Chapter 5160-41 HCBS Waiver VII Program

5160-41-05 Waiting lists for home and community-based services administered by the Ohio department of developmental disabilities.

(A) Purpose

This rule sets forth the requirements of a county board of developmental disabilities to establish and maintain a waiting list for home and community-based services.

(B) Definitions

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code with local administrative authority.

(2) "DODD" means the Ohio department of developmental disabilities established under section 121.02 of the Revised Code.

(3) "Home and community-based services" means services provided under a medicaid-funded waiver pursuant to section 5111.871 of the Revised Code.

(4) "ODJFS" means the Ohio department of job and family services as established under section 121.02 of the Revised Code.

(5) "Waiting lists" means a list established and maintained in accordance with rule 5123:2-1-08 of the Administrative Code.

(C) Requirements

(1) County boards shall establish and maintain waiting lists for home and community-based services in accordance with rule 5123:2-1-08 of the Administrative Code.

(2) There shall be no waiting list for the following services:

(a) Medicaid state plan services.

(b) Home and community-based services for individuals already enrolled in a home and community-based services waiver administered by DODD who are assessed and determined to have a need for the services covered by the waiver in which the individual is enrolled.

(c) Home and community-based services to children who are subject to a determination under section 121.38 of the Revised Code and require the services.

(D) Due process shall be available to an individual aggrieved by an action of a county board related to the establishment or maintenance of, placement on, the failure to offer services in accordance with, or removal from a waiting list.

(E) DODD shall monitor compliance with this rule by the county boards and their contract agencies.

Replaces: 5101:3-41-05

Effective: 09/15/2011
R.C. 119.032 review dates: 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.85 , 5111.871 , 5123.046 , 5126.042
Prior Effective Dates: 2/15/02 (Emer.), 5/09/02

5160-41-08 Free choice of provider requirements for medicaid home and community-based services programs administered by the Ohio department of developmental disabilities.

(A) The purpose of this rule is to set forth the requirements the Ohio department of developmental disabilities (DODD) must meet to assure free choice of provider.

(B) The (DODD), through an interagency agreement with the Ohio department of job and family services (ODJFS), acts as the administrative agency for components of the medicaid home and community-based services programs in accordance with section 5111.91 of the Revised Code. In accordance with section 5111.871 of the Revised Code, the DODD, as the designated administrator, shall promulgate rule(s) to require that recipients of home and community-based services are provided choice of medicaid home and community-based providers consistent with federal free choice of provider requirements set forth in 42 C.F.R. 431.51 (as amended December 4, 2007). Any rule(s) authorized by this rule and promulgated by the DODD are valid only to the extent they are consistent with 42 C.F.R. 431.51 . If the rules promulgated by DODD are capable of more than one interpretation, they shall be applied in a manner most consistent with the letter and intent of 42 C.F.R. 431.51 .

(C) Rules promulgated by DODD shall establish policies related to the provision of free choice of medicaid home and community-based service providers for each service specified in a recipient's individual service plan and shall include the following:

(1) The general roles and responsibilities of the county board of mental retardation and developmental disabilities as specified in rule 5123: 2-9-11 of the Administrative Code.

(2) The roles and responsibilities of the county board of developmental disabilities for the assurance of due process and fair hearing rights regarding recipients' free choice of medicaid home and community-based service providers.

(3) The roles and responsibilities of DODD for monitoring and assuring compliance with recipients' free choice of medicaid home and community-based service provider requirements.

(D) ODJFS shall conduct periodic monitoring and compliance reviews related to free choice of medicaid home and community-based service providers.

Effective: 09/15/2011
R.C. 119.032 review dates: 06/28/2011 and 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.871
Rule Amplifies: 5111.85 , 5111.871
Prior Effective Dates: 7/1/05

5160-41-11 Home and community-based waiver services-payment for waiver services administered by the department of developmental disabilities.

(A) Purpose.

The purpose of this rule is to establish the payment standards governing reimbursement for home and community-based services (HCBS) provided by certified or licensed waiver providers to individuals enrolled in a HCBS program as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5111.85 and 5111.873 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS) in accordance with sections 5111.91 and 5111.871 of the Revised Code.

