(A) Purpose.
(1) The purpose of this rule is to
establish the self-empowered life funding waiver as a component of the medicaid
home and community-based services program pursuant to sections 5166.02 and
5166.20 of the Revised Code.
(2) The self-empowered life funding
waiver program provides necessary waiver services to individuals who meet
criteria for a developmental disabilities level of care in accordance with rule
5123-8-01 of the Administrative Code, as well as other eligibility requirements
established in this rule.
(3) The Ohio department of developmental
disabilities (DODD), through an interagency agreement with the Ohio department
of medicaid (ODM), administers the self-empowered life funding waiver program
on a daily basis in accordance with section 5162.35 of the Revised
Code.
(4) This waiver will provide services
under a participant-directed model to individuals with developmental
disabilities in order to avoid or delay institutionalization.
(B) Definitions.
(1) "County board" means a
county board of developmental disabilities established under Chapter 5126. of
the Revised Code.
(2) "Home and community-based
services (HCBS)" means any federally approved medicaid waiver service
provided to a waiver enrollee as an alternative to institutional care under
Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42
U.S.C.1396n, as in effect on October 1, 2019, under which federal reimbursement
is provided for designated home and community-based services to eligible
individuals.
(3) "Individual" means a person
with a developmental disability who is eligible to receive HCBS as an
alternative to placement in an intermediate care facility for individuals with
intellectual disabilities (ICF/IID) under the applicable HCBS waiver. A
guardian or authorized representative may give, refuse to give, or withdraw
consent for services or may receive notice on behalf of an individual to the
extent permitted by applicable law.
(4) "Individual Service Plan
(ISP)" means a written description of the services, supports, and
activities to be provided to an individual in accordance with paragraph (H) of
this rule.
(5) "Participant direction" has
the same meaning as defined in rule 5123-9-40 of the Administrative
Code.
(6) "Provider" means a person
or agency certified or licensed by DODD that has met the provider qualification
requirements to provide the specific self-empowered life funding waiver service
as specified in paragraph (J)(1) of this rule and holds a valid medicaid
provider agreement in accordance with paragraph (J)(2) of this
rule.
(7) "SSA" means a service and
support administrator who is certified in accordance with rule 5123:2-5-02 of
the Administrative Code and who provides the functions of service and support
administration.
(8) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
enrollment date or a subsequent eligibility re-determination date.
(C) Request for a referral for the self-empowered life funding
waiver.
(1) Individuals seeking to enroll in the
self-empowered life funding waiver program may do one of the
following:
(a) Request a referral through a local county job and family
services (CDJFS);
(b) Request a referral to a local county board;
(c) Request a referral online through the Ohio benefits
self-service portal (www.benefits.Ohio.gov);
(d) Request a referral over the phone
(800-324-8680).
(2) The county board is responsible for
explaining to individuals requesting HCBS the services available through the
self-empowered life funding waiver benefit package including the amount, scope
and duration of services and any applicable benefit package
limitations.
(D) Eligibility criteria for the self- empowered life funding
waiver.
(1) The individual requesting a referral
for the self-empowered life funding waiver program must be determined to meet
the criteria for a developmental disabilities level of care in accordance with
rule 5123-8-01 of the Administrative Code upon initial enrollment and no later
than every twelve months thereafter; and
(2) The individual's medicaid
eligibility has been established in accordance with Chapters 5160:1-1 to
5160:1-6 of the Administrative Code; and
(3) The individual's health and
welfare needs can be met through the utilization of self-empowered life funding
waiver services at or below the federally approved cost limitation and other
formal and informal supports regardless of funding source.
(E) Self-empowered life funding waiver enrollment, continued
enrollment, and disenrollment.
(1) Individuals who meet the eligibility
criteria in paragraph (D) of this rule, or their legal representative, shall be
informed of the following:
(a) All services available on this self-empowered life funding
waiver, and any choices that the individual may make regarding those
services;
(b) Any feasible alternative to the waiver; and
(c) The right to choose either institutional or home and
community-based services.
(2) DODD shall allocate waivers to the
county board in accordance with section 5166.22 of the Revised
Code.
(3) The county board shall offer an
available self-empowered life funding waiver to eligible individuals in
accordance with applicable waiting list category requirements set forth in
rules 5160-41-05 and 5123-9-04 of the Administrative Code.
(4) An individual's continued
enrollment in the self-empowered life funding waiver program shall be
redetermined no less frequently than every twelve months beginning with the
individual's initial enrollment date or subsequent redetermination date.
Individuals must continue to meet the eligibility criteria specified in
paragraph (D) of this rule to continue enrollment in the waiver
program.
(5) The maximum number of individuals
that can be enrolled in the self-empowered life funding waiver program
statewide shall not exceed the allowable number specfied as federally
approved.
(6) The individual must require at least
one waiver service monthly, or, if less than monthly, require monthly
monitoring of the individual's health and welfare. If no services are
planned to be delivered in a month, monthly monitoring of the individual's
health and welfare must be required in the ISP, as designated in paragraph (H)
of this rule, and must include at least periodic face-to-face
monitoring.
(7) While enrolled in the self-empowered
life funding waiver program, if the enrollee does not receive any waiver
services for one month, the county board shall assess the enrollee's
current need for waiver services, monitor the individual to verify the
individual's ongoing need for waiver enrollment, and discuss these needs
with the enrollee and their representative. As a result of the assessment and
discussion, if no waiver services are needed, the enrollee shall be recommended
for disenrollment from the waiver program and shall be given notification of
hearing rights as established in paragraph (M) of this rule.
(F) The self-empowered life funding waiver program benefit
package, as included in the federally approved waiver application, is limited
to the services specified in Chapters 5123:2-9 and 5123-9 of Administrative
Code.
