual's guardian, as applicable, with the option of having the individual's needs met in an intermediate care facility for individuals with intellectual disabilities or through community-based alternative services. Once an individual or individual's guardian chooses the setting in which he or she prefers to receive services, the county board shall take action to ensure the individual's immediate need is met, including by enrollment in a home and community-based services waiver, if necessary. Such action may also include assisting the individual or the individual's guardian, as applicable, in identifying and accessing alternative services that are available to meet the individual's needs.

(4) When a county board places an individual's name on the waiting list for home and community-based services, the county board shall:

(a) Record, in the department's web-based waiting list management system:

(i) The individual's status date; and

(ii) For an individual included in the transitional list of individuals waiting for home and community-based services defined in paragraph (B) (17) of this rule, the individual's date of request.

(b) Notify the individual or the individual's guardian, as applicable, that the individual's name has been placed on the waiting list for home and community-based services.

(c) Provide contact information to the individual or the individual's guardian, as applicable, for a person at the county board who can assist in identifying and accessing alternative services that address, to the extent possible, the individual's needs.

(5) Annually, a county board shall:

(a) Review the waiting list assessment tool and service needs of each individual whose name is included on the waiting list for home and community-based services with the individual and the individual's guardian, as applicable; and

(b) Assist the individual or the individual's guardian, as applicable, in identifying and accessing alternative services.

(6) Under any circumstances, when a county board determines an individual's status has changed with regard to having an immediate need and/or having a current need or an individual's status date has changed, the county board shall update the individual's record in the department's web-based waiting list management system.

(E) Order for enrolling individuals in locally-funded home and community-based services waivers

(1) Individuals shall be selected for enrollment in locally-funded home and community-based services waivers in this order:

(a) Individuals with immediate need who require waiver funding to address the immediate need.

(b) Individuals who have met multiple criteria for current need for twelve or more consecutive months and who were not offered enrollment in a home and community-based services waiver in the prior calendar year. When two or more individuals meet the same number of criteria for current need, the individual with the earliest of either the status date or date of request shall be selected for enrollment.

(c) Individuals who have met multiple criteria for current need for less than twelve consecutive months. When two or more individuals meet the same number of criteria for current need, the individual with the earliest of either the status date or date of request shall be selected for enrollment.

(d) Individuals who meet a single criterion for current need. When two or more individuals meet a single criterion for current need, the individual with the earliest of either the status date or date of request shall be selected for enrollment.

(2) Individuals with immediate need and individuals with current need may be enrolled in locally-funded home and community-based services waivers concurrently.

(3) Meeting the criteria for immediate need and/or current need does not guarantee enrollment in a locally-funded home and community-based services waiver within a specific timeframe.

(4) When an individual is identified as next to be enrolled in a locally-funded home and community-based services waiver, the county board shall determine the individual's eligibility for enrollment in a home and community-based services waiver. When the county board determines an individual is eligible for enrollment in a home and community-based services waiver, the county board shall determine which type of locally-funded home and community-based services waiver is sufficient to meet the individual's needs in the most cost-effective manner.

(F) Order for enrolling individuals in state-funded home and community-based services waivers

(1) The department shall determine the order for enrolling individuals in state-funded home and community-based services waivers.

(2) Meeting the criteria for immediate need and/or current need does not guarantee enrollment in a state-funded home and community-based services waiver within a specific timeframe.

(G) Change in an individual's county of residence

When an individual on the waiting list for home and community-based services moves from one county to another and the individual or the individual's guardian, as applicable, notifies the receiving county board, the receiving county board shall within ninety calendar days of receiving notice, review the individual's waiting list assessment tool.

(1) When the receiving county board determines that the individual has a current need which cannot be met by community-based alternative services in the receiving county (including a situation in which an individual has a current need despite the individual's enrollment in a home and community-based services waiver), the receiving county board shall update the individual's county of residence in the department's web-based waiting list management system without changing the status date or date of request assigned by the previous county board.

(2) When the receiving county board determines that the individual has a current need which can be met by community-based alternative services in the receiving county, the receiving county board shall assist the individual or the individual's guardian, as applicable, in identifying and accessing those services.

(H) Removal from waiting list for home and community-based services

A county board shall remove an individual's name from the waiting list for home and community-based services:

(1) When the county board determines that the individual no longer has a condition described in paragraph (D)(2)(a) of this rule;

(2) When the county board determines that the individual no longer has a current need;

(3) Upon request of the individual or the individual's guardian, as applicable;

(4) Upon enrollment of the individual in a home and community-based services waiver that meets the individual's needs;

(5) If the individual or the individual's guardian, as applicable, declines enrollment in a home and community-based services waiver or community-based alternative services that are sufficient to meet the individual's needs;

(6) If the individual or the individual's guardian, as applicable, fails to respond to attempts by the county board to contact the individual or the individual's guardian by at least two different methods, one of which shall be certified mail to the last known address of the individual or the individual's guardian, as applicable;

(7) When the county board determines the individual does not have a developmental disabilities level of care in accordance with rule 5123:2-8-01 of the Administrative Code;

(8) When the individual is no longer a resident of Ohio; or

(9) Upon the individual's death.

(I) Advancement from transitional list of individuals waiting for home and community-based services to waiting list for home and community-based services

(1) The department shall maintain the transitional list of individuals waiting for home and community-based services as defined in paragraph (B)(17) of this rule until December 31, 2020.

(2) A county board shall administer the waiting list assessment tool to each individual residing in the county whose name is included on the transitional list of individuals waiting for home and community-based services.

(a) The county board shall administer the waiting list assessment tool to each individual residing in the county whose name is included on the transitional list of individuals waiting for home and community-based services who receives service and support administration when the individual service plan is next scheduled for review following the effective date of this rule.

(b) The county board shall administer the waiting list assessment tool to each individual residing in the county whose name is included on the transitional list of individuals waiting for home and community-based services who does not receive service and support administration no later than December 31, 2020. A county board may request and the department may provide assistance to identify, locate, contact, or administer the waiting list assessment tool to individuals residing in the county but unknown to the county board.

(c) There are three possible outcomes of administration of the waiting list assessment tool:

(i) The county board determines the individual has an immediate need, in which case the individual shall receive services in accordance with paragraph (D)(3)(b) of this rule;

(ii) The county board determines the individual has a current need, in which case the county board shall use community-based alternative services in the county to meet the individual's needs or if the individual's needs cannot be met by community-based alternative services in the county, the county board shall add the individual's name to the waiting list for home and community-based services; or

(iii) The county board determines the individual has neither an immediate need nor a current need.

(d) Once the waiting list assessment tool has been administered to an individual whose name is included on the transitional list of individuals waiting for home and community-based services and a determination made, the county board shall notify the department and the department shall remove the individual's name from the transitional list of individuals waiting for home and community-based services.

