Chapter 5160-33 Assisted living HCBS waiver program

5160-33-02 Definitions for the assisted living home and community based services waiver (HCBS) program.

(A) The purpose of this rule is to define the terms used in Chapter 5160-33 of the Administrative Code governing the medicaid assisted living HCBS waiver program.

As used in this chapter:

(B) "ADL" means activities of daily living including bathing; grooming; toileting; dressing; eating; and mobility, which refers to bed mobility, transfer, and locomotion as these are defined in 5160-3-05 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) " Assisted living waiver" (ALW) means the home and community based services waiver, approved by the centers for medicare and medicaid services, that is administered by the Ohio department of aging.

(E) "Authorized representative" has the same meaning as in rule 5160-1-33 of the Administrative Code.

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

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

(H) "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 that administers the medicaid program and approves HCBS waivers.

(I) "Case management" means a set of person centered activities provided by ODA's designee that are undertaken to ensure that the individual 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.

(J) "Certified" or "certification" means providers certified by the Ohio department of aging (ODA) to provide services for assisted living HCBS waiver individuals pursuant to Chapter 173-39 of the Administrative Code.

(K) "HCBS" or "home and community-based services" means services furnished under the provisions set forth in 42 C.F.R. 441 Subpart G ( October 1, 2016) that permit individuals to live in a home setting rather than a nursing facility (NF) or hospital. HCBS waiver services are approved by CMS for specific populations and are not otherwise available under the medicaid state plan.

(L) "Home first" means the component of the assisted living HCBS waiver program that offers priority enrollment in the waiver for certain individuals in accordance with section 173.542 of the Revised Code.

(M) "Individual" is a person enrolled on the assisted living HCBS waiver.

(N) "Level of care" (LOC) means the designation describing an individual's functional levels and nursing needs pursuant to the criteria set forth in rules 5160-3-05, 5160-3-06, 5160-3-07, and 5160-3-08 of the Administrative Code.

(O) "NF" means a nursing facility as defined in section 5165.01 of the Revised Code.

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

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

(R) "PASSPORT" means preadmission screening system providing options and resources today.

(S) "ODA's designee" has the same meaning as in rule 173-39-01 of the Administrative Code. "

(T) "Residential care facility" means a residential care facility as defined in section 3721.01 of the Revised Code that is issued a license pursuant to section 3721.02 of the Revised Code.

(U) "Room and board" means a payment made by an individual enrolled in the assisted living waiver directly to the ODA certified assisted living waiver provider. When paying "room" the individual shall not be charged for the same furnishings and other shelter expenses the residential care facility provides at no cost to private pay non-waiver residents pursuant to the facility's resident agreement. The term "board" means three meals a day or any other full nutritional regimen.

Room and board does not include charges for ancillary items, services, and/or social activities purchased or paid for by the individual including hygiene and supplies not provided through medicaid and reflected on the individual's care plan, recreation and activities, and/or other items or services purchased by the individual; however ODA certified assisted living providers may, at their own discretion, provide ancillary items, services and/or social activities as part of the room and board payment.

(V) "Service Plan" has the same meaning as the person-centered service plan in paragraph (B) in rule 5160-44-02 of the Administrative Code.

Cite as Ohio Admin. Code 5160-33-02

Effective: 4/1/2017
Five Year Review (FYR) Dates: 12/27/2016 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/06, 12/31/09, 9/29/2011

5160-33-03 Eligibility for the assisted living home and community based services (HCBS) waiver program.

(A) The purpose of this rule is to outline the requirements that must be met for an individual to be eligible to enroll in the assisted living HCBS waiver.

(B) To be eligible for the assisted living program, an individual must meet all of the following requirements:

(1) The individual must have an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code.

(2) If the individual requires skilled nursing care beyond supervision of special diets, application of dressings, or administration of medication, it must be provided in accordance with rule 3701-17-59.1 of the Administrative Code.

(3) At the time of enrollment, and while receiving assisted living HCBS services, the individual must reside in an approved living unit in a licensed residential care facility (RCF) certified by the Ohio department of aging (ODA) that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, including:

(a) A residential care facility that is owned or operated by a metropolitan housing authority that has a contract with the United States department of housing and urban development to receive an operating subsidy or rental assistance for the residents of the facility;

(b) A county or district home licensed as a residential care facility.

(4) The individual must participate in the development of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(5) The individual must have been determined eligible for medicaid in accordance with rules 5160:1-2-03 and 5160:1-1-58 5160:1-1 to 5160:1-5 of the Administrative Code.

(6) The cost of the twelve-month service plan does not exceed the cost limit in effect for the program that is based on the maximum per-diem rate for assisted living services plus the maximum amount authorized for community transition services.

(7) The individual must have the ability to make room and board payments calculated at the current supplemental security income (SSI) federal benefit level minus fifty dollars.

(8) The individual is age twenty-one or older at the time of enrollment.

(9) The assisted living HCBS waiver has not reached the centers for medicare and medicaid services (CMS) authorized limit of participants for the current year.

(10) The individual's health related needs, as determined by ODA's designee, can be safely met while residing in a setting described in paragraph (B)(3) of this rule.

(C) Providers shall not charge or collect room and board payments from indviduals in excess of the room and board payment calculated in paragraph (B)( 7) of this rule.

(D) If, at any time, the individual fails or ceases to meet any of the eligibility requirements identified in this rule, the individual shall be denied or disenrolled from the assisted living HCBS waiver. In such instances, the individual shall be notified of his or her hearing rights in accordance with division 5101:6 of the Administrative Code.

Cite as Ohio Admin. Code 5160-33-03

Effective: 11/25/2016
Five Year Review (FYR) Dates: 09/30/2020
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/2006, 3/22/2008, 9/19/2009, 9/29/2011, 10/4/2015

5160-33-04 Enrollment process for assisted living home and community based services (HCBS) waiver program.