(C) Individuals enrolled in the individual options or level one HCBS programs administered by DODD shall be subject to the payment standards set forth in rules 5101:3-41-18 and 5101:3-41-19 of the Administrative Code.

(D) The standards and procedures set for prior authorization as defined in rule 5101:3-41-12 of the Administrative Code shall apply for individuals enrolled on the individual options waiver.

(E) For purposes of payment, HCBS services provided to individuals enrolled on the level one or individual options waivers must meet the definition of the waiver service as defined in the federally approved waiver document.

(F) Projection of costs for HCBS services.

(1) Beginning on and after December 31, 2010, the county boards of developmental disabilities shall project waiver service costs in accordance with the individual service plan for individuals initially enrolled on the individual options or level one waivers or at an enrollee's annual re-determination date for waiver services by using the authorized cost projection tool as referenced in rule 5123:2-9-06 of the Administrative Code.

(2) HCBS service cost projections made in accordance with paragraph (F)(1) of this rule shall be completed no later than December 31, 2011.

(3) DODD providers of HCBS waiver services shall have access to the cost projection tool upon request to the department. Providers may prepare draft versions of the cost projection tool and forward to the county board for consideration.

(G) Homemaker personal care rate modification for former residents of developmental centers.

(1) DODD shall pay an add-on rate modification for routine homemaker personal care services to providers serving individuals that are former residents of developmental centers in accordance with section 263.20.70 Amended Substitute House Bill No. 153 of the 129th General Assembly. The add-on will apply if the following conditions are met:

(a) The individual was a resident of a developmental center prior to enrollment in the individual options waiver; and

(b) The homemaker personal care service is identified in the individual service plan and the individual began receiving the service on or after July 1, 2011; and

(c) The director of DODD determines that the homemaker personal care add-on is warranted by the individual's special circumstances, including the individual's diagnosis, service needs, or length of stay at the developmental center, and that serving the individual through the individual options waiver is fiscally prudent for the medicaid program.

(2) The homemaker personal care rate add-on modification referenced in paragraph (G) of this rule shall be limited to fifty-two cents for each fifteen minute unit of routine homemaker personal care service provided to the individual.

(3) The homemaker personal care rate add-on modification amount shall be limited to former developmental center residents during the first year of their waiver enrollment and shall apply for enrollments beginning on or after July 1, 2011 and ending June 30, 2013.

(4) DODD shall provide ODJFS with supporting documentation of the homemaker personal care rate add-on for former developmental center residents upon request.

(H) ODJFS authority.

ODJFS retains the final authority to establish payment rates for waiver services approved under the level one and individual options waivers and has final approval of any policies and rules that govern any component of the medicaid program.

(I) Due process.

(1) Applicants for waiver enrollment or individuals enrolled on any waiver administered by DODD shall be afforded 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) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD, and/or the county board of developmental disabilities is required during the hearing proceedings to justify the decision under appeal, in accordance with section 5126.055 of the Revised Code.

Replaces: 5101:3-41-11

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Effective: 03/19/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.873 , 5111.91 , 5111.871
Rule Amplifies: 5111.85 , 5111.873
Prior Effective Dates: 7/1/05, 10/1/07, 12/21/07 (Emer.), 3/20/08, 7/1/10, 7/15/11

5160-41-12 Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver.

(A) Purpose.

The purpose of this rule is to authorize the process for prior authorization of waiver services when an individual funding level exceeds the funding range determined by the Ohio developmental disabilities profile (ODDP) for individuals enrolled in the individual options waiver.

(B) Standards and procedures.

(1) The prior authorization process shall be followed in accordance with rule 5123:2-9-07 of the Administrative Code.

(2) The Ohio department of developmental disabilities (DODD) shall inform the office of medical assistance (OMA) of all approvals and denials. OMA may review all approvals and denials and may take corrective action in accordance with 42 C.F.R. 431.246 .

(3) DODD and the county board shall maintain all records related to the review of prior authorizations for a period of six years following receipt of the request.

(C) Provider payment standards.

Provider payment standards for the individual options waiver are established in rule 5101:3-41-18 and Chapter 5123:2-9 of the Administrative Code.

(D) Monitoring, compliance, and sanctions.