(3) The county board or the department shall attempt to contact each individual whose name is included on the transitional list of individuals waiting for home and community-based services or the individual's guardian, as applicable, by at least two different methods, one of which shall be certified mail to the last known address of the individual or the individual's guardian, as applicable. The department shall remove an individual's name from the transitional list of individuals waiting for home and community-based services when the individual or the individual's guardian, as applicable:

(a) Fails to respond to attempts by the county board or the department to establish contact; or

(b) Declines an assessment of the individual using the waiting list assessment tool.

(J) Due process

(1) Due process shall be afforded to an individual aggrieved by an action of a county board related to:

(a) The approval, denial, withholding, reduction, suspension, or termination of a service funded by the state medicaid program;

(b) Placement on, denial of placement on, or removal from the waiting list for home and community-based services or the transitional list of individuals waiting for home and community-based services; or

(c) A dispute regarding an individual's date of request or status date.

(2) Due process shall be provided in accordance with section 5160.31 of the Revised Code and Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

Replaces: 5123:2-1-08

Click to view Appendix

Effective: 9/1/2018
Five Year Review (FYR) Dates: 09/01/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5126.042
Rule Amplifies: 5123.04, 5126.042 , 5126.044, 5126.054, 5126.055
Prior Effective Dates: 07/01/1976, 12/11/1983, 07/01/1991 (Emer.), 09/13/1991, 04/22/1993, 06/02/1995 (Emer.), 12/09/1995, 02/28/1996 (Emer.), 05/18/1996, 05/28/1996, 07/12/1997, 08/01/2001, 01/02/2002 (Emer.), 03/21/2002, 12/01/2011, 01/01/2016

5123-9-05 Management of an individual's personal funds by a developmental center.

(A) Purpose

The purpose of this rule is to establish the procedures that a developmental center shall follow when it manages an individual's personal funds.

(B) Definitions

(1) "Earned income" means salary, wages, royalties, honoraria, or net earnings from self-employment as defined in rule 5101:1-39-15 of the Administrative Code. When an individual receives remuneration for services performed in a sheltered workshop, rule 5101:1-39-14.4 of the Administrative Code shall be followed in determining whether that remuneration is earned income or unearned income.

(2) "Individual" means an individual admitted to a developmental center who is enrolled in the intermediate care facility for the mentally retarded program.

(3) "Monthly personal needs allowance" means the amount of earned income and unearned income an individual may retain each month in accordance with paragraph (D) of this rule.

(4) "Personal needs account" has the same meaning as a personal needs allowance account in rule 5101:3-3-16.9 of the Administrative Code.

(5) "Personal needs allowance" has the same meaning as in rule 5101:1-39-24 of the Administrative Code.

(6) "Unearned income" means all income that is not earned income including, but not limited to, social security disability benefits, supplemental security income, and other public benefits an individual receives.

(C) Management of personal funds

(1) A developmental center shall permit an individual to manage his or her financial affairs and teach an individual to do so to the extent of the individual's abilities.

(2) A developmental center shall manage an individual's personal funds if the individual or the individual's guardian makes a written request for such assistance to the developmental center. In the absence of such request, the individual or his or her legal guardian or other authorized representative is responsible for managing the individual's personal funds and ensuring that the funds are used to meet the individual's needs.

(D) Monthly personal needs allowance

(1) Each individual shall retain a portion of his or her monthly income as a monthly personal needs allowance. An individual's monthly personal needs allowance shall be determined in accordance with paragraph (D)(2) of this rule. The remainder of an individual's monthly income shall be applied to the individual's medicaid cost of care in accordance with rule 5101:1-39-24 of the Administrative Code. An individual who does not have monthly income is not eligible to receive a personal needs allowance.

(2) The monthly personal needs allowance of an individual shall be calculated as follows:

(a) An individual who has only unearned income shall receive a personal needs allowance of up to forty dollars of his or her unearned income per month.

(b) An individual who has only earned income shall receive a personal needs allowance of up to sixty-five dollars of his or her gross earnings per month.

(c) An individual who has both unearned income and earned income shall receive a personal needs allowance of up to a combined maximum of one hundred five dollars per month (i.e., forty dollars in unearned income and sixty-five dollars in earned income).

(E) Management of individual's monthly personal needs allowance

(1) A developmental center shall deposit an individual's monthly personal needs allowance into a personal needs account.

(2) An individual's personal needs account is the exclusive property of the individual, who may use the funds in the account as he or she chooses. Funds in the account may be used to purchase only those items and services requested by the individual, the individual's legal guardian, or other authorized representative.

(3) When an individual requests an item or service that may be purchased with funds from the individual's personal needs account, a developmental center shall inform the individual of the cost and the amount that will be withdrawn from his or her personal needs account to pay for the item or service.

(4) Items and services that may be purchased with funds from an individual's personal needs account include, but are not limited to:

(a) Telephone;

(b) Television or radio for personal use;

(c) Personal comfort items including smoking materials, notions, novelties, and confections;

(d) Cosmetics and grooming items and services in excess of those for which payment is made under the medicaid program;

(e) Personal reading material;

(f) Stationary or stamps;

(g) Personal clothing;

(h) Specialty laundry services such as dry cleaning, mending, or hand-washing;

(i) Flowers or plants;

(j) Gifts purchased on behalf of an individual;

(k) Non-covered special care services such as privately hired nurses or nurse aides;

(l) Social events or entertainment offered outside the scope of a developmental center's activities program;

(m) Private rooms, except when therapeutically required for infection control or similar reasons;

(n) Specially prepared or alternative food instead of food generally prepared by the developmental center other than special diets ordered by an individual's physician or that permit an individual to continue with his or her established dietary habits required for good cause;

(o) Irrevocable burial accounts;

(p) Funerals; and

(q) Burial plots.

(5) Irrevocable burial accounts, pre-need funeral contracts, and burial plots are excludable as a countable resource if they meet the requirements of rules 5101:1-39-27.4 and 5101:1-39-32.2 of the Administrative Code.

(6) A developmental center may not charge an individual's personal needs account for items and services that the developmental center is required to furnish in order to participate in the medicaid program, and that are included in medicaid payments made to the developmental center.

(7) Items and services that may not be purchased with funds from an individual's personal needs account include, but are not limited to:

(a) Nursing services;

(b) Dietary services;

(c) Activities programs;

(d) Room and bed maintenance services;

(e) Routine personal hygiene items and services required to meet the needs of the individual, including but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soap or specialized cleaning agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, deodorant, incontinence care supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over-the-counter drugs, hair and nail hygiene services, bathing, and basic personal laundry;

(f) Medically-related social services;

(g) Medical supplies such as irrigation trays, catheters, drainage bags, syringes, and needles;

(h) Durable medical equipment;

(i) Air conditioners or charges to an individual for the use of electricity;

(j) Therapy or podiatry services; and

(k) Charges for telephone consultation by physicians or other personnel.

(8) Funds in an individual's personal needs account that are not expended during the month shall be carried forward to the subsequent month and treated as a resource and are subject to resource requirements of Chapter 5101:1-39 of the Administrative Code.

