5123:2-9-54 Home and community-based services waivers - home modification services under the transitions developmental disabilities waiver.

(A) Purpose

The purpose of this rule is to define home modification services under the transitions developmental disabilities waiver and set forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.

(B) Definitions

(1) "Agency provider" means an entity that employs persons for the purpose of providing services for which the entity must be approved by the Ohio department of medicaid.

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

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

(4) "Home-modification services" means environmental accessibility adaptations to structural elements of the interior or exterior of an individual's home as identified in the individual service plan, that enable the individual to function with greater independence in the home and remain in the community. Home modification services shall not otherwise be available through any other funding source and shall enable the individual to function with greater independence, avoid institutionalization, and reduce the need for human assistance. Home modification services may include repair of previous home modifications excluding those necessitated as a result of confirmed misuse, abuse, or negligence. Home modification services shall not include:

(a) Changes to a home that are of general utility and are not directly related to the environmental accessibility needs of the individual (e.g., carpeting, roof repair, and central air conditioning);

(b) Adaptations that add to the total square footage of the home;

(c) Services performed in excess of what is approved pursuant to, and specified in, the individual service plan;

(d) The same type of home modification for the same individual during the same twelve-month calendar year, unless there is a documented need for the home modification or a documented change in the individual's medical and/or physical condition that requires the replacement; or

(e) Additional modification or repair of previous home modifications necessitated as a result of confirmed misuse, abuse, or negligence.

(5) "Independent provider" means a non-agency, self-employed person approved by the Ohio department of medicaid to provide services who 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.

(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.

(C) Provider qualifications

(1) Home-modification services 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) Home modification services 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) All providers of home modification services, other than family members who provide home modification services, shall hold licensure, insurance, and bonding for general contracting services of applicable jurisdictions and provide proof to the department and the Ohio department of medicaid upon request.

(D) Requirements for service delivery

(1) Home modification services shall be provided pursuant to an individual service plan that conforms to the requirements of paragraph (F) of rule 5123:2-9-50 of the Administrative Code.

(2) The property owner must give written consent for the home modification services and indicate an understanding that the transitions developmental disabilities waiver shall not pay to have the property returned to its pre-modification condition.

(3) In consultation with the individual, the service and support administrator shall:

(a) Develop job specifications to meet the individual's environmental accessibility needs with the lowest cost alternative.

(b) Send the home modification services specifications to at least three home modification services providers and invite the submission of bids.

(c) Review all submitted bids to determine, among the submitted bids, which is the lowest responsive and most responsible bidder, with price and other relevant factors being considered in the selection process.

(d) Approve only the lowest cost alternative that meets the individual's needs as determined during the assessment process.

(4) Providers of home modification services who wish to be considered in the process set forth in paragraph (D)(3) of this rule, shall submit bids that include all of the following:

(a) A drawing or diagram of the home modification;

(b) An itemized list of all materials needed for the home modification;

(c) An itemized list of the cost of the materials needed for the home modification;

(d) An itemized list of the labor costs;

(e) A written statement of all warranties provided, including at a minimum, a one-year warranty for all materials and workmanship associated with the home modification; and

(f) A written attestation that the provider and all employees and subcontractors to be used to perform the home modifications have the necessary experience and skills, and meet all of the provider requirements set forth in Chapter 5123:2-9 of the Administrative Code.

(E) Documentation of services

Service documentation for home modification services shall include each of the following to validate payment for medicaid services:

(1) Documentation that the home modification services were completed in accordance with the agreed upon specifications using all of the materials and equipment cited in the bid.

(2) Documentation that the individual and the service and support administrator have verified work completed as home modification services was tested and is in proper working order.

(3) Documentation that the home modification services meet all applicable state and local building codes.

(4) Documentation that the home modification services provided meet the individual's needs and comply with, as applicable, the Americans with Disabilities Act (as in effect on the effective date of this rule), the Fair Housing Act (as in effect on the effective date of this rule), and the "Uniform Federal Accessibility Standards" (as in effect on the effective date of this rule). If services provided as home modification services require customization in order to meet the individual's needs, and that customization will not be compliant with the Americans with Disabilities Act, the Fair Housing Act, or the "Uniform Federal Accessibility Standards," the services shall be prior-approved by the department, in consultation with the individual and the individual's interdisciplinary team.

(F) Payment standards

(1) The billing unit, service code, and payment rate for home modification services are contained in the appendix to this rule.

(2) Providers shall submit claims for payment for home modification services to the Ohio department of medicaid in accordance with rule 5160-41-22 of the Administrative Code.

(3) Payment for home modification services shall not exceed ten thousand dollars within a calendar year.

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Effective: 07/01/2014
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5166.21
Rule Amplifies: 5123.04 , 5166.21
Prior Effective Dates: 03/30/1990 (Emer.), 06/29/1990, 07/01/1990, 03/12/1992 (Emer.), 06/01/1992, 07/31/1992 (Emer.), 10/30/1992, 07/01/1993 (Emer.), 07/30/1993, 09/01/1993, 01/01/1996, 07/01/1998, 07/01/2006, 07/01/2010, 01/01/2013