(1) DODD shall submit to OMA, on a quarterly basis, a summary of requests for prior authorization received. DODD shall also systematically evaluate compliance with prior authorization requirements by verifying that each individual's funding level is maintained within the prior authorized amount. Results of this evaluation shall be provided in writing to OMA no less than quarterly.

(2) OMA shall periodically analyze the frequency and distribution of all requests for prior authorization to identify statistically significant patterns or trends.

(E) Due process.

Applicants for waiver enrollment or individuals enrolled on any waiver administered by DODD shall be afforded 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.

(F) OMA authority.

OMA retains the final authority to establish payment rates for waiver services approved under the individual options waiver, and to approve individual service plans, and has final approval of any policies and rules that govern any component of the medicaid program.

Replaces: Part of 5101:3-41-12

Effective: 01/17/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.871 , 5123.04
Rule Amplifies: 5111.871 , 5123.04
Prior Effective Dates: 7/1/05

5160-41-15 Home and community based waiver services-reimbursement for adult day services as administered by the department of developmental disabilities.

(A) Individuals receiving an adult day service through a medicaid waiver program administered by the Ohio department of developmental disabilities (DODD) in accordance with sections 5111.85 and 5111.873 of the Revised Code shall be subject to payment standards set forth in this rule and in the following rules of the Administrative Code as specified:

(1) Vocational habilitation shall be in accordance with rules 5123:2-9-14 and 5123:2-9-19 of the Administrative Code.

(2) Supported employment- community shall be in accordance with rules 5123:2-9-15 and 5123:2-9-19 of the Administrative Code.

(3) Supported employment- enclave shall be in accordance with rules 5123:2-9-16 and 5123:2-9-19 of the Administrative Code.

(4) Adult day support shall be in accordance with rules 5123:2-9-17 and 5123:2-9-19 of the Administrative Code.

(5) Non medical transportation shall be in accordance with rules 5123:2-9-18 and 5123:2-9-19 of the Administrative Code.

(B) County boards of developmental disabilities shall submit cost reports to the DODD for the purpose of allocating adult day services costs. The format of the cost report shall be designed by DODD and accepted by ODJFS.

(C) Due process.

(1) Applicants for waiver enrollment or individuals enrolled on a waiver administered by DODD shall be afforded 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) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD and/or the county board of developmental disabilities is required during the hearing proceedings to justify the decision under appeal in accordance with section 5126.055 of the Revised Code.

(D) Monitoring.

ODJFS shall monitor reimbursement made under authority of this rule as necessary to ensure that the funding applicable to home and community-based services (HCBS) is used for authorized purposes in compliance with laws, regulations and provisions governing the medicaid program.

Replaces: 5101:3-41-15

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Effective: 09/15/2012
R.C. 119.032 review dates: 09/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.873 , 5111.85
Rule Amplifies: 5111.873 , 5111.85
Prior Effective Dates: 1/01/07, 07/01/07, 10/01/07

5160-41-16 Assistance to enable a county board of developmental disabilities to pay non-federal share of medicaid expenditures for home and community-based services.

(A) Purpose.

This rule authorizes the provisions set forth in rule 5123:1-5-02 of the Administrative Code which sets forth the process a county board of developmental disabilities must follow to request assistance from the department of developmental disabilities(DODD) in the event of failure of a county property tax levy for home and community-based services (HCBS) to individuals with developmental disabilities in that county.

(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" means medicaid-funded home and community-based services provided pursuant to section 5111.871 of the Revised Code.

(3) "OBM" means the office of budget and management as established by section 121.02 of the Revised Code.

(4) "ODJFS" means the Ohio department of job and family services as established under section 121.02 of the Revised Code.

(5) "DODD" means the Ohio department of developmental disabilities established under section 121.02 of the Revised Code.

(C) Requirements.

(1) A county board of developmental disabilities may request assistance from the DODD to pay the non-federal share of medicaid expenditures for HCBS services when a local county board operating levy fails in accordance with rule 5123:1-5-02 of the Administrative Code.

(2) Prior to a county board of developmental disabilities receiving assistance, the DODD shall notify and consult with both OBM and the ODJFS, office of Ohio health plans.

