Chapter 5160-32 Choices Program

5160-32-02 Definitions for the choices home and community-based services (HCBS)waiver program.

Definitions as used in this chapter:

(A) "ADL" means activities of daily living including bathing; grooming; toileting; dressing; eating; and mobility that refers to bed mobility, transfer, and locomotion as these are defined in rules 5101:3-3-06 and 5101:3-3-08 of the Administrative Code.

(B) "Agency Provider" means an established business who employs staff to provide choices program services, has a signed medicaid provider agreement with the Ohio department of job and family services (ODJFS) to provide choices program services, and meets the choices conditions of participation set forth in rule 5101:3-32-04 of the Administrative Code.

(C) "Assessment" means a face-to-face evaluation used to obtain information about an individual including his or her condition, personal goals and preferences, functional limitations, health status and other factors that are relevant to the authorization and provision of services. Assessment information supports the determination that an individual requires waiver services as well as the development of a service plan.

(D) "Authorized representative" means a person eighteen years of age or older, who is chosen by and acts on behalf of an individual who is applying for or receiving medical assistance. In accordance with rule 5101:1-38-01.2 of the Administrative Code, the individual must provide a written statement naming the authorized representative and the duties that the named authorized representative may perform on the individual's behalf.

(E) "C.F.R." means the code of federal regulations.

(F) "Caregivers" mean relatives, friends, and/or significant others who voluntarily provide assistance to the consumer and are responsible for the consumer's care on a continuing basis.

(G) "Case management" means a set of person centered activities provided by the PASSPORT administrative agency that are undertaken to ensure that the waiver consumer receives appropriate and necessary services. Under a HCBS waiver, these activities may include, but are not necessarily limited to, assessment, service plan development, service plan implementation and service monitoring as well as assistance in accessing waiver, state plan, and other non-medicaid services and resources.

(H) "CDJFS" means a county department of job and family services.

(I) "Choices" or "choices home and community based services (HCBS) waiver program" means an HCBS waiver program which provides home and community-based services including the opportunity to self-direct certain waiver services to individuals age sixty and over who have the level of care required for placement in a nursing facility if the waiver program were not available and meet the choices program eligibility and enrollment criteria as described in Chapter 5101:3-32 of the Administrative Code.

(J) "CMS" means the centers for medicare and medicaid services, a federal agency that is part of the United States department of health and human services, and which administers the medicaid program and approves home and community-based services (HCBS) waivers.

(K) "Consumer" means the choices HCBS waiver program participant. Consumer includes the individual's legal representative and/or authorized representative, as applicable, who assists in directing the consumer's care.

(L) "Direct service worker" means the paid agency provider staff or individual provider who has in-person contact with the choices consumer while providing choices services.

(M) "FMS" or "financial management service" is a support provided to waiver participants who direct some or all of their waiver services. In the choices waiver, this support is provided as an administrative activity. When used in conjunction with the self-direction authority available to consumer in choices, this support includes operating a payroll service for participant-employed workers and making required payroll withholdings.

(N) "IADL" means instrumental activities of daily living including shopping; meal preparation; laundry; community access activities that include telephoning, transportation, legal or financial; and environmental maintenance activities that are house cleaning, heavy chores, and yard work or maintenance, as these are defined in rule 5101:3-3-08 of the Administrative Code.

(O) "Individual provider" means a person with a signed medicaid provider agreement with ODJFS to provide choices services, and who meets the choices HCBS waiver program conditions of participation set forth in rule 5101:3-32-04 of the Administrative Code and who is not the spouse, parent, stepparent, and/or legal guardian of the consumer.

(P) "ODA" means the Ohio department of aging.

(Q) "ODJFS" means the Ohio department of job and family services.

(R) "PAA" means PASSPORT administrative agency.

(S) "PASSPORT" means the preadmission screening system providing options and resources today HCBS waiver program authorized in section 173.40 of the Revised Code.

(T) "Service Plan" means a written, person centered plan between the consumer, the consumer's case manager at the PAA and, as applicable, the consumer's caregiver(s). The service plan specifies the services that are provided to the consumer, regardless of funding source, to address the consumer's individual care needs as identified in the consumer's assessment.

Effective: 09/29/2011
R.C. 119.032 review dates: 07/14/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85
Prior Effective Dates: 8/30/01, 7/01/05, 7/01/06

5160-32-03 Eligibility for enrollment for the choices home and community-based services (HCBS) waiver program.

