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