(3) Documentation submitted by a county board to make a request for assistance and/or any documentation used by the department to determine a decision of approval or denial shall be made available to OBM or ODJFS upon request.

Effective: 09/01/2010
R.C. 119.032 review dates: 09/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.01 , 5111.02 , 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85

5160-41-17 Medicaid home and community-based services program - self-empowered life funding waiver.

(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 5111.85 and 5111.87 of the Revised Code.

(2) The self-empowered life funding waiver program provides necessary waiver services to individuals who meet the level of care criteria for an intermediate care facility for individuals with mental retardation and other developmental disabilities as set forth in rule 5101:3-3-07 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 job and family services (ODJFS), administers the self-empowered life funding waiver program on a daily basis in accordance with section 5111.91 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) "Adult" means an individual who is at least twenty-two years old or an individual who is eligible for adult day support, vocational habilitation, supported employment-enclave, or integrated employment.

(2) "Agency with choice" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(3) "Budget authority" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(4) "Child" means an individual twenty-one years of age or younger who is not eligible for adult day support, vocational habilitation, supported employment-enclave, or integrated employment.

(5) "Co-employer" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(6) "Common law employer" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(7) "County board of developmental disabilities (CBDD)" means a board established under Chapter 5126. of the Revised Code.

(8) "Employer authority" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(9) "Financial management services" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(10) "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 amended, under which federal reimbursement is provided for designated home and community-based services to eligible individuals.

(11) "Individual" means a person with mental retardation or other developmental disability who is eligible to receive HCBS as an alternative to placement in an intermediate care facility for the mentally retarded under the applicable HCBS waiver. A guardian or authorized representative may take any action on behalf of the individual, may make choices for an individual or may receive notice on behalf of an individual to the extent permitted by applicable law.

(12) "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.

(13) "Participant direction" has the same meaning as defined in rule 5123:2-9-40 of the Administrative Code.

(14) "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.

(15) "SSA" means a service and support administrator who is certified in accordance with rules adopted by the DODD under Chapter 5123:2-5 of the Administrative Code and who provides the functions of service and support administration.

(16) "Waiver eligibility span" means the twelve-month period following either an individual's initial enrollment date or a subsequent eligibility re-determination date.

(C) Application for the self-empowered life funding waiver.

(1) Individuals seeking to enroll in the self-empowered life funding waiver program must complete the JFS 02399 "Request for Medicaid Home and Community-Based Services (HCBS) " (rev. 1/2012). Forms shall be available at all CBDD. Forms are also available at the county department of job and family services (CDJFS). Forms are to be used in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(2) The CBDD 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 applying for the self-empowered life funding waiver program must be determined to require the level of care provided in an ICF/MR and be eligible for ICF/MR services upon initial enrollment and no later than every twelve months thereafter, as specified in rules 5101:3-3-07 and 5123:2-9-01 of the Administrative Code and in accordance with the process set forth in rule 5101:3-3-15.5 of the Administrative Code; and

(2) The individual's medicaid eligibility has been established in accordance with Chapters 5101:1-37 to 5101:1-42 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.

(4) The individual must require, at a minimum, one waiver service as described in paragraph (F) of this rule, to be considered eligible for this waiver.

(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, as delineated in paragraph (F) of this rule, 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 waiver slots to the county board in accordance with section 5111.872 of the Revised Code.

(3) DODD shall reserve capacity under the self-empowered life funding waiver for children with intensive behavioral needs as federally approved.

(4) The CBDD shall offer available self-empowered life funding waiver slots to eligible individuals in accordance with applicable waiting list category requirements set forth in rules 5101:3-41-05 and 5123:2-1-08 of the Administrative Code.

(5) 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.

(6) 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.

(7) 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.