(F) Safeguards to prevent misuse of individual's funds

(1) A developmental center shall establish and maintain a system that ensures full and complete accounting for an individual's funds.

(2) A developmental center shall not commingle the funds in an individual's personal needs account with the developmental center's funds or with the funds of any person other than another individual.

(3) A developmental center shall provide an individual with access to petty cash (less than fifty dollars) on an ongoing basis and arrange for an individual to access a larger amount of funds (fifty dollars or more) as necessary. The developmental center shall document each transaction involving an individual and his or her personal needs account. The developmental center shall maintain receipts for all purchases over fifty dollars for a single item purchased by the individual unless otherwise specified in the individual's plan and for all purchases the developmental center makes on behalf of the individual. The receipt shall identify the item(s) purchased, the date, and the amount of the expenditure. The developmental center shall obtain other proof of purchase if a receipt is unavailable. If other proof of purchase is unavailable, the developmental center shall provide written verification of the amount of funds given to the individual or expended on his or her behalf and what was purchased with the funds.

(4) A developmental center shall maintain a detailed ledger account of revenue and expenses for each personal needs account managed by the developmental center. The ledger account shall:

(a) Specify all funds received by or deposited with the developmental center;

(b) Specify the dates and reasons for all expenditures;

(c) Specify at all times the balance due the individual; and (d) Be available to the individual or the individual's legal guardian or other authorized representative for review.

(5) Upon request, a developmental center shall furnish receipts to an individual or the individual's legal guardian or other authorized representative in accordance with paragraph (F)(3) of this rule for purchases made with funds from the individual's personal needs account.

(6) Within thirty days after the end of the quarter, a developmental center shall make available upon request a written quarterly statement to each individual, the individual's legal guardian, or other authorized representative, of all financial transactions made by the developmental center on the individual's behalf.

(G) Notice to individual of when balance of funds may affect medicaid eligibility

(1) A developmental center shall give written notification to each individual whose personal funds are managed by the developmental center, the individual's legal guardian, or other authorized representative, when the amount of funds in the individual's personal needs account reaches two hundred dollars less than the resource limits set forth in rules 5101:1-39-05 and 5101:1-39-01.1 of the Administrative Code.

(2) The notice shall inform the individual that he or she may lose medicaid eligibility if the funds in the individual's personal needs account, in addition to the value of the individual's other nonexempt resources, reaches the individual's resource limit amount.

(3) The developmental center shall retain a copy of the notice in the individual's file.

(H) Notice to county department of job and family services

A developmental center shall report to the county department of job and family services any balance in an individual's personal needs allowance account that exceeds the individual's resource limit in accordance with paragraph (F)(2) of rule 5101:3-3-16.9 of the Administrative Code.

(I) Referral to county department of job and family services

If an individual is considering using funds in his or her personal needs account to purchase life insurance, grave space, a burial account, or other item that may be considered a countable resource, a developmental center shall refer the individual or the individual's legal guardian or other authorized representative to the county department of job and family services for an explanation of the effect the purchase may have on the individual's medicaid eligibility.

(J) Release of funds upon discharge or transfer

Within thirty days of discharge or transfer of an individual, a developmental center shall release to the individual, the individual's legal guardian, or other authorized representative, all of the funds in the individual's personal needs account, except for those funds that exceed the individual's resource limit, and a final itemized statement of the individual's personal needs account.

(K) Conveyance of funds upon death

Upon the death of an individual, a developmental center shall distribute any funds in the individual's personal needs account in accordance with section 5123.28 of the Revised Code.

(L) Review of rule

This rule shall be reviewed at least every five years to determine whether it should be continued without amendment, be amended, or be rescinded.

Replaces: 5123-9-05

Effective: 01/01/2011
Promulgated Under: 111.15
Statutory Authority: 5111.114, 5121.01 to 5121.21, 5123.04, 5123.06, 5123.28, 5123.95
Rule Amplifies: 5111.114, 5121.01 to 5121.21, 5123.04, 5123.06, 5123.28, 5123.95
Prior Effective Dates: 02/10/1979, 07/01/1980, 06/12/1981, 07/15/1983, 07/08/1985, 01/21/1991

5123-9-06 [Rescinded] Behavior modification/behavior management programs.

Effective: 07/17/2014
Promulgated Under: 111.15
Statutory Authority: 5123.04, 5123.86
Rule Amplifies: 5123.04, 5123.86
Prior Effective Dates: 05/15/1978, 07/01/1980, 03/20/1982, 02/18/1989, 06/15/1990

5123-9-07 [Rescinded] Operation of developmental center commissaries.

Effective: 07/27/2013
Promulgated Under: 111.15
Statutory Authority: 5123.04, 5123.29
Rule Amplifies: 5123.04, 5123.29
Prior Effective Dates: 07/01/1980, 10/09/1989

5123-9-08 Industrial and entertainment fund.

[This rule designated an internal management rule. For a copy of this rule, contact the Ohio Legislative Service Commission.]

5123-9-09 Department clearinghouse. [Rescinded].

Rescinded eff 8-7-95

5123-9-22 Home and community-based services waivers - community respite under the individual options, level one, and selfempowered life funding waivers.

(A) Purpose

This rule defines community respite and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(2) "Community respite" means services provided to an individual unable to care for himself or herself furnished on a short-term basis because of the absence or need for relief of those persons routinely providing the care. 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.

(3) "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.

(4) "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.

(5) "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.

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

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

(8) "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.

(9) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code.

(10) "Independent provider" means a self-employed person who provides services for which he or she must be certified in accordance with 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 service plan" means the written description of services, supports, and activities to be provided to an individual.

(13) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(14) "Money management" has the same meaning as in rule 5123:2-9-20 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) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123:2-9-32 of the Administrative Code.

(17) "Remote monitoring" has the same meaning as in rule 5123:2-9-35 of the Administrative Code.

(18) "Residential respite" has the same meaning as in rule 5123-9-34 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 paragraph (E) of this rule to validate payment for medicaid services.

(20) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

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

(22) "Waiver nursing services" has the same meaning as in rule 5123:2-9-39 of the Administrative Code.

(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 website (http://dodd.ohio.gov).

(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) and 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 rule 5123:2-1-11 of the Administrative Code.

(2) The individual service plan shall address 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 participant-directed homemaker/personal care 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 are 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 shall be adjusted by the behavioral support rate modification to reflect the needs of an individual requiring behavioral support upon determination by the department that the individual meets the criteria set forth in paragraph (F)(3)(a) of this rule.

(a) The department shall determine that an individual meets the criteria for the behavioral support rate modification when:

(i) 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

(ii) A behavioral support strategy that is a component of the individual service plan has been developed in accordance with the requirements in rules established by the department; and

(iii) The individual either:

(a) Has a response of "yes" to at least four items in question thirty- two of the behavioral domain of the Ohio developmental disabilities profile; or

(b) Requires a structured environment that, if removed, will result in the individual's engagement in behavior destructive to self or others.