The following criteria must be met in order for a consumer to be eligible for enrollment:

(A) The consumer must be age sixty or older at time of enrollment.

(B) The consumer must have an intermediate or skilled level of care in accordance with rule 5101:3-3-05 or rule 5101:3-3-06 of the Administrative Code.

(C) The consumer must be eligible for medicaid as determined by the county department of job and family services (CDJFS) in accordance with rules 5101:1-38-01.8 and 5101:1-38-01.6 of the Administrative Code.

(D) Prior to enrollment in the choices program the consumer must be a current preadmission screening systems providing options and resources today (PASSPORT) program participant.

(E) The needed services are not readily available through another source at the level required to allow the individual to live in the community.

(F) The individual's health related needs can be safely met in a home setting as determined by the passport administrative agency (PAA).

(G) The individual agrees to participate in choices and shall not be simultaneously enrolled in another home and community based medicaid waiver, residential state supplement (RSS), or the program of all inclusive care for the elderly (PACE ) while enrolled in choices.

(H) While receiving choices program services, the consumer shall reside in the service area defined in the approved 1915(c) waiver for the choices program.

(I) The consumer shall not reside in any of the following living arrangements while enrolled in the choices program:

(1) Adult foster home certified under section 5119.362 of the Revised Code;

(2) Adult family homes or adult group homes as defined in section 3722.01 of the Revised Code that is licensed as an adult care facility under section 3722.04 of the Revised Code;

(3) Residential care facility as defined in section 3721.02 of the Revised Code;

(4) Community alternative home as defined in section 3724.01 of the Revised Code that is licensed under section 3724.03 of the Revised Code;

(5) Residential facility of the type defined in division (A)(1)(d)(ii) of section 5119.22 of the Revised Code that is licensed by the Ohio department of mental health (ODMH);

(6) An apartment or room that is used to provide community mental health housing services, is certified by the ODMH under division (M) of section 5119.611 of the Revised Code, and is approved by a board of alcohol, drug addiction, and mental health services in accordance with division (A)(14) of section 340.03 of the Revised Code;

(7) Hospital or nursing facility (NF) as defined in rule 5101:3-31-02 of the Administrative Code;

(8) "Keys amendment facility" as defined in section 1616(e) of the Social Security Act; or

(9) Any other facility that is licensed and/or certified by any state or local government.

(J) The consumer or the consumer's authorized representative must be willing and capable of directing provider activities. The consumer's capability to self-direct their services is demonstrated through a consumer certification process conducted by the PAA. To obtain certification, the consumer or his or her designee must meet all of the following:

(1) Attend all required trainings;

(2) Demonstrate all skills necessary to supervise direct service workers, including but not limited to:

(a) An understanding of what service activities are covered that the consumer may self-direct and provider requirements including criminal records check requirements; and

(b) Methods for selecting and dismissing providers; and

(c) Methods for entering into written agreements with providers for specific activities and corresponding payment rates; and

(d) Methods for training providers to meet the consumer's specific needs; and

(e) Methods for supervising and monitoring providers' performance of specific activities, including written approval of provider time sheets and billing invoices; and

(f) Development of a reliable service delivery back-up plan for situations in which a provider is unable to deliver the agreed-upon service(s); and

(g) Methods for lodging complaints, including use of the regional and state long term care ombudsman, and familiarity with the state's Ohio department of aging (ODA) ombudsman long term care complaint line; and

(h) Familiarity with state appeal and fair hearing request procedures; and

(i) Record keeping and ability to manage service delivery.

(3) Agree to actively participate with the case manager in the development, monitoring and revision of the service plan.

(4) Agree to inform the case manager of negotiated rates prior to delivery of choices services. ODA and/or the PAA retains the authority to approve negotiated rates.

(5) The consumer must use the financial management service (FMS) to process all consumer-directed individual provider claims.

(K) If, at any time, the individual or consumer fails or ceases to meet any of the eligibility criteria identified in this rule, he or she shall be denied or disenrolled from choices. In such instances, he or she shall be notified by the CDJFS and entitled to hearing rights in accordance with rules contained in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(L) The choices program has not reached the center for medicaid and medicare services (CMS) authorized limit of participants for the current year.

(M) The waiver service cost of the twelve-month service plan does not exceed the individual cost limit. The individual cost limit is calculated by ODA at least biennially. The cost limit is the dollar amount equal to sixty per cent of the total medicaid cost for NF services. The total medicaid cost for NF services is obtained by multiplying the average annual medicaid NF per diem rate by the number of days in the most recent state fiscal year in which data is available.