(8) While enrolled in the self-empowered life funding waiver program, if the enrollee does not receive any waiver services as listed in paragraph (F) of this rule for one month , the county board shall, within fifteen days after the end of the calendar month, assess the enrollee's current need for waiver services, 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) Self-empowered life funding waiver program benefit package, as included in the federally approved waiver document:

The self-empowered life funding waiver program benefit package is limited to the following services:

(1) Support broker;

(2) Community inclusion- personal assistance;

(3) Community inclusion- transportation;

(4) Participant-directed goods and services;

(5) Participant family stability assistance;

(6) Functional behavioral assessment;

(7) Clinical therapeutic intervention;

(8) Community respite;

(9) Residential respite;

(10) Remote monitoring;

(11) Remote monitoring equipment;

(12) Integrated employment;

(13) Adult day supports;

(14) Vocational habilitation;

(15) Supported employment-enclave;

(16) Non-medical transportation.

(G) Limits on self-empowered life funding waiver services.

(1) Self-empowered life funding waiver benefit limitations shall be in accordance with the benefit limitations as established in rule 5123:2-9-40 of the Administrative Code.

(2) Adults receiving services under the self-empowered life funding waiver are subject to a benefit limitation not to exceed forty thousand dollars per waiver eligibility span.

(3) Children receiving services under the self-empowered life funding waiver are subject to a benefit limitation not to exceed twenty-five thousand dollars per waiver eligibility span.

(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.

(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 developed 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 division 5123:2 of the Administrative Code; and

(d) The ISP shall be developed to include only waiver services which are consistent with efficiency, economy and quality of care; and

(e) The ISP is subject to approval by ODJFS and DODD pursuant to section 5111.871 of the Revised Code. Notwithstanding the procedures set forth in this rule, ODJFS may in its sole discretion, and in accordance with section 5111.852 of the Revised Code direct the CBDD or DODD to amend ISPs for individuals if ODJFS determines that such services are medically necessary and the procedures set forth in division 5101:3 of the Administrative Code 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 Chapters 5101:3-41 and 5123:2-9 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 in accordance with section 5126.046 of the Revised Code. This list will be accessible to county boards and individuals applying for or receiving services. The CBDD shall provide information about the internet-based provider list to applicants and enrollees and shall assist an individual to access this list to assure the individual's free choice of qualified providers.

(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 division 5123:2 of the Administrative Code; and

(2) Self-empowered life funding waiver services shall be provided by persons or agencies who have a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code; and

(3) 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

(4) Self-empowered life funding waiver services shall be provided in accordance with each enrollee's ISP as specified in paragraph (G) of this rule; and

(5) No provider of self-empowered life funding waiver services shall enter into or maintain any contract 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 rule 5101:3-41-20 and Chapter 5123:2-9 of the Administrative Code.

(L) Monitoring, compliance, and sanctions.

ODJFS shall conduct periodic monitoring and compliance reviews related to the self- empowered life funding waiver program in accordance with Chapter 5111. 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 CBDD shall furnish to ODJFS, 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 ODJFS, CMS, and the medicaid fraud control unit or their designee.

(M) Due process.

(1) Whenever an applicant for or enrollee of the self-empowered life funding waiver program is affected by any action proposed or taken by DODD and/or ODJFS, or when action is recommended by the CBDD, the entity recommending or taking the 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. Such actions may include, but are not limited to, the approval, denial, or termination of enrollment or a denial or change in the level, and/or type of waiver services delivered to a self-empowered life funding waiver enrollee.

(2) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD and the CBDD is required during the hearing proceedings to justify the decision under appeal.

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.87 , 5111.872 , 5111.91 , 5111.871 , 5111.852
Rule Amplifies: 5111.85 , 5111.87

5160-41-18 Individual options waiver-payment standards.

(A) Purpose.

The purpose of this rule is to establish the payment standards for the individual options home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.

(C) Individuals enrolled in the individual options HCBS program administered by DODD shall be subject to payment standards set forth in this rule and the rules associated with the individual options waiver program as established in Chapter 5123:2-9 of the Administrative Code.

(D) Payment for individual options waiver services shall not exceed the maximum rates established in Chapter 5123:2-9 of the Administrative Code.

(E) Claims for the provision of HCBS shall be submitted in accordance with the process specified in rule 5123:2-9-06 of the Administrative Code.

(F) Claims for the provision of HCBS shall be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in a waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) An individual enrolled in a DODD administered waiver program which offers institutional respite as one of the waiver services shall not be considered a resident of an intermediate care facility (ICF) if an ICF is providing the institutional respite service.