(b) The duration of the behavioral support rate modification 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.

(c) The purpose of the behavioral support rate modification is to provide funding for the implementation of behavioral support strategies by staff who have the level of training necessary to implement the strategies; the department retains the right to verify that staff who implement behavioral support strategies have received training (e.g., specialized training recommended by clinicians or the team or training regarding an individual's behavioral support strategy) that is adequate to meet the needs of the individuals served.

(4) Payment rates for community respite shall be adjusted by the medical assistance rate modification to reflect the needs of an individual requiring medical assistance upon determination by the county board that the individual meets the criteria set forth in paragraph (F)(4)(a) of this rule.

(a) The county board shall determine that an individual meets the criteria for the medical assistance rate modification when:

(i) The individual requires routine feeding and/or the administration of prescribed medication through gastrostomy or jejunostomy tube, and/or requires the administration of routine doses of insulin through subcutaneous injection or insulin pump; or

(ii) The 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) The 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 prescribed medication or topical prescribed medication or a health-related activity as defined in rule 5123:2-6-01 of the Administrative Code.

(b) The duration of the medical assistance rate modification 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.

(5) Community respite provided to individuals enrolled in the individual options waiver is subject to the funding ranges and individual funding levels set forth in rule 5123:2-9-06 of the Administrative Code.

(6) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, money management, participant-directed homemaker/ personal care, residential respite, and transportation, alone or in combination, shall not exceed five thousand three hundred twenty-five dollars per waiver eligibility span.

(7) Payment for community respite shall not include payment for room and board or transportation.

Replaces: 5123:2-9-22

Click to view Appendix

Click to view Appendix

Effective: 7/5/2018
Five Year Review (FYR) Dates: 07/05/2023
Promulgated Under: 119.03
Statutory Authority: 5123.1611, 5123.049, 5123.04
Rule Amplifies: 5123.049, 5123.045, 5123.04 , 5166.21, 5123.1611, 5123.161 , 5123.16
Prior Effective Dates: 07/15/2011, 07/01/2012, 09/01/2013, 01/01/2016, 04/01/2017

5123-9-25 Home and community-based services waivers - specialized medical equipment and supplies under the individual options and level one waivers.

(A) Purpose

This rule defines specialized medical equipment and supplies and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(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 in accordance with 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 5123-9-26 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 shall 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 waiver 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 waiver 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 pursuant to 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 website (http://dodd.ohio.gov).

(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 attending to service 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 rule 5123:2-1-11 of the Administrative Code.

(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.

Replaces: 5123:2-9-25

Click to view Appendix

Effective: 6/1/2018
Five Year Review (FYR) Dates: 06/01/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16 , 5123.161 , 5123.1611 , 5166.21
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012, 09/01/2013

5123-9-26 Home and community-based services waivers - personal emergency response systems under the level one waiver.

(A) Purpose

This rule defines personal emergency response systems and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(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 in accordance with 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 5123-9-25 of the Administrative Code.

(14) "Three-year period" means the three-year period beginning with the individual's initial waiver 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 waiver 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 pursuant to 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 website (http://dodd.ohio.gov).

(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 rule 5123:2-1-11 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.

Replaces: 5123:2-9-26

Click to view Appendix

Effective: 6/1/2018
Five Year Review (FYR) Dates: 06/01/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16 , 5123.161 , 5123.1611 , 5166.21
Prior Effective Dates: 04/28/2003, 07/01/2006, 03/19/2012, 09/01/2013

5123-9-30 Home and community-based services waivers - homemaker/ personal care under the individual options and level one waivers.

(A) Purpose

This rule defines homemaker/personal care and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(3) "Community respite" has the same meaning as in rule 5123-9-22 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 for individuals with intellectual disabilities.

(7) "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.

(8) "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.

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

(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 to ensure the health and welfare of an individual who lives in the community. Homemaker/personal care advances the individual's independence within his or her home and community and helps the individual meet daily living needs. Examples of supports that may be provided as homemaker/personal care include:

(a) Self-advocacy training to assist in the expression of personal preferences, self-representation, self-protection from and reporting of abuse, neglect, and exploitation, asserting individual rights, and making increasingly responsible choices.

(b) Self-direction, including the identification of and response to dangerous or threatening situations, making decisions and choices affecting the individual's life, and initiating changes in living arrangements and life activities.

(c) Daily living skills including training in and providing assistance with routine household tasks, meal preparation, personal care, self-administration of medication, and other areas of day-to-day living including proper use of adaptive and assistive devices, appliances, home safety, first aid, and communication skills such as using the telephone.

(d) Implementation of recommended therapeutic interventions under the direction of a professional or extension of therapeutic services, which consist of reinforcing physical, occupational, speech, and other therapeutic programs for the purpose of increasing the overall effective functioning of the individual.

(e) Behavioral support strategies including training and assistance in appropriate expressions of emotions or desires, assertiveness, acquisition of socially-appropriate behaviors, or extension of therapeutic services for the purpose of increasing the overall effective functioning of the individual.

(f) Medical and health care services that are integral to meeting the daily needs of the individual such as routine administration of medication or tending to the needs of individuals who are ill or require attention to their medical needs on an ongoing basis.

(g) Emergency response training including development of responses in case of emergencies, prevention planning, and training in the use of equipment or technologies used to access emergency response systems.

(h) Community access services that explore community services available to all people, natural supports available to the individual, and develop methods to access additional services, supports, and activities needed by the individual to be integrated in and have full access to the community.

(i) When provided in conjunction with other components of homemaker/ personal care, assistance with personal finances which may include training, planning, and decision-making regarding the individual's personal finances.

(12) "Independent provider" means a self-employed person who provides services for which he or she must be certified in accordance with 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 employment support" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

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

(16) "Informal respite" has the same meaning as in rule 5123:2-9-21 of the Administrative Code.

(17) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.

(18) "Money management" has the same meaning as in rule 5123:2-9-20 of the Administrative Code.

(19) "Non-medical transportation" has the same meaning as in rule 5123:2-9-18 of the Administrative Code.

(20) "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.

(21) "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.

(22) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123:2-9-32 of the Administrative Code.

(23) "Residential respite" has the same meaning as in rule 5123-9-34 of the Administrative Code.

(24) "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.

(25) "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.

(26) "Shared living" has the same meaning as in rule 5123:2-9-33 of the Administrative Code.

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

(28) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

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

(30) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver 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.

(3) An applicant seeking approval to provide homemaker/personal care shall complete and submit an application through the department's website (http://dodd.ohio.gov).

(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 or approved 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 direct services staff member of an agency provider shall successfully complete on-the-job training specific to each individual he or she serves that includes:

(a) What is important to the individual and what is important for the individual;and

(b) The individual's support needs including, as applicable, behavioral support strategy, management of the individual's funds, and medication administration/delegated nursing.

(6) Each independent provider and each direct services staff member of an agency provider 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 direct services staff member relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The role and responsibilities of the independent provider or direct services staff member with regard to services including person-centered planning, community integration, self-determination, and self-advocacy.

