This rule sets forth requirements for serving persons determined to require a developmental disabilities level of care residing at an intermediate care facility for individuals with intellectual disabilities (ICFIID) whose care needs are not adequately measured by the resident assessment classification system and case mix payment system described in rule 5123:2-7-20 of the Administrative Code.
(2) "Department" means the Ohio department of developmental disabilities.
(3) "Designated outlier coordinator" means a department staff member who coordinates the general operations of the ICFIID outlier services program. The designated outlier coordinator works with providers of outlier services, individuals requesting and receiving outlier services, other persons whom individuals have identified, other service agencies, and other department staff. The designated outlier coordinator's duties include, but are not limited to:
(a) Assisting with the initial approval and ongoing monitoring of an ICFIID providing outlier services;
(b) Coordinating the processing of pre-admission and continued stay prior authorization requests for individuals; and
(c) Reviewing assessments, individual plans, day programming plans, staffing plans, and other documents.
(4) "Individual plan" means a written description of the services to be provided to an individual, developed by an interdisciplinary team that represents the professions, disciplines, or service areas that are relevant to identifying the individual's needs, as described by the comprehensive functional assessments.
(5) "Invasive mechanical ventilator" means a ventilator that is interfaced directly with the individual via an artificial airway (e.g., tracheostomy tube). Invasive mechanical ventilators (volume and/or pressure) are life support devices designed specifically for invasive mechanical ventilation applications and must accommodate direct current backup power supply and include disconnect, high pressure, low pressure, and power loss alarms.
(6) "Nurse" means a person authorized by Chapter 4723. of the Revised Code to engage in the practice of nursing as a registered nurse or a licensed practical nurse.
(7) "Outlier services" means those clusters of services that have been determined by the department to require reimbursement rates established pursuant to section 5124.152 of the Revised Code when delivered by qualified providers to individuals who have been prior-authorized to receive a category of service identified as an outlier service by the department as set forth in Chapter 5123:2-7 of the Administrative Code.
(8) "Pediatric ventilator services" means services provided by an ICFIID that holds an effective provider agreement with the Ohio department of medicaid and that is approved by the department to deliver outlier services to individuals less than twenty-two years of age who are dependent on invasive mechanical ventilators.
(9) "Physician" means a person authorized by Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery.
(10) "Plan of correction" means a corrective action plan prepared by an ICFIID in response to deficiencies cited by the department or the Ohio department of health. The plan shall conform to regulations and guidelines and include information that describes how the deficiency will be corrected, when it will be corrected, how other residents that may be affected by the deficiency will be identified, and how the ICFIID will ensure that compliance is maintained upon correction.
(11) "Prior authorization assessment for pediatric ventilator services" means an evaluation to determine if an individual meets the eligibility criteria to receive pediatric ventilator services set forth in paragraphs (C)(3) to (C)(7) of this rule that shall take place only after the individual is determined to meet the financial eligibility and level of care requirements set forth in paragraphs (C)(1) and (C)(2) of this rule.
(12) "Prior authorization for pediatric ventilator services" means department approval obtained by an ICFIID to provide pediatric ventilator services to a specific individual for specific time-limited initial or continued stay periods. Prior authorization for pediatric ventilator services shall be required for the ICFIID to be authorized by the department to receive reimbursement for services rendered to the individual. Reimbursement may be denied for any service not rendered in accordance with Chapters 5160-3 and 5123:2-7 of the Administrative Code.
(14) "Respiratory care professional" means a person who is licensed under Chapter 4761. of the Revised Code to practice the full range of respiratory care services described in division (A) of section 4761.01 of the Revised Code.
(C) Individual eligibility criteria
To receive prior authorization for pediatric ventilator services, an individual shall:
(1) Have been determined by the county department of job and family services to meet the medicaid financial eligibility standards for institutional care.
(2) Have obtained a developmental disabilities level of care determination from the department within the last thirty calendar days, or, at the time of prior authorization assessment for pediatric ventilator services, be determined by the department to meet the criteria for a developmental disabilities level of care in accordance with rule 5123:2-8-01 of the Administrative Code.