(A) Individuals who wish to enroll in the assisted living HCBS waiver must have an eligibility determination made by the county department of job and family services (CDJFS) and an assessment of assisted living HCBS waiver eligibility made by the ODA's designee. The individual may contact either the CDJFS or ODA's designee to start the enrollment process and the two agencies shall coordinate processing the request for enrollment into the assisted living HCBS waiver program:

(1) Individuals initially contacting the CDJFS will complete the JFS 07200 "Request for Cash, Food Stamps, and Medical Assistance" (rev. 03/10) and the JFS 02399 "Request for Medicaid Home and Community Based Services" (rev. 01/06) in accordance with rules 5160:1-1 to 5160:1-5 of the Administrative Code. The CDJFS shall notify the ODA's designee of the individual's application for waiver services. The ODA's designee shall initiate contact with the individual to complete the enrollment process.

(2) Individuals initially contacting ODA's designee will receive an in-person assessment to determine eligibility for the assisted living HCBS waiver program. If the individual has not already initiated an application for medicaid or waiver eligibility as described in paragraph (A)(1) of this rule, ODA's designee may assist the individual.

(B) If the individual has been determined eligible and a waiver slot is available, the individual shall be enrolled in accordance with the assisted living HCBS waiver's home first component, if applicable, and rule 173-38-03 of the Administrative Code.

(C) Pursuant to rule 5160:1-2-01.6 of the Administrative Code, if a individual is determined eligible for medicaid by the CDJFS, the individual shall not enroll in the assisted living HCBS waiver program until ODA's designee establishes a waiver program enrollment date and authorizes the provision of waiver services by an ODA certified assisted living provider. The waiver program enrollment date shall in no way restrict retroactive eligibility for non-assisted living waiver services available to individuals through the medicaid state plan.

(D) Any applicant for assisted living services 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.

Cite as Ohio Admin. Code 5160-33-04

Effective: 4/1/2017
Five Year Review (FYR) Dates: 12/27/2016 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/06, 3/22/08, 9/19/09, 9/29/2011

5160-33-05 Provider conditions of participation for the assisted living home and community based services (HCBS) waiver program.

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

(B) In order to obtain a medicaid provider agreement to be an assisted living services provider, the provider must be certified by the Ohio department of aging (ODA) or its designee in accordance with the provisions of rule 173-39-03 of the Administrative Code.

(C) Individuals enrolled in the assisted living HCBS waiver shall be given a free choice of qualified providers in accordance with rule 173-42-06 of the Administrative Code and 42 C.F.R. 431.51 (as in effect on October 1, 2016).

Cite as Ohio Admin. Code 5160-33-05

Effective: 4/1/2017
Five Year Review (FYR) Dates: 12/27/2016 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/206, 9/29/2011

5160-33-06 Covered services for the assisted living services home and community based services (HCBS) waiver program.

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

(B) The assisted living HCBS waiver benefit package is limited to the following services:

(1) Assisted living services as set forth in rule 173-39-02.16 of the Administrative Code, and

(2) Community transition services as set forth in rule 173-39-02.17 of the Administrative Code.

(C) Services will be delivered consistent with the individual's person-centered service plan.

Cite as Ohio Admin. Code 5160-33-06

Effective: 4/1/2017
Five Year Review (FYR) Dates: 12/27/2016 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/2016, 9/29/2011

5160-33-07 Assisted living home and community based services (HCBS) waiver rate setting.

(A) The purpose of this rule is to describe the methods used to determine provider rates for the assisted living HCBS waiver as set forth in appendix A to rule 5160-1- 06.5 of the Administrative Code.

(B) Provider rates will be determined for the following categories:

(1) Per job bid rate or deposit made.

(2) Unit rate.

(C) A per job bid rate or deposit made shall be determined on a per job basis for the community transition service as set forth in rule 173-39-02.17 of the Administrative Code. The cost per job shall be reimbursed at a per job bid rate that is negotiated and approved by Ohio department of aging's (ODA) designee and accepted by the individual. The per job bid rate includes the cost of the purchase, delivery, and set-up of items. Deposits made include set-up fees or deposits for utility service access.

(D) A unit rate shall be based on a three-tiered model, and shall not exceed the amounts in appendix A to rule 5160-1- 06.5 of the Administrative Code. These rates will be used for assisted living services as set forth in rule 173-39-02.16 of the Administrative Code.

(1) The rate for assisted living services for each individual shall be determined by the ODA's designee through an assessment of the individual's service needs in four areas:

(a) Cognitive impairments,

(b) Medication administration,

(c) Nursing services, and

(d) Functional impairments.

(2) The assisted living HCBS waiver provider must agree to provide the services in the individual's person-centered service plan at the rate determined by the assessment.

(E) ODA certified assisted living providers shall only be reimbursed for assisted living services authorized by ODA's designee and reflected on the individual's person-centered service plan.

(F) Assisted living service payment constitutes payment in full and may not be construed as a partial payment when the payment amount is less than the provider's charge. The provider may not bill the individual of assisted living HCBS waiver program services for any difference between the medicaid payment and the provider's charge or request that the individual share in the cost through a co-payment or other similar charge.

(G) The assisted living service payment is for assisted living services as defined in rule 173-39-02.16 of the Administrative Code and does not include payment for room and board as calculated pursuant to rule 5160-33-03 of the Administrative Code, which is the responsibility of the individual.

Cite as Ohio Admin. Code 5160-33-07

Effective: 4/1/2017
Five Year Review (FYR) Dates: 12/27/2016 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 173.54
Prior Effective Dates: 7/1/06, 3/22/08, 9/19/09, 9/29/2011