(ii) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(iii) 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.

(iv) The requirements relative to the independent provider's or direct services staff member's role in providing behavioral 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 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.

(7) 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.

(8) 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) A provider of homemaker/personal care shall not also provide money management or shared living to the same individual.

(3) Homemaker/personal care shall not be provided to an individual at the same time as residential respite.

(4) Homemaker/personal care services may extend to those times when the individual is not physically present and the provider is performing homemaker activities on behalf of the individual.

(5) 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, group employment support, individual employment support, or vocational habilitation.

(6) A provider shall not bill for homemaker/personal care provided by the driver during the same time non-medical transportation is provided.

(7) An agency provider shall develop and implement a documented process by which it reviews and manages overtime of staff members who provide homemaker/ personal care in a manner that ensures the health and safety of individuals served and staff members and considers the specific needs of individuals served, the abilities of staff members, and patterns of overtime with the goal of reducing overtime.

(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) Times the delivered service started and stopped.

(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 are 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 by agency providers.

(3) Payment rates for homemaker/personal care shall be adjusted to reflect the number of individuals being served and the number of people providing services.

(a) When two individuals are being served by one person, the base rate shall be one hundred seven per cent of the base rate for one-to-one service. When three individuals are being served by one person, the base rate shall be one hundred seventeen per cent of the base rate for one-to-one service. When four or more individuals are being served by one person, the base rate shall be one hundred thirty per cent of the base rate for one-to-one service.

(b) The base rate is divided by the number of individuals being served to determine the rate apportioned to each individual.

(c) When multiple staff members of an agency provider simultaneously provide services to more than one individual, the payment rate is adjusted to reflect the average staff-to-individual ratio at which services are provided. The calculation of rates apportioned to each individual when multiple staff members simultaneously provide services to more than one individual are contained in the "Application of Appendix A to Rule 5123-9-30" (July 1, 2018), which is available at the department's website (http://dodd.ohio.gov).

(4) Payment rates for routine homemaker/personal care shall be adjusted by the behavioral support rate modification to reflect the needs of an individual requiring behavioral support upon determination by the department that the individual meets the criteria set forth in paragraph (F)(4)(a) of this rule. The amount of the behavioral support rate modification applied to each fifteen-minute billing unit of service is contained in appendix A to this rule.

(a) The department shall determine that an individual meets the criteria for the behavioral support rate modification when:

(i) 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

(ii) A behavioral support strategy that is a component of the individual service plan has been developed in accordance with the requirements in rules established by the department; and

(iii) The individual either:

(a) Has a response of "yes" to at least four items in question thirty- two of the behavioral domain of the Ohio developmental disabilities profile; or

(b) Requires a structured environment that, if removed, will result in the individual's engagement in behavior destructive to self or others.

(b) The duration of the behavioral support rate modification 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.

(c) The purpose of the behavioral support rate modification is to provide funding for the implementation of behavioral support strategies by staff who have the level of training necessary to implement the strategies; the department retains the right to verify that staff who implement behavioral support strategies have received training (e.g., specialized training recommended by clinicians or the team or training regarding an individual's behavioral support strategy) that is adequate to meet the needs of the individuals served.

(5) Payment rates for routine homemaker/personal care provided to individuals enrolled in the individual options waiver shall be adjusted by the complex care rate modification to reflect the needs of an individual requiring total support from others upon determination by the county board that the individual meets the criteria set forth in paragraph (F)(5)(a) of this rule. The amount of the complex care rate modification applied to each fifteen-minute billing unit of service is contained in appendix A to this rule.

(a) The county board shall determine that an individual meets the criteria for the complex care rate modification based on the individual's responses to specific questions on the Ohio developmental disabilities profile that indicate that the individual:

(i) Must be transferred and moved; and

(ii) Cannot walk, roll from back to stomach, or pull himself or herself to a standing position; and

(iii) Requires total support in toileting, taking a shower or bath, dressing/ undressing, and eating.

(b) The duration of the complex care rate modification 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.

(6) Payment rates for routine homemaker/personal care shall be adjusted by the medical assistance rate modification to reflect the needs of an individual requiring medical assistance upon determination by the county board that the individual meets the criteria set forth in paragraph (F)(6)(a) of this rule. The amount of the medical assistance rate modification applied to each fifteen-minute billing unit of service is contained in appendix A to this rule.

(a) The county board shall determine that an individual meets the criteria for the medical assistance rate modification when:

(i) The individual requires routine feeding and/or the administration of prescribed medication through gastrostomy or jejunostomy tube, and/or requires the administration of routine doses of insulin through subcutaneous injection or insulin pump; or

(ii) The 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) The 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 prescribed medication or topical prescribed medication or a health-related activity as defined in rule 5123:2-6-01 of the Administrative Code.

(b) The duration of the medical assistance rate modification 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.

(7) Payment rates for routine homemaker/personal care shall be adjusted by the staff competency rate modification when homemaker/personal care is provided by independent providers or staff of agency providers who meet the criteria set forth in paragraph (F)(7)(a) of this rule and as determined in accordance with, as applicable, paragraph (F)(7)(b) or (F)(7)(c) of this rule. The amount of the staff competency rate modification applied to each fifteen-minute billing unit of service is contained in appendix A to this rule.

(a) An independent provider or a staff member of an agency provider shall be determined eligible for the staff competency rate modification when he or she:

(i) Has successfully completed at least two years of full-time (or equivalent part-time) paid work experience providing direct services to individuals; and

(ii) Either:

(a) Holds a "Professional Advancement Through Training and Education in Human Services" or "DSPaths" certificate of initial proficiency or certificate of advanced proficiency; or

(b) Within the past five years has successfully completed at least sixty hours of competency-based training. For purposes of this paragraph, "competency-based training" means online or in-person training in topics not otherwise required by rule 5123:2-2-01, rule 5123:2-17-02, Chapter 5123:2-3, Chapter 5123:2-9, or Chapter 5123-9 of the Administrative Code that:

(i) Is accredited by the "National Alliance for Direct Support Professionals" and offered through "Relias" or "DirectCourse College of Direct Support";

(ii) Requires the learner to demonstrate proficiency via testing or portfolio development; and

(iii) Offers proof of successful completion that is available for print, download, or issue to the learner that includes the name of the learner, the course title, the completion date, and the number of hours of training completed.

(b) Eligibility for the staff competency rate modification for an independent provider shall be determined by the department when documentation submitted by the independent provider through the department's website (http://dodd.ohio.gov) demonstrates that the independent provider meets the criteria set forth in paragraph (F)(7)(a) of this rule.

(c) Eligibility for the staff competency rate modification for a staff member of an agency provider shall be determined by the employing agency provider. The employing agency provider shall review, verify, and maintain documentation that demonstrates that the staff member meets the criteria set forth in paragraph (F)(7)(a) of this rule.