(3) Be less than twenty-two years of age.
(4) Require the use of an invasive mechanical ventilator.
(5) Have been an inpatient, for at least ninety days within the past twelve months, in an acute care hospital for treatment of a life-threatening or complex medical condition. If the individual has been an inpatient in an acute care hospital for treatment of a life-threatening or complex medical condition within the past twelve months but for less than ninety days, an ICFIID may submit to the department, and the department may approve, a written request to waive the ninety-day requirement. The request shall include a description of the clinical services the individual continues to require and an attestation by the ICFIID that it is able to meet the individual's needs.
(6) Have achieved a stabilized medical condition so that the immediate services of an acute care hospital, including daily physician visits, are not medically necessary.
(7) Require monitoring by a nurse twenty-four hours per day and professional assessment by a registered nurse on a daily basis.
(D) ICFIID eligibility criteria
(1) An ICFIID shall complete and submit to the department an application for approval to provide pediatric ventilator services. The application is available at the department's website (http://dodd.ohio.gov/). The ICFIID shall provide any additional information requested by the department and may be subject to documentation review and on-site visits by department personnel.
(2) In order to be approved to provide pediatric ventilator services and qualify for enhanced payment for provision of pediatric ventilator services to prior-authorized individuals, an ICFIID shall:
(a) Be an Ohio medicaid-certified ICFIID and agree to cooperate with the department's oversight of pediatric ventilator services;
(c) Fully meet all standards for residential facilities licensed in accordance with section 5123.19 of the Revised Code or have an approved and implemented plan of correction and have not demonstrated a pattern of repeat deficiencies.
(d) Fully meet all standards for Ohio medicaid ICFIID certification or meet the medicaid program requirements of a facility for which the Ohio department of health found deficiencies, have an approved and implemented plan of correction, and have not demonstrated a pattern of repeat deficiencies.
(i) An emergency action plan in place in the event of a power failure;
(ii) An on-site backup generator service for all equipment including suction lines, oxygen lines, and emergency power to ventilators;
(iii) Sufficient backup ventilators on-site and available in the event of mechanical failure as well as any other equipment necessary to meet the needs of individuals in the event of an emergency; and
(iv) An emergency response plan in place in the event of natural or human-made disasters that provides for the safe transport of individuals to a safe area with appropriate resources available to ensure the health and safety of the individuals.
(f) Schedule direct care staff to ensure that adequately trained staff are present and on duty twenty-four hours per day, every day of the year. Staffing shall be sufficient to ensure that urgent, emergent, and routine resident needs are identified appropriately and in a timely manner and are met through the implementation of intervention strategies reflected in each resident's individual plan. Absences of staff for breaks and meals shall not compromise this staffing arrangement.
(g) Ensure that staff who manage pediatric ventilator services have evidence of at least two years of work experience with individuals who have complex medical conditions.
(h) Address through staff training programs, the specific medical domains a staff member must master for a thorough understanding and demonstration of competency in order to meet the specialized needs of residents requiring pediatric ventilator services. Initial and continuing direct care staff training shall include:
(i) Orientation to the ICFIID's status as a provider of pediatric ventilator services, including the individual eligibility criteria set forth in paragraph (C) of this rule and the ICFIID eligibility criteria set forth in paragraph (D) of this rule;
(ii) Information about the specific health care needs of the current residents of the ICFIID who receive pediatric ventilator services;
(iii) Accepted best practices and innovative approaches to meet residents' needs;
(iv) Training to ensure nursing care competence for patients under twenty-two years of age, including specialized training on developmental needs that improve an individual's overall functional status; and
(v) Due to the increased risk of infection for residents of ICFIID who receive pediatric ventilator services, steps to be taken to minimize risk of transmission of contagious or infectious diseases.
(i) Agree to furnish or arrange to have furnished all medically necessary services to individuals who are dependent on invasive mechanical ventilators, regardless of whether the services are reimbursable through the ICFIID cost report mechanism or directly to the provider of such services.