(b) An ICF providing respite services for any DODD administered waiver program that offers such services shall not bill medicaid through the ICF program. Payments for respite services shall be made through the waiver program in which the individual is enrolled.

(G) Payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.

(H) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the individual options waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Replaces: 5160-41-18

Effective: 07/01/2014
R.C. 119.032 review dates: 07/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02 , 5166.23
Rule Amplifies: 5166.02 , 5166.23 , 5162.35 , 5166.21
Prior Effective Dates: 3/19/12

5160-41-19 Level one waiver-payment standards.

(A) Purpose.

The purpose of this rule is to establish the payment standards for the level one home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.

(C) Individuals enrolled in the level one HCBS program administered by DODD shall be subject to payment standards set forth in this rule and the rules associated with the level one waiver program as established in Chapter 5123:2-9 of the Administrative Code.

(D) Payment for level one waiver services shall not exceed the maximum rates established in Chapter 5123:2-9 of the Administrative Code.

(E) Claims for the provision of HCBS shall be submitted in accordance with the process specified in rule 5123:2-9-06 of the Administrative Code.

(F) Claims for the provision of HCBS shall be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in a waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services shall not be considered a resident of an intermediate care facility (ICF) if an ICF is providing the residential respite service.

(b) An ICF providing residential respite services for any DODD administered waiver program that offers such services shall not bill medicaid through the ICF program. Payments for residential respite services shall be made through the waiver program in which the individual is enrolled.

(G) Payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.

(H) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the level one waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Replaces: 5160-41-19

Effective: 07/01/2014
R.C. 119.032 review dates: 07/01/2019
Promulgated Under: 119.03
Statutory Authority: 5166.02 , 5166.23
Rule Amplifies: 5166.02 , 5166.23 , 5162.35 , 5166.21
Prior Effective Dates: 3/19/12, 9/1/2013

5160-41-20 Self-empowered life funding - payment standards as administered by the department of developmental disabilities.

(A) Purpose.

The purpose of this rule is to establish the payment standards governing reimbursement for home and community-based services (HCBS) provided by certified or licensed waiver providers to individuals enrolled in the self-empowered life funding waiver program as a component of the medicaid program and as administered by the Ohio department of developmental disabilities (DODD) in accordance with sections 5111.85 and 5111.873 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of job and family services (ODJFS) in accordance with sections 5111.91 and 5111.871 of the Revised Code.

(C) Individuals enrolled in the self-empowered life funding waiver administered by the DODD shall be subject to the payment standards set forth in this rule.

(D) The standards and procedures set for prior authorization as defined in rule 5101:3-41-12 of the Administrative Code shall not apply to individuals enrolled on the self-empowered life funding waiver.

(E) For purposes of payment, HCBS services provided to individuals enrolled on the self-empowered life funding waiver must meet the definition of the waiver service as federally approved.

(F) Budget limitations.

(1) Children receiving services under the self-empowered life funding waiver shall be subject to a budget limitation of twenty-five thousand dollars for the individual's waiver eligibility span.

(2) Adults receiving services under the self-empowered life funding waiver shall be subject to a budget limitation of forty-thousand dollars for the individual's waiver eligibility span.

(G) Individuals enrolled in the self-empowered life funding HCBS program administered by DODD shall be subject to the payment standards set forth in this rule and in the following rules of the Administrative Code as specified:

(1) Community inclusion shall be in accordance with rule 5123:2-9-42 of the Administrative Code.

(2) Residential respite shall be in accordance with rule 5123:2-9-34 of the Administrative Code.

(3) Supported employment- enclave shall be in accordance with rules 5123:2-9-16 and 5123:2-9-19 of the Administrative Code.

(4) Participant-directed goods and services shall be in accordance with rule 5123:2-9-45 of the Administrative Code.

(5) Participant/family stability assistance shall be in accordance with rule 5123:2-9-46 of the Administrative Code.

(6) Support brokerage shall be in accordance with rule 5123:2-9-47 of the Administrative Code.

(7) Clinical/therapeutic intervention shall be in accordance with rule 5123:2-9-41 of the Administrative Code.

(8) Residential and community respite shall be in accordance with rule 5123:2-9-34 of the Administrative Code.