(d) The cost of a staff competency rate modification is excluded from an individual's waiver budget limitation.

(8) 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.

(9) 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 for individuals with intellectual disabilities when the following conditions are met:

(a) The individual was a resident of an intermediate care facility for individuals with intellectual disabilities 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 for individuals with developmental disabilities 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.

(10) The amount of the payment rate modifications set forth in paragraphs (F)(8) and (F)(9) 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.

(11) 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:

(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 beginning and ending times during which supervision or supports were provided to the individual.

(d) The payment rate modifications set forth in paragraphs (F)(4), (F)(5), (F) (6), (F)(7), (F)(8), and (F)(9) of this rule are not applicable to the on-site/ on-call payment rates for homemaker/personal care.

(12) Payment for homemaker/personal care shall not include room and board, items of comfort and convenience, or costs for the maintenance, upkeep, and improvement of the home.

(13) Under the level one waiver, payment for community respite, homemaker/ personal care, informal respite, money management, participant-directed homemaker/personal care, residential respite, and transportation, alone or in combination, shall not exceed five thousand three hundred twenty-five dollars per waiver eligibility span.

Replaces: 5123:2-9-30

Click to view Appendix

Click to view Appendix

Effective: 7/5/2018
Five Year Review (FYR) Dates: 07/05/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.049, 5123.16 , 5123.161 , 5123.1611 , 5166.21, 5123.04, 5123.045
Prior Effective Dates: 07/24/1995, 04/28/2003, 07/01/2005, 04/20/2006, 07/01/2006, 07/01/2007, 12/21/2007 (Emer.), 03/20/2008, 07/01/2010, 04/19/2012, 09/01/2013, 01/01/2014, 07/01/2014, 01/01/2016, 04/01/2017, 09/01/2017, 02/15/2018

5123-9-34 Home and community-based services waivers - residential respite under the individual options, level one, and selfempowered life funding waivers.

(A) Purpose

This rule defines residential respite and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(2) "Community respite" has the same meaning as in rule 5123-9-22 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 5123-9-30 of the Administrative Code.

(6) "Independent provider" means a self-employed person who provides services for which he or she must be certified in accordance with 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) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.

(11) "Money management" has the same meaning as in rule 5123:2-9-20 of the Administrative Code.

(12) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123:2-9-32 of the Administrative Code.

(13) "Residential respite" means services provided to an individual unable to care for himself or herself furnished on a short-term basis because of the absence or need for relief of those persons routinely providing care. Residential respite shall only be provided in:

(a) An intermediate care facility for individuals with intellectual disabilities;

(b) A residential facility licensed by the department pursuant to section 5123.19 of the Revised Code; or

(c) A residence, other than an intermediate care facility for individuals with intellectual disabilities or a residential facility licensed by the department pursuant to section 5123.19 of the Revised Code, where residential respite is provided by an agency provider.

(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) "Transportation" has the same meaning as in rule 5123:2-9-24 of the Administrative Code.

(16) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver 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 for individuals with intellectual disabilities;

(b) A residential facility licensed by the department pursuant to 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 website (http://dodd.ohio.gov).

(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 rule 5123:2-1-11 of the Administrative Code.

(2) The individual service plan shall address emergency and replacement coverage should the individual unexpectedly need to leave the residential respite service delivery location.

(3) Residential respite may be provided at a residence other than an intermediate care facility for individuals with intellectual disabilities or a residential facility licensed by the department pursuant to section 5123.19 of the Revised Code only when:

(a) Each individual who receives homemaker/personal care or participant- directed homemaker/personal care and permanently resides at the residence consents to the provision of residential respite at the residence; and

(b) The total number of persons with developmental disabilities being served at the residence does not exceed four.

(4) Residential respite is limited to ninety calendar days of service per waiver eligibility span.

(5) Residential respite shall not be provided to an individual at the same time as homemaker/personal care or participant-directed homemaker/personal care.

(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 rule 5123:2-9-06 of the Administrative Code.

(4) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, money management, participant-directed homemaker/ personal care, residential respite, and transportation, alone or in combination, shall not exceed five thousand three hundred twenty-five dollars per waiver eligibility span.

(5) Payment for residential respite shall not include payment for room and board or transportation.

Replaces: 5123:2-9-34

Click to view Appendix

Effective: 7/5/2018
Five Year Review (FYR) Dates: 07/05/2023
Promulgated Under: 119.03
Statutory Authority: 5123.1611, 5123.049, 5123.04
Rule Amplifies: 5123.04 , 5166.21, 5123.1611, 5123.161 , 5123.16 , 5123.049, 5123.045
Prior Effective Dates: 07/15/2011, 07/01/2012, 09/01/2013, 01/01/2016, 04/01/2017

5123-9-40 Home and community-based services waivers-administration of the self-empowered life funding waiver.

(A) Purpose

This rule implements the self-empowered life funding 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. 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 no longer eligible for educational services based on his or her graduation, receipt of a diploma or equivalency certificate, or permanent discontinuation of educational services within parameters established by the Ohio department of education.

(2) "Agency with choice" means a service arrangement in which an agency provider acts as a co-employer with an individual. Under this arrangement, the individual 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 eligible for educational services.

(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. The agency with choice or a financial management services entity conducts all necessary payroll functions and is legally responsible for 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 with holdings. 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" has the same meaning as in section 5123.01 of the Revised Code.

(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 may designate another person to assist 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 (H) 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 and holds a valid medicaid provider agreement with the Ohio department of medicaid.

(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) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver 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

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 type, amount, scope, and duration of services and any applicable benefit package limitations.

(E) Criteria for enrolling in the self-empowered life funding waiver

To be enrolled in the self-empowered life funding waiver:

(1) The individual must meet the eligibility criteria for enrollment in home and community-based services waivers set forth in rule 5123:2-9-01 of the Administrative Code;

(2) 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

(3) 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 (H)(1) or (H)(2) of this rule, for at least one service the individual receives under the waiver.

(F) Self-empowered life funding waiver enrollment, continued enrollment, and disenrollment

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:

(1) All services available under the self-empowered life funding waiver, as delineated in paragraph (G) of this rule, and any choices that the individual may make regarding those services;

(2) Any feasible alternative to the waiver; and

(3) The right to choose either institutional care or home and community-based services.