(i) The ICFIID shall ensure that physician services are available twenty-four hours per day.
(ii) A physician shall complete an assessment of the individual at least once every thirty calendar days for the first ninety calendar days and at least once every ninety calendar days thereafter if the individual maintains a stable status with no acute complications related to ventilator support. If acute care needs requiring hospitalization present upon return to the ICFIID, a physician shall complete an assessment of the individual at least once every thirty calendar days for the first ninety calendar days and at least once every ninety calendar days thereafter.
(iii) The ICFIID shall ensure that respiratory care services are available twenty-four hours per day. Medically necessary respiratory care services shall be provided by a respiratory care professional or by a nurse who the ICFIID has determined has the training, knowledge, skill, and ability to complete the services in coordination with the respiratory care professional, and as ordered by a physician.
(iv) The ICFIID, in consultation with a physician and a respiratory care professional, shall develop a facility plan for providing care to individuals who are dependent on invasive mechanical ventilators. The plan shall address maintenance of ventilators, required modification and maintenance of facilities, and special accommodations required to ensure that all needs, including but not limited to, hygiene, bathing, dietary, social, and transportation, of individuals who are dependent on invasive mechanical ventilators, are met.
(v) The ICFIID shall ensure that services by registered nurses are available twenty-four hours per day.
(vi) Nursing care and any personal care that may be required for the health, safety, and wellbeing of the individuals served shall be available twenty-four hours per day. Nursing personnel shall be sufficient to ensure prompt recognition of any adverse change in an individual's condition and to facilitate nursing, medical, or other appropriate interventions, up to and including transfers to an acute care hospital.
(vii) The need for physical, occupational, and/or speech therapy services shall be assessed and services shall be provided as needed by therapists licensed to practice in Ohio.
(viii) If an individual is receiving enteral feedings and there is a complication of medical status secondary to the nutritional status, a dietary consultation by a person licensed to practice dietetics in Ohio shall be made available to that individual.
(j) Prior to admission of an individual who requires pediatric ventilator services, arrange for a suitable school or day program for the individual and submit the plan for such program to the designated outlier coordinator or other department designee.
(k) Prior to admission of an individual who requires pediatric ventilator services, develop and submit to the designated outlier coordinator or other department designee accurate assessments or reassessments by an interdisciplinary team that address the individual's health, social, psychological, educational, vocational, and chemical dependency needs. Health information shall include a copy of the medical assessment completed by a pediatric physician who has knowledge of and experience with the individual and shall include a clinical summary, need for invasive mechanical ventilation (including viability and plan for weaning), detailed therapy assessment with recommended therapy plan, medication needs, and any other medical information relevant to the individual's care needs.
(l) Ensure that a registered nurse submits a written summary of clinical status to the primary care physician on a monthly basis. The physician shall review and sign the summary and place it in the individual's medical record.
(m) Due to the complex and intensive needs of individuals who require pediatric ventilator services, develop a transitional plan prior to admission of an individual to ensure that the ICFIID is able to meet the individual's health, safety, and behavioral support needs from the day of admission. The transitional plan shall address major concerns and shall be provided to the designated outlier coordinator or other department designee upon request.
(n) Within thirty calendar days after admission, develop accurate assessments or reassessments by an interdisciplinary team that address the individual's health, social, psychological, educational, vocational, and chemical dependency needs in order to supplement the preliminary evaluation described in paragraph (D)(2)(k) of this rule, which was conducted prior to admission. The ICFIID shall provide the assessments or reassessments to the designated outlier coordinator or other department designee upon request.
(o) Develop a comprehensive individual plan within thirty calendar days of an individual's admission, with input from the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable. The ICFIID shall provide a copy of the individual plan to the designated outlier coordinator or other department designee upon request.
(i) The individual plan shall be reviewed by the appropriate program staff at least quarterly and revised as necessary with input from the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable.