(1) If the PAA determines that the applicant's needs cannot be met within the cost limit the individual shall not be enrolled; however if a consumer who is enrolled on the waiver and receiving choices services experiences a change in his or her condition that causes the cost of care to exceed the cost limit, the consumer may remain on the waiver at a higher cost, not to exceed one hundred per cent of the total medicaid cost for NF services to avoid service disruption to the consumer if the PAA grants approval to do so.

(2) If the consumer's needs exceed one hundred per cent of the total medicaid cost of NF services, the consumer shall be disenrolled from the waiver.

(N) Prior to choices enrollment the individual's attending physician must approve that the services contained in the individual's service plan are appropriate to meet the individual's needs. The approval may be either verbal or written; however if the approval is verbal, written approval of the service plan must be obtained within thirty days of the consumer's enrollment date. If the written approval is not obtained within this timeframe, the individual shall be deemed to have not met the eligibility criteria set forth in this rule and be disenrolled from the choices waiver pursuant to paragraph (K) of this rule.

Effective: 09/29/2011
R.C. 119.032 review dates: 07/14/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85
Prior Effective Dates: 8/30/01, 7/01/05, 7/01/06, 10/01/07

5160-32-04 Provider conditions of participation for the choices home and community based services (HCBS) waiver program.

(A) The purpose of this rule is to establish the conditions of participation under which providers are able to participate in the choices HCBS waiver program.

(B) In order to obtain a medicaid provider agreement to be a choices provider, the provider must be certified by the Ohio department of aging (ODA) or its designee in accordance with the provisions of Chapter 173-39 of the Administrative Code.

(1) The provider may be certified as either:

(a) An ODA certified long-term care agency providers in accordance with the provisions of rule 173-39-03 of the Administrative Code, or

(b) An ODA certified long-term care non-agency provider in accordance with the provisions of rule 173-39-03 of the Administrative Code, or

(c) An ODA certified consumer-directed individual provider in accordance with the provisions of rule 173-39-03 of the Administrative Code.

(C) Individuals enrolled in the choices HCBS waiver shall be given a free choice of qualified providers as set forth in 42 C.F.R. 431.51 (as in effect on October 1, 2010).

Effective: 09/29/2011
R.C. 119.032 review dates: 07/14/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85
Prior Effective Dates: 8/30/01, 7/01/05, 7/01/06, 7/01/07

5160-32-05 Choices home and community based services (HCBS) waiver covered services.

(A) The purpose of this rule is to establish services covered by the choices HCBS waiver program.

(B) The Ohio department of aging (ODA) is responsible for the daily operation of the choices HCBS waiver. ODA will operate this waiver pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS), in accordance with sections 5111.91 and 5111.851 of the Revised Code.

(C) The choices HCBS waiver program benefit package is limited to the following services:

(1) Home care attendant services as set forth in rule 173-39-02.4 of the Administrative Code;

(2) Minor home modification, maintenance and repair services as set forth in rule 173-39-02.9 of the Administrative Code;

(3) Alternative meal services as set forth in rule 173-39-02.2 of the Administrative Code;

(4) Home delivered meal services as set forth in rule 173-39-02.14 of the Administrative Code;

(5) Emergency response systems services as set forth in rule 173-39-02.6 of the Administrative Code;

(6) Home medical equipment and supplies services as set forth in rule 173-39-02.7 of the Administrative Code;

(7) Adult day services as set forth in rule 173-39-02.1 of the Administrative Code; and

(8) Pest control services as set forth in rule 173-39-02.3 of the Administrative Code.

(D) Services will be delivered consistent with the consumer service plan .

Effective: 09/29/2011
R.C. 119.032 review dates: 07/14/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85
Prior Effective Dates: 8/30/01, 7/01/05, 07/01/06

5160-32-06 Enrollment process for choices home and community based services (HCBS) waiver program.

The current effective choices waiver is set to expire on June 30, 2014. Therefore, in accordance with Section 173.53 of the Revised Code, enrollment in the Choices waiver is suspended effective March 1, 2014. This suspension shall remain in effect until the choices waiver is terminated.

(A) The purpose of this rule is to establish the standards and procedures for an individual to enroll in the choices HCBS waiver program.

(B) An individual must be currently enrolled in the PASSPORT HCBS waiver program as described in Chapter 5160-31 of the Administrative Code to begin the choices waiver program enrollment process. The individual, a family member or case manager may initiate the choices enrollment process by contacting choices HCBS waiver program staff to request enrollment.