(G) Self-empowered life funding waiver benefit package

The self-empowered life funding waiver benefit package is comprised of:

(1) Adult day support in accordance with rule 5123:2-9-17 of the Administrative Code;

(2) Career planning in accordance with rule 5123:2-9-13 of the Administrative Code;

(3) Clinical/therapeutic intervention in accordance with rule 5123-9-41 of the Administrative Code;

(4) Community respite in accordance with rule 5123-9-22 of the Administrative Code;

(5) Functional behavioral assessment in accordance with rule 5123-9-43 of the Administrative Code;

(6) Group employment support in accordance with rule 5123:2-9-16 of the Administrative Code;

(7) Individual employment support in accordance with rule 5123:2-9-15 of the Administrative Code;

(8) Non-medical transportation in accordance with rule 5123:2-9-18 of the Administrative Code;

(9) Participant-directed goods and services in accordance with rule 5123-9-45 of the Administrative Code;

(10) Participant-directed homemaker/personal care in accordance with rule 5123:2-9-32 of the Administrative Code;

(11) Participant/family stability assistance in accordance with rule 5123-9-46 of the Administrative Code;

(12) Remote monitoring in accordance with rule 5123:2-9-35 of the Administrative Code;

(13) Remote monitoring equipment in accordance with rule 5123:2-9-35 of the Administrative Code;

(14) Residential respite in accordance with rule 5123-9-34 of the Administrative Code;

(15) Support brokerage in accordance with rule 5123-9-47 of the Administrative Code;

(16) Transportation in accordance with rule 5123:2-9-24 of the Administrative Code;

(17) Vocational habilitation in accordance with rule 5123:2-9-14 of the Administrative Code; and

(18) Waiver nursing delegation in accordance with rule 5123:2-9-37 of the Administrative Code.

(H) 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 respite;

(c) Functional behavioral assessment;

(d) Participant-directed goods and services;

(e) Participant-directed homemaker/personal care;

(f) Participant/family stability assistance;

(g) Remote monitoring;

(h) Remote monitoring equipment;

(i) Residential respite; and

(j) Support brokerage.

(2) Individuals enrolled in the self-empowered life funding waiver may exercise employer authority for:

(a) Functional behavioral assessment;

(b) Participant-directed goods and services;

(c) Participant-directed homemaker/personal care;

(d) Participant/family stability assistance; and

(e) Support brokerage.

(3) Individuals enrolled in the self-empowered life funding waiver may not exercise budget authority or employment authority for:

(a) Adult day support;

(b) Career planning;

(c) Group employment support;

(d) Individual employment support;

(e) Non-medical transportation;

(f) Transportation;

(g) Vocational habilitation; or

(h) Waiver nursing delegation.

(I) 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 support brokerage shall not exceed eight thousand dollars per waiver eligibility span.

(b) 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 appendix B to rule 5123:2-9-19 of the Administrative Code apply to adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation provided under the self-empowered life funding waiver.

(J) 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 that meets the requirements set forth in rule 5123:2-1-11 of the Administrative Code.

(2) The individual service plan is subject to approval by the department and the Ohio department of medicaid pursuant to section 5166.21 of the Revised Code. 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 a county board to amend the individual service plan for an individual if the Ohio department of medicaid determines that such services are medically necessary and the procedures set forth in Chapter 5160-1 of the Administrative Code would not accommodate a request for such medically necessary services.

(K) 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 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.

(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 calendar 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.

(L) 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 calendar days after the service is provided. Payment shall be made in accordance with the requirements of rule 5160-1-19 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 5160-1-08 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 5160:1-6-07 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 medicaid, 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 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 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 rule 5160-1-25 of the Administrative Code.

(M) Due process rights and responsibilities

(1) An applicant for or recipient of self-empowered life funding waiver services may use the process set forth in section 5160.31 of the Revised Code and rules implementing that statute, for any purpose authorized by that statute. The process set forth in section 5160.31 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) An applicant for or recipient of self-empowered life funding waiver services shall use the process set forth in section 5160.31 of the Revised Code and rules implementing that statute for any challenge related to the type, amount, scope, or duration of services included in or excluded from an individual service plan.

(N) Ohio department of medicaid authority

The Ohio department of medicaid 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.

(O) Monitoring, compliance, and quality assurance

The Ohio department of medicaid shall conduct periodic monitoring and compliance reviews related to the self-empowered life funding waiver in accordance with Chapter 5166. 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. The financial management services entity under contract with the state, a self-empowered life funding waiver provider, the department, and a county board shall furnish to the Ohio department of medicaid, 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. An individual enrolled in the self-empowered life funding waiver shall cooperate with all monitoring, compliance, and quality assurance reviews conducted by the Ohio department of medicaid, the department, a county board, the centers for medicare and medicaid services, and the medicaid fraud control unit or their designees.

Replaces: 5123:2-9-40

Effective: 9/23/2018
Five Year Review (FYR) Dates: 09/23/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049
Rule Amplifies: 5123.04, 5123.045, 5123.049 , 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 07/01/2012, 04/01/2017, 02/01/2018

5123-9-41 Home and community-based services waivers - clinical/therapeutic intervention under the self-empowered life funding waiver.

(A) Purpose

This rule defines clinical/therapeutic intervention and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(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 medicaid state plan. 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 a licensed psychologist, licensed professional clinical counselor, licensed professional counselor, licensed independent social worker, licensed social worker working under the supervision of a licensed independent social worker, or certified Ohio behavior analyst. 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 medicaid state plan to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. A functional behavioral assessment describes the relationship between a skill or performance problem and the variables that contribute to its occurrence. A functional behavioral assessment may provide information to develop a hypothesis as to why an individual engages in a 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 self-employed person who provides services for which he or she must be certified in accordance with rule 5123:2-2-01 of the Administrative Code 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 purpose 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 may designate another person to assist 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) "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) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility redetermination 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 medicaid;

and

(c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov).

(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 or certified 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 or certified 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:

(i) Have experience providing one-to-one care for an individual with developmental disabilities who needs significant behaviorally-focused interventions;

(ii) Have undergone two monitored sessions with an individual with developmental disabilities who needs significant behaviorally-focused interventions;

(iii) Hold a "Registered Behavior Technician" credential issued by the behavior analyst certification board; or

(iv) Hold a "Board Certified Assistant Behavior Analyst" credential issued by the behavior analyst certification board.

(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 applicable provisions of 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 rule 5123:2-1-11 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 unit, service codes, and payment rates for clinical/therapeutic intervention are contained in the appendix to this rule.

(2) The payment rate for clinical/therapeutic intervention provided by an independent provider shall be negotiated by the individual and the independent 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 rate for clinical/therapeutic intervention provided by an agency provider shall be the lesser of the agency provider's usual and customary charge or the statewide payment rate contained in the appendix to this rule.

Replaces: 5123:2-9-41

Click to view Appendix

Effective: 9/23/2018
Five Year Review (FYR) Dates: 09/23/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049
Rule Amplifies: 5123.04, 5123.045, 5123.049 , 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 07/01/2012

5123-9-43 Home and community-based services waivers - functional behavioral assessment under the self-empowered life funding waiver.

(A) Purpose

This rule defines functional behavioral assessment and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the administrative code.

(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 medicaid state plan to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. A functional behavioral assessment describes the relationship between a skill or performance problem and the variables that contribute to its occurrence. A functional behavioral assessment may provide information to develop a hypothesis as to why an individual engages in a 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 self-employed person who provides services for which he or she must be certified in accordance with 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. An individual may designate another person to assist 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) "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) "Usual and customary charge" means the amount charged to other persons for the same service.