(ii) The ICFIID shall notify the designated outlier coordinator or other department designee whenever an individual experiences a significant change in medical status, including hospitalization.
(iii) The ICFIID shall prepare a quarterly report in a format approved by the department that summarizes the resident's individual plan, progress, changes in treatment, current status relative to discharge goals, and any updates to the discharge plan, including referrals made and anticipated time frames. The ICFIID shall provide a copy of the quarterly report to the designated outlier coordinator or other department designee upon request.
(iv) The designated outlier coordinator or other department designee may visit the ICFIID at any time. The ICFIID shall provide any documents or information requested by the designated outlier coordinator or other department designee.
(p) Within thirty calendar days after admission, develop a written discharge plan with the interdisciplinary team in conjunction with the individual and others concerned with the individual's welfare. The discharge plan shall include a description of targeted medical/health status indicators that would signify the resident could be safely discharged. The ICFIID shall provide a copy of the discharge plan to the designated outlier coordinator or other department designee upon request.
(q) Accept payment for the provision of services at the non-outlier ICFIID reimbursement rate if prior authorization for pediatric ventilator services requested for an individual already residing in the ICFIID is denied.
(E) Outlier per diem rate
(1) An ICFIID's per diem rate shall be set in accordance with Chapter 5124. of the Revised Code and applicable rules in Chapter 5123:2-7 of the Administrative Code. An outlier per diem rate for pediatric ventilator services, determined and applied in accordance with paragraph (H) of this rule, shall be added to the ICFIID's per diem rate.
(2) With the exception of any specific items that are direct-billed in accordance with rule 5123:2-7-11 of the Administrative Code, the ICFIID shall agree to accept as payment in full the per diem rate established for pediatric ventilator services in accordance with this rule, and to make no additional charge to the individual, to any member of the individual's family, or to any other source for covered pediatric ventilator services.
(F) Prior authorization for services
(1) Payment for pediatric ventilator services covered by the medicaid program shall be available only upon prior authorization by the department for each individual in accordance with the procedures set forth in this rule. The prior authorization procedures set forth in this rule are in addition to the developmental disabilities level of care review process set forth in rule 5123:2-8-01 of the Administrative Code.
(a) Unless the individual is seeking a change of payer, prior authorization for pediatric ventilator services shall occur prior to admission to the ICFIID.
(b) In the case of requests for continued stay, prior authorization for pediatric ventilator services shall occur no later than the final day of the previously authorized pediatric ventilator services stay.
(2) A request for prior authorization for pediatric ventilator services shall be submitted to the department in writing via email to firstname.lastname@example.org.
(3) It is the responsibility of the ICFIID to ensure that all required information is provided to the department as requested. An initial request for prior authorization for pediatric ventilator services is considered complete when:
(a) A request has been accurately completed and submitted via the medicaid information technology system;
(b) A developmental disabilities level of care has been issued in accordance with rule 5123:2-8-01 of the Administrative Code and a determination regarding the feasibility of community-based care has been made; and
(c) The designated outlier coordinator has received supporting documentation exhibiting evidence that the applicant meets the eligibility criteria set forth in paragraphs (C)(3) to (C)(7) of this rule. The ICFIID shall retain a duplicate copy of all submitted documentation. Supporting documentation may include, but is not limited to, the preliminary evaluation, assessments, and transitional plan required prior to admission as set forth in paragraph (D) of this rule.
(4) The department's determination shall be based on the completed initial stay request and any additional information or documentation necessary to make the determination of eligibility for pediatric ventilator services, which may include a face-to-face visit by at least one department representative with the individual and, if applicable, the individual's parent, the individual's guardian, or other person whom the individual has identified and, to the extent possible, the individual's formal and informal care givers, to review and discuss the individual's care needs and preferences.
(5) Based upon a comparison of the individual's condition, service needs, and the requested placement site with the eligibility criteria set forth in paragraph (C) of this rule, the department shall conduct a review of the application, assessment report, and supporting documentation about the individual's condition and service needs to determine whether the individual is eligible for pediatric ventilator services.