(G) Self-empowered life funding waiver benefit limitations shall
be in accordance with the benefit limitations as established in rule 5123-9-40
of the Administrative Code.
(H) Self-empowered life funding service plan
requirements.
(1) All services shall be provided to an
individual enrolled in the self-empowered life funding waiver program pursuant
to a written ISP.
(2) The ISP shall be developed by
qualified persons with input from the self-empowered life funding waiver
enrollee and the SSA in accordance with section 5126.15 of the Revised Code.
Providers shall participate in the ISP meetings when a request for their
participation is made by the individual enrollee.
(3) The ISP shall contain
the following required criteria, and will comport with the outlined procedures
for review and revision:
(a) The ISP shall list the self-empowered life funding waiver
services and the non-waiver services, regardless of funding source, that are
necessary to ensure the enrollee's health and welfare; and
(b) The ISP shall contain the following medicaid required
elements:
(i) Type of service to be provided; and
(ii) Amount of service to be provided; and
(iii) Frequency and duration of each service to be provided;
and
(iv) Type of provider to furnish each service.
(c) The ISP shall be reviewed on at least an annual basis
consistent with the individual's redetermination as indicated in paragraph
(E) of this rule or as the individual's needs change and in accordance
with rule 5123:2-1-11 of the Administrative Code; and
(d) The SSA shall review and revise the ISP more frequently than
the required annual basis under the following circumstances:
(i) At the request of the
individual or a member of the individual's team; or
(ii) Whenever the
individual's assessed needs, situation, circumstances or status changes;
or
(iii) If the individual
chooses a new provider or type of service or support; or
(iv) As a result of the
continuous review process of the ISP; or
(v) Identified trends and
patterns of unusual or major unusal incidents; or
(vi) When services are
reduced, denied, or terminated.
(e) The ISP shall be developed to include only waiver services
which are consistent with efficiency, economy and quality of care;
and
(f) The ISP is subject to approval by ODM and DODD pursuant to
section 5166.05 of the Revised Code. Notwithstanding the procedures set forth
in this rule, ODM may in its sole discretion, and in accordance with section
5166.05 of the Revised Code direct the county board or DODD to amend ISPs for
individuals if ODM determines that such services are medically necessary and
the procedures set forth in this rule would not accommodate a request for such
medically necessary services.
(I) Free choice of provider.
Individuals enrolled in the self-empowered life
funding waiver program shall be given a free choice of qualified self-empowered
life funding waiver providers in accordance with rules 5160-41-08 and
5123:2-9-11 of the Administrative Code. A provider is qualified if they meet
the standards established in paragraph (J)(2) of this rule. DODD shall create
and maintain an internet-based list of those providers who are qualified to
provide self- empowered life funding waiver services. This list will be
accessible to county boards and individuals applying for or receiving services.
The county board shall assist an individual, as needed, with exercising the
right to free choice of provider in accordance with rule 5123:2-9-11 of the
Administrative Code.
(J) Provision of self-empowered life funding waiver
services.
(1) Self-empowered life funding waiver
services shall be provided by persons or agencies who have certification or
licensure in accordance with section 5123.045 of the Revised Code and
administrative rules promulgated by DODD; or
(2) At the discretion of DODD, any provider approved by ODM
or certified by the Ohio department of aging (ODA) may also be eligible to
provide waiver services so long as the provider has satisfied the requirements
for certificiation by DODD for the same or similar services; and
(3) Self-empowered life funding waiver
services shall be provided by persons or agencies who have a valid medicaid
provider agreement in accordance with rule 5160-1-17.2 of the Administrative
Code; and
(4) Self-empowered life funding services
shall be provided only to individuals who have met the eligibility requirements
in paragraph (D) of this rule and are enrolled in the self-empowered life
funding waiver program at the time of service delivery; and
(5) Self-empowered life funding waiver
services shall be provided in accordance with each enrollee's ISP as
specified in paragraph (H) of this rule; and
(6) No provider of self-empowered life
funding waiver services shall enter into or maintain any contract with an
enrollee for the provision of waiver services except as noted in paragraph
(J)(2) of this rule.
(K) Provider payment standards.
Provider payment standards for the self-empowered
life funding waiver are established in Chapters 5160-41, 5123:2-9, and 5123-9
of the Administrative Code.
(L) Monitoring, compliance, and sanctions.
ODM shall conduct periodic monitoring and
compliance reviews related to the self-empowered life funding waiver program in
accordance with section 5162.10 of the Revised Code. Reviews may consist of,
but are not limited to, physical inspections of records and sites where
services are provided, interviews of providers, recipients, and administrators
of waiver services. Certified self-empowered life funding waiver providers, in
accordance with the medicaid provider agreement, DODD, and county board shall
furnish to ODM, the center for medicare and medicaid services (CMS), and the
medicaid fraud control unit or their designees any records related to the
administration and/or provision of self- empowered life funding waiver
services. Individuals enrolled in the self-empowered life funding waiver
program shall cooperate with all monitoring, compliance, and quality assurance
reviews conducted by ODM, CMS, and the medicaid fraud control unit or their
designee.
(M) Due process.
(1) When DODD, ODM, or the county board
takes action to approve, deny, or terminate enrollment in the self-empowered
life funding waiver, or to deny or change the level and/or type of waiver
services delivered to a self-empowered life funding waiver enrollee, the entity
recommending or taking action will provide medicaid due process in accordance
with section 5101.35 of the Revised Code through the state fair hearing
process, and as specified in Chapters 5101:6-1 to 5101:6-9 of the
Administrative Code.
(2) When an individual requests a
hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative
Code, the participation of DODD and the county board is required during the
hearing proceedings to justify the decision under appeal.