(12) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver 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 medicaid;

and

(c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov).

(2) Functional behavioral assessment shall be provided by a person who has the experience necessary to perform psychometric tests that assess an individual's functional behavioral level and who is a:

(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) Certified Ohio behavior analyst certified by the state pursuant to section 4783.04 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 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 applicable provisions of 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

Functional behavioral assessment shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 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 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 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 medicaid state plan for the same functional behavioral assessment.

Replaces: 5123:2-9-43

Click to view Appendix

Effective: 9/23/2018
Five Year Review (FYR) Dates: 09/23/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049
Rule Amplifies: 5123.04, 5123.045, 5123.049 , 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 07/01/2012

5123-9-45 Home and community-based services waivers - participant-directed goods and services under the self-empowered life funding waiver.

(A) Purpose

This rule defines participant-directed goods and services and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Community respite" has the same meaning as in rule 5123-9-22 of the Administrative Code.

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

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

(4) "Financial management services entity" means a governmental entity and/or another third-party entity designated by the Ohio department of medicaid to perform necessary financial transactions on behalf of individuals enrolled in the self-empowered life funding waiver.

(5) "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 may designate another person to assist 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) "Participant-directed goods and services" means services, equipment, or supplies not otherwise provided through the self-empowered life funding waiver or through the medicaid state plan that address a need identified in the individual service plan and meet all of the following requirements:

(a) The services, equipment, or supplies are required to assist the individual with achieving one of more of the following outcomes:

(i) Decrease the need for other medicaid home and community-based services;

(ii) Promote inclusion in the community;

(iii) Increase the individual's safety in his or her home;

(iv) Increase the individual's independence;

(v) Improve cognitive, social, or behavioral functions; or

(vi) Develop or maintain personal, social, or physical skills.

(b) The individual does not have funds to purchase the services, equipment, or supplies, and they are not available through another source.

(c) The services, equipment, or supplies are required to ensure the health and welfare of the individual.

(d) The services, equipment, or supplies are the least costly alternative that reasonably meets the individual's assessed need as evidenced through the county board's established cost comparison process.

(e) The services, equipment, or supplies are for the direct medical or remedial benefit of the 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) "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.

(11) "Usual and customary charge" means the amount charged to other persons for the same service.

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

(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) Provision of participant-directed goods and services shall be coordinated by a financial management services entity.

(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 rule 5123:2-1-11 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:

(a) Experimental treatments;

(b) Items used solely for entertainment or recreational purposes;

(c) Tobacco products or alcohol;

(d) Items considered by the federal food and drug administration as experimental or investigational or not approved to treat a specific condition;

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

(f) Equipment, supplies, and devices of the same type for the same individual, unless there is a documented change in the individual's condition that warrants the replacement;

(g) Home modifications that are of general utility or that add to the total square footage of the home; or

(h) Items that are illegal or otherwise prohibited through federal or state regulations.

(4) Prior to authorizing services, equipment, or supplies as participant-directed goods and services in the individual service plan or submitting a request for processing to the financial management services entity, an individual's service and support administrator shall ensure that:

(a) The services, equipment, or supplies meet the definition of participant directed goods and services set forth in paragraph (B)(7) of this rule;

(b) A person-centered assessment of the individual has been conducted and supports the medical necessity of the services, equipment, or supplies; and

(c) Documentation on hand demonstrates that no other source is available to pay for the services, equipment, or supplies.

(5) A county board shall submit requests for the following services, equipment, or supplies to the department for review prior to authorizing them as participant-directed goods and services in the individual service plan:

(a) Appliances;

(b) Fences;

(c) Pools, spas, saunas, trampolines, and play sets;

(d) Home modifications exceeding ten thousand dollars;

(e) Services, equipment, or supplies that may otherwise be available to the individual through the self-empowered life funding waiver (e.g., as community respite) or the medicaid state plan; and

(f) Services, equipment, or supplies that may otherwise be available to the individual through Ohio's early and periodic screening, diagnostic, and treatment (i.e., "Healthchek") program or pursuant to the Individuals with Disabilities Education Act.

(6) The department shall review requests submitted in accordance with paragraph (D)(5) of this rule and issue a determination within thirty calendar days of receiving all requested information. When the department determines that the request shall be denied, the department shall notify the county board and the individual in writing. The notice shall advise the individual of his or her right to due process.

(7) Requests submitted to the department in accordance with paragraph (D)(5) of this rule less than forty-five days in advance of the last day of an individual's waiver eligibility span may not be resolved with sufficient time to purchase the services, equipment, or supplies within that waiver eligibility span.

(E) Documentation of services

(1) Paragraph (K) of rule 5123-9-40 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.

Replaces: 5123:2-9-45

Click to view Appendix

Effective: 9/23/2018
Five Year Review (FYR) Dates: 09/23/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049
Rule Amplifies: 5123.04, 5123.049 , 5166.21
Prior Effective Dates: 07/01/2012

5123-9-46 Home and community-based services waivers - participant/ family stability assistance under the self-empowered life funding waiver.

(A) Purpose

This rule defines participant/family stability assistance and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(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 in accordance with 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 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 may designate another person to assist 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.

(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) "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 medicaid;

and

(c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov).

(2) An 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 certified 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 applicable provisions of 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 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 medicaid;

and

(c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov).

(2) Participant/family stability assistance-counseling shall be provided by a person who is a:

(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 certified 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 applicable provisions of 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

Participant/family stability assistance shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 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 unit, service codes, and payment rate 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.

Replaces: 5123:2-9-46

Click to view Appendix

Effective: 9/23/2018
Five Year Review (FYR) Dates: 09/23/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049
Rule Amplifies: 5123.04, 5123.045, 5123.049 , 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 07/01/2012

5123-9-47 Home and community-based services waivers-support brokerage under the self-empowered life funding waiver.

(A) Purpose

This rule defines support brokerage and sets 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 directly employs at least one person in addition to the chief executive officer for the purpose of providing services for which the entity must be certified in accordance with rule 5123:2-2-01 of the Administrative Code.

(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 in accordance with 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 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 may designate another person to assist 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.

(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 waiver 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 medicaid; and

(iii) Has completed and submitted an application through the department's website (http://dodd.ohio.gov).

(b) An unpaid volunteer who has the qualifications specified in paragraph (C) (2) of this rule.

(2) Support brokerage shall be provided by a person who:

(a) Has 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, has successfully completed the support broker training established by the department.

(3) An 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 an individual's:

(a) Guardian;

(b) Spouse;

(c) Parent when the individual is less than eighteen years of age; or

(d) Family member when the family member resides with the individual.

(6) Failure to comply with this rule and applicable provisions of 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

Support brokerage shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 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 unit, 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.

Replaces: 5123:2-9-47

Click to view Appendix

Effective: 9/23/2018
Five Year Review (FYR) Dates: 09/23/2023
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049
Rule Amplifies: 5123.04, 5123.045, 5123.049 , 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 07/01/2012