(6) The department shall issue a notice of determination within thirty calendar days of receipt of a complete request for prior authorization indicating approval or denial of the request to the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable, and the ICFIID. The department shall send a copy of the notice to the county department of job and family services to be maintained in the individual's case record.
(a) When a request for prior authorization for pediatric ventilator services is denied, notice shall specify the reason for denial and explain the individual's right to a state hearing in accordance with section 5101.35 of the Revised Code.
(b) When a request for prior authorization for pediatric ventilator services is approved, the notice shall include an assigned prior authorization number, the number of days for which pediatric ventilator services are authorized, and the date on which payment is authorized to begin. The notice shall also include the name, location, and phone number of the department staff member who is assigned to monitor the individual's progress at the ICFIID.
(i) Individuals who are determined to have met the eligibility criteria set forth in paragraph (C) of this rule may be approved for an initial stay of a maximum of one hundred eighty-four days. The number of days prior-authorized for each eligible individual shall be based upon the submitted application materials, consultation with the individual's attending physician, and/or any additional consultations or materials required by the assessor to make a reasonable estimation regarding the individual's probable need for pediatric ventilator services.
(ii) Continued stay determinations shall be based on reports from the ICFIID submitted to the designated outlier coordinator regarding critical events and the status of the individual's condition and discharge planning options, face-to-face assessments conducted by the department, and/or other information determined by the department. When the department determines that the individual continues to meet the eligibility criteria set forth in paragraph (C) of this rule, and the ICFIID submits a request for continued stay in accordance with paragraph (F)(8) of this rule, continued stays may be approved for maximum increments of one hundred eighty-four days.
(c) Reimbursement for pediatric ventilator services shall be limited to services approved as indicated in the approval letter.
(7) An individual is expected to be discharged to the setting specified in the individual's discharge plan at the end of the prior-authorized initial or continued stay, and progress toward that end shall be monitored by the department or its designee throughout the individual's stay in the ICFIID.
(8) Pediatric ventilator services may be extended beyond the previously approved length of stay if the ICFIID submits a written request to the department proving that it is not possible to implement the individual's discharge plan. Such requests shall be submitted at least thirty calendar days prior to the last day of the previously authorized stay, unless there is a significant change of circumstances within the week preceding the expected discharge date that prevents implementation of the discharge plan.
(G) Payment authorization The payment authorization date shall be one of the following, but shall not be earlier than the effective date of the individual's developmental disabilities level of care determination:
(1) The date of admission to the ICFIID; or
(2) The date of prior authorization for pediatric ventilator services approval, if the individual was already a resident of an ICFIID that provides pediatric ventilator services but was using another payer source.
(H) Initial and subsequent contracted rates
(1) The department shall establish the initial and subsequent contracted rates in accordance with Chapter 5124. of the Revised Code. All rate adjustments determined in accordance with this rule shall be effective on the payment authorization date determined in accordance with paragraph (G) of this rule through the date of discharge from the ICFIID or until the date the individual no longer meets the eligibility criteria set forth in paragraph (C) of this rule.
(2) An ICFIID may bill the pediatric ventilator services revenue code for each individual whose initial or continued stay prior authorization has been approved in accordance with paragraph (F) of this rule.
(4) The ICFIID shall be responsible for contacting the designated outlier coordinator no later than by the close of the next business day following the discharge of an individual or point at which the individual no longer meets the eligibility criteria established in paragraph (C) of this rule to ensure processing time for recalculation and application of the pediatric ventilator services outlier per diem rate to the ICFIID per diem rate.
(5) The pediatric ventilator services outlier per diem rate will be specific to the individual approved to receive pediatric ventilator services in the amount of three hundred dollars.
Five Year Review (FYR) Dates: 02/16/2022
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.02, 5124.03, 5124.152, 5162.021
Rule Amplifies: 5123.04, 5124.02, 5124.03, 5124.15 , 5124.152, 5124.25, 5162.021
Prior Effective Dates: 10/01/2013