(9) Functional behavioral assessment shall be in accordance with rule 5123:2-9-43 of the Administrative Code.

(10) Adult day support shall be in accordance with rules 5123:2-9-17 and 5123:2-9-19 of the Administrative Code.

(11) Vocational habilitation shall be in accordance with rules 5123:2-9-14 and 5123:2-9-19 of the Administrative Code.

(12) Integrated employment shall be in accordance with rule 5123:2-9-44 of the Administrative Code.

(13) Non medical transportation shall be in accordance with rules 5123:2-9-18 and 5123:2-9-19 of the Administrative Code.

(14) Remote monitoring shall be in accordance with rule 5123:2-9-35 of the Administrative Code.

(15) Remote monitoring equipment shall be in accordance with rule 5123:2-9-35 of the Administrative Code.

(H) For purposes of payment, HCBS services provided to individuals enrolled on the self-empowered life funding waiver must meet the definition of the waiver service as federally approved.

(I) Payment for self-empowered life funding waiver services shall not exceed the rates established in appendix A to this rule.

(J) The provider shall bill DODD its usual and customary charge or a rate that does not exceed the maximum rate established in appendix A to this rule.

(K) Payments made to certified or licensed waiver providers by the DODD are subject to the provision, conditions, and payment standards set forth in this rule. Payment of services made under the authority of this rule shall not exceed the maximum payment rates set forth in appendix A to this rule.

(L) Certified or licensed waiver providers shall submit claims for the self-empowered life funding services through an approved financial management services agency designated by the DODD and ODJFS.

(M) Certified or licensed waiver providers of HCBS shall receive payment for the provision of HCBS as indicated in this rule when the following conditions exist:

(1) The waiver service is provided by an independent or agency provider that has certification or licensure for each service they provide in accordance with applicable requirements; and

(2) The waiver service is provided by an independent or agency provider that has a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code; and

(3) The waiver service is provided to an individual who is enrolled in a waiver program at the time of service; and

(4) The waiver service is provided in accordance with the enrollee's individual service plan; and

(5) The waiver service is provided within the limitations specified by the waiver program in which the individual is enrolled; and

(6) The waiver service is provided to an enrollee who is not an inpatient of a hospital, residing in a nursing facility or an intermediate care facility for individuals with mental retardation and other developmental disabilities (ICF/MR).

(a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services shall not be considered a resident of an ICF/MR if an ICF/MR is providing the residential respite service.

(b) An ICF/MR providing residential respite services for any DODD administered waiver program that offers such services shall not bill medicaid through the ICF/MR program. Payments for residential respite services shall be made through the waiver program in which the individual is enrolled.

(N) Payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.

(O) ODJFS authority.

ODJFS retains the final authority to establish payment rates for waiver services approved under the self-empowered life funding waiver and has final approval of any policies and rules that govern any component of the medicaid program.

(P) Monitoring.

(1) ODJFS will monitor payment made under authority of this rule as necessary to ensure that the funding applicable to HCBS are used for authorized purposes in compliance with laws, regulations, and the provisions governing the medicaid program.

(2) ODJFS and DODD may recover any overpayment identified by requesting voluntary repayment, or through provider payment offsets, or formal adjudicatory or non-adjudicatory recovery proceedings.

(Q) Due process.

(1) Applicants for waiver enrollment or individuals enrolled on any waiver administered by DODD shall be afforded 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) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD, and/or the county board of developmental disabilities is required during the hearing proceedings to justify the decision under appeal, in accordance with section 5126.055 of the Revised Code.

Click to view Appendix

Effective: 07/01/2012
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.85 , 5111.873 , 5111.91 , 5111.871
Rule Amplifies: 5111.85 , 5111.873

5160-41-21 Medicaid home and community-based services program-transitions developmental disabilities waiver.

(A) Purpose.

(1) The purpose of this rule is to authorize rules governing the transitions developmental disabilities waiver, a component of the medicaid home and community-based services (HCBS) program pursuant to sections 5111.85 and 5111.87 of the Revised Code.

(2) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of job and family services (ODJFS), administers the transitions developmental disabilities waiver program on a daily basis in accordance with section 5111.91 of the Revised Code.

