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 5101:3-33 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 Chapter 5101:3-3 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 HCBS waiver" means the medicaid program that serves individuals residing in licensed residential care facilities that are certified by ODA and enrolled on the waiver who would otherwise receive services in a nursing facility if the waiver program were not available.

(E) "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.

(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 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.

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

(K) "Consumer" means the program participant and the representative who assists in directing the consumer's care.

(L) "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, 2009) 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.

(M) "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 5111.894 of the Revised Code.

(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 5101:3-3-05, 5101:3-3-06, 5101:3-3-07 and 5101:3-3-08 of the Administrative Code.

(O) "NF" means a nursing facility as defined in section 5111.20 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) "PAA" means PASSPORT administrative agency.

(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 a consumer enrolled in the assisted living waiver directly to the ODA certified assisted living waiver provider. When paying "room" the consumer 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 consumer including hygiene and supplies not provided through medicaid and reflected on the consumer's care plan, recreation and activities, and/or other items or services purchased by the consumer; 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" 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 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/01/06/ 12/31/09

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 criteria 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 5101:3-3-05 or 5101:3-3-06 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 a residential care facility (RCF) certified by the Ohio department of aging (ODA), 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 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.

(5) 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.

(6) 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.

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

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

(9) The individual's health related needs, as determined by the PASSPORT administrative agency, can be safely met in a RCF as described in paragraph (B)(3) of this rule.

(C) Providers shall not charge or collect room and board payments from consumers in excess of the room and board payment calculated in paragraph (B)(6) of this rule.

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

(E) An individual who has been enrolled in the assisted living HCBS waiver may subsequently be enrolled in hospice, however, an individual who is enrolled in hospice and is not currently enrolled in a HCBS waiver is not subsequently eligible for assisted living HCBS enrollment.

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 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/1/06, 3/22/08, 9/19/09

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 PASSPORT administrative agency (PAA). The individual may contact either the CDJFS or the PAA 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 5101:1-38- 01.2and 5101:1-38.01.6 of the Administrative Code. The CDJFS shall notify the PAA of the individual's application for waiver services. The PAA shall initiate contact with the individual to complete the enrollment process.

(2) Individuals initially contacting the PAA 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, the PAA may assist the individual.

(B) If the individual has been determined eligible and a waiver slot is available, the consumer 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 5101:1-38-01.6 of the Administrative Code, if a consumer is determined eligible for medicaid by the CDJFS, the consumer shall not enroll in the assisted living HCBS waiver program until the PAA establishes a waiver program enrollment date and authorizes the provision of waiver services by an ODA certified RCF. The waiver program enrollment date shall in no way restrict retroactive eligibility for non-assisted living waiver services available to consumers 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.

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 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/01/06, 3/22/08, 9/19/09

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, 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 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/1/06

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 defined in rule 173-39-02.16 of the Administrative Code, and

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

(C) Services will be delivered consistent with the consumer's 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 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/1/06

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 5101:3-1-06.5 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 consumer. 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 5101:3-1-06.5 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 consumer shall be determined by the preadmission screening system providing options and resources today (PASSPORT) administrative agency through an assessment of the consumer'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 consumer's plan of care at the rate determined by the assessment.

(E) ODA certified assisted living providers shall only be reimbursed for assisted living services authorized by the PASSPORT administrative agency (PAA) and reflected on the consumer's 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 consumer of assisted living HCBS waiver program services for any difference between the medicaid payment and the provider's charge or request that the consumer 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 5101:3-33-03 of the Administrative Code, which is the responsibility of the consumer.

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 , 5111.89
Rule Amplifies: 5111.85 , 5111.89
Prior Effective Dates: 7/1/06, 3/22/08, 9/19/09, 7/1/07