(C) An individual who is seeking enrollment in the choices HCBS waiver program must meet the program eligibility requirements as described in rule 5160-32-03 of the Administrative Code prior to enrollment.

(D) Any applicant for choices HCBS waiver program services is entitled to notice and hearing rights as set forth in section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

(1) The PASSPORT administrative agency (PAA) must notify the individual and authorized representative, if any, of the approval for enrollment for an individual determined to meet all choices HCBS waiver program eligibility criteria.

(2) If the PAA determines that the individual does not meet the criteria for enrollment in the choices HCBS waiver program, the PAA shall notify the county department of job and family services (CDJFS). The CDJFS shall send notice of the waiver application denial to the individual and his or her authorized representative, if any.

(3) If the CDJFS determines the individual is not eligible for medicaid, the CDJFS shall send notice of denial to the individual and his or her authorized representative, if any, and notify the PAA of its determination.

(E) If an individual meets all of the eligibility criteria in rule 5160-32-03 of the Administrative Code, but a slot is not available for enrollment in the choices waiver program, the individual shall be placed on a waiting list and offered enrollment in accordance with Chapter 173-44 of the Administrative Code.

Effective: 03/01/2014
R.C. 119.032 review dates: 11/29/2013 and 03/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5166.02 , 173.53
Prior Effective Dates: 8/30/01, 7/01/05, 7/01/06, 9/29/11

5160-32-07 Choices home and community based services (HCBS) waiver rate setting.

(A) The purpose of this rule is to establish how the rates of reimbursement are set for choices HCBS waiver program services.

(B) Choices HCBS waiver program providers must be long-term care providers certified by the Ohio department of aging (ODA) with an effective medicaid provider agreement in place before service delivery is initiated.

(C) Consumers enrolled in the choices HCBS waiver and may negotiate reimbursement rates with ODA-certified long-term care providers for certain choices HCBS waiver program covered services .

(1) Consumers enrolled in the choices HCBS waiver may negotiate rates for the following services specified in rule 5101:3-32-05 of the Administrative Code:

(a) Home care attendant service (HCAS);

(b) Alternative meals;

(c) Home medical equipment and supplies;

(d) Pest control; and

(e) Minor home modification, maintenance, and repair services.

(2) The consumer shall have in effect, before HCAS services are delivered, a signed agreement with each ODA-certified consumer-directed individual provider delivering HCAS services to the consumer. The agreement shall:

(a) Include the rate of reimbursement negotiated with the provider;

(b) Specify the time period the rates shall be in effect;

(c) Base rates on the units of service as set forth in Chapter 173-39 of the Administrative Code;

(d) Be signed by the choices HCBS waiver program participant and the HCAS provider.

(3) The rates negotiated by the choices HCBS waiver consumer with providers of services in paragraph (C) of this rule shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code. The negotiated rate shall be reviewed by the consumer's case manager and reflected on the consumer's service plan prior to service delivery.

(4) Should the consumer choose not to negotiate a rate of reimbursement for any of the services in paragraph (C) of this rule, the service shall be reimbursed at a rate proposed by the provider and accepted by the consumer and the consumer's case manager. The accepted rate shall be reflected on the consumer's service plan and shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code.

(D) ODA certified long-term care providers shall be reimbursed in accordance with an agreement signed between the provider and the PASSPORT administrative agency (PAA) for the following services:

(1) Adult day health;

(2) Home delivered meals;

(3) Personal emergency response system; and

(4) Home medical equipment and supplies.

The reimbursement rates contained in the agreement shall be set in accordance with rule 5101:3-31-07 of the Administrative Code. The rate shall be reflected on the consumer's service plan and shall not exceed the maximum allowed per unit of service as specified in appendix A to rule 5101:3-1-06.4 of the Administrative Code.

(E) Payment for choices HCBS wavier covered services constitutes payment in-full and may not be construed as a partial payment when the payment amount is less than the provider's usual and customary charge. The provider may not bill the consumer for any difference between the medicaid payment and the provider's charge or request the recipient to share in the cost through a co-payment or other similar charge. The provider shall accept medicaid payment as payment in full.

Effective: 09/29/2011
R.C. 119.032 review dates: 07/14/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85 , 173.403
Prior Effective Dates: 8/30/01, 7/1/05, 7/1/11 (Emer.)