(B) Individuals enrolled in the transitions developmental disabilities HCBS program administered by DODD shall be subject to the service requirements set forth in this rule and in the following rules of the Administrative Code as specified:

(1) Adult day health center services shall be in accordance with rule 5123:2-9-51 of the Administrative Code.

(2) Emergency response service shall be in accordance with rule 5123:2-9-52 of the Administrative Code.

(3) Home-delivered meals shall be in accordance with rule 5123:2-9-53 of the Administrative Code.

(4) Home modification services shall be in accordance with rule 5123:2-9-54 of the Administrative Code.

(5) Out-of-home respite shall be in accordance with rule 5123:2-9-55 of the Administrative Code.

(6) Personal care aide services shall be in accordance with rule 5123:2-9-56 of the Administrative Code.

(7) Supplemental adaptive and assistive devices shall be in accordance with rule 5123:2-9-57 of the Administrative Code.

(8) Supplemental transportation services shall be in accordance with rule 5123:2-9-58 of the Administrative Code.

(9) Waiver nursing services shall be in accordance with rule 5123:2-9-59 of the Administrative Code.

(10) General program standards shall be in accordance with rule 5123:2-9-50 of the Administrative Code.

(C) Due process.

(1) Applicants for waiver enrollment or individuals enrolled on a waiver administered by DODD shall be afforded 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) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD and/or the county board of developmental disabilities is required during the hearing proceedings to justify the decision under appeal in accordance with section 5126.055 of the Revised Code.

Effective: 01/01/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.85
Rule Amplifies: 5111.85 , 5111.87 , 5111.91 , 5111.871

5160-41-22 Transitions developmental disabilities - payment standards.

(A) Definitions of terms used for billing and calculating rates.

(1) "Base rate," as used in appendix A to this rule, means the amount paid for up to the first four units of service delivered.

(2) "Billing unit," as used in appendix A to this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(3) "Group rate," as used in paragraph (D)(1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation where a waiver nursing and/or personal care aide service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of waiver service, or a combination of waiver services.

(5) "Medicaid maximum rate" means the maximum amount that will be paid by medicaid for the service rendered.

(a) The medicaid maximum rate is set forth in appendix A to this rule.

(b) For the billing codes in appendix A to this rule, the medicaid maximum rate is:

(i) The base rate as defined in paragraph (A)(1) of this rule, or

(ii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A)(7) of this rule for each additional unit of service delivered.

(iii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A)(7) of this rule for each additional unit of service delivered.

(6) "Modifier," as used in paragraph (E) of this rule, means the additional two-alpha-numeric-digit billing codes that providers are required to use to provide additional information regarding service delivery.

(7) "Unit rate," as used in appendix A to this rule, means the amount paid for each fifteen minute unit following the base rate paid for the first four units of service provided.

(B) In order for a provider to submit a claim for transitions developmental disabilities waiver services, the services must be provided in accordance with Chapter 5123:2-9 of the Administrative Code.

(C) The amount of reimbursement for a service shall be the lesser of the provider's billed charge or the medicaid maximum rate.

(D) Required modifiers.

(1) The "HQ" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement at a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "U" modifier must be used when a provider submits a claim for billing code T1002 and the consumer is receiving infusion therapy.

(3) The "U2" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to a consumer for the same date of service.

(4) The "U3" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to a consumer for the same date of service.

(5) The "U4" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(E) Claims shall be submitted to, and reimbursement shall be provided by, the office of medical assistance (OMA).

(F) Monitoring.

The OMA shall monitor reimbursement made under authority of this rule as necessary to ensure that the funding applicable to home and community-based services (HCBS) is used for authorized purposes in compliance with laws, regulations and provisions governing the medicaid program.

(G) OMA authority.

The OMA retains the final authority to establish payment rates for waiver services approved under the transitions developmental disabilities waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Replaces: 5101:3-47-06

Click to view Appendix

Effective: 01/01/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0213 , 5111.85
Rule Amplifies: 5111.02 , 5111.021 , 5111.213, 5111.85 , 5111.871
Prior Effective Dates: 11/1/04, 7/1/06, 7/1/08, 1/1/10, 4/1/11, 10/01/2011