Chapter 5160-46 Ohio home care waiver

5160-46-02 Ohio home care waiver program: eligibility and enrollment.

(A) To be eligible for enrollment in the Ohio home care waiver program, an individual must meet all of the following requirements:

(1) Be between the ages of birth through age fifty-nine;

(2) Be determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-5 of the Administrative Code;

(3) Participate in an initial assessment to determine if the individual has needs that can be met through the Ohio home care waiver program;

(4) Be determined to have a nursing facility (NF) -based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code;

(5) In the absence of the Ohio home care waiver program, require hospitalization or institutionalization in a NF to meet his or her needs;

(6) Be determined to require and agree to receive at least one waiver service monthly that is otherwise unavailable through another source (including, but not limited to, private pay, community resources and/or the medicaid state plan) in an amount sufficient to meet the individual's assessed needs;

(7) Be able to establish residency in a place that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and that is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act ( 42 U.S.C. 1382(e) ( January 1, 2016)), residential care facility, adult foster home or another group living arrangement subject to state licensure or certification.

(8) Sign an agreement prior to waiver enrollment confirming that the individual has been informed of service alternatives, choice of qualified providers available in the Ohio home care waiver program and the options of institutional and community-based care, and he or she elects to receive Ohio home care waiver services; and

(9) Have needs that can be safely met through the Ohio home care waiver in a home or community setting as determined by the Ohio department of medicaid (ODM) or its designee.

(B) Subject to paragraph (H) of this rule, to be enrolled and maintain enrollment in the Ohio home care waiver program, an individual must be determined by ODM or its designee to meet all of the following requirements:

(1) Be determined eligible for the Ohio home care waiver program in accordance with paragraph (A) of this rule;

(2) Reside in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act ( 42 U.S.C. 1382(e) ( January 1, 2016)), residential care facility, adult foster home or another group living arrangement subject to state licensure or certification.

(3) Have his or her health and welfare assured while enrolled on the waiver;

(4) Participate in the development and implementation of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code, and consent to the plan by signing and dating it;

(5) Agree to and receive case management services from ODM or its designee including, but not limited to:

(a) Annual and other assessments, as needed,

(b) Home safety evaluations,

(c) Contact with the case manager and/or the individual's team members, including, but not limited to telephone communications, and face-to-face and in-home visits; and

(6) Agree to and participate in quality assurance and participant satisfaction activities during his or her enrollment on the Ohio home care waiver program including, but not limited to, face-to-face visits.

(C) An individual shall be given priority for assessment to determine eligibility for enrollment in the Ohio home care waiver when ODM is made aware that he or she meets the criteria for any of the priority categories set forth in paragraphs (C)(1) to (C)(6) of this rule.

(1) The individual is under twenty-one years of age, and at the time of application,:

(a) Received inpatient hospital services for at least fourteen consecutive days; or

(b) Had at least three inpatient hospital stays during the preceding twelve months.

(2) The individual is at least twenty-one but less than sixty years of age and received inpatient hospital services for at least fourteen consecutive days immediately preceding the date of application.

(3) The individual is under sixty years of age and received private duty nursing services in accordance with rule 5160-12-02 of the Administrative Code for at least twelve consecutive months immediately preceding application.

(4) The individual is under sixty years of age, lives in the community and is at imminent risk of institutionalization due to the documented loss of a primary caregiver. In such instances, there must be written evidence (such as a doctor's order, a death certificate, or documentation that the primary caregiver is institutionalized or relocated out of the area) that substantiates the primary caregiver is unavailable to provide care and support, and without Ohio home care waiver services, the individual will require care in an inpatient hospital setting or a nursing facility (NF).

(5) The individual is under sixty years of age and resides in a medicaid-funded NF at the time of application.

(6) The individual is under sixty years of age, is determined by ODM to be eligible for the HOME choice ("Helping Ohioans Move, Expanding Choice") program in accordance with rule 5160-51-02 of the Administrative Code, and resides in a residential treatment facility as defined in rule 5160-51-01 of the Administrative Code, or an inpatient hospital setting.

(D) If an individual fails to meet any of the requirements set forth in paragraph (A) and/or paragraph (B) of this rule, the individual shall be denied enrollment on the Ohio home care waiver program.

(E) Once enrolled on the Ohio home care waiver program, an individual's NF level of care shall be reassessed at least annually, and more frequently if there is a significant change in the individual's situation that may impact his or her health and welfare. If the reassessment determines the individual no longer meets the requirements set forth in paragraph (A) and/or paragraph (B) of this rule, he or she shall be disenrolled from the Ohio home care waiver program.

(F) If, at any other time, it is determined that an individual enrolled on the Ohio home care waiver program no longer meets the requirements set forth in paragraph (A) and/or paragraph (B) of this rule, he or she shall be disenrolled from the Ohio home care waiver program. Reassessment pursuant to paragraph (E) is not required to make this determination.

(G) If an individual is denied enrollment in the Ohio home care waiver program pursuant to paragraph (D) of this rule, or is disenrolled from the waiver pursuant to paragraph (E) or (F) of this rule, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(H) The number of individuals enrolled in the Ohio home care waiver shall not exceed the centers for medicare and medicaid services (CMS) -authorized limit for the waiver program year.



Effective: 7/1/2016
Five Year Review (FYR) Dates: 04/15/2016 and 07/01/2021
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5164.02, 5162.03, 5166.121
Prior Effective Dates: 4/4/77, 12/21/77, 6/1/80, 5/1/87, 4/1/88, 5/15/89, 3/1/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/30/93, 7/1/98, 9/29/00, 8/1/01, 3/1/02 (Emer), 5/30/02, 7/1/06, 2/8/09, 12/1/14

5160-46-04 Ohio home care waiver: definitions of the covered services and provider requirements and specifications.

This rule sets forth definitions of some services covered by the Ohio home care waiver. This rule also sets forth the provider requirements and specifications for the delivery of those Ohio home care waiver services. The services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) Personal care aide services.

(1) "Personal care aide services" are defined as services provided pursuant to the person-centered services plan that assist the individual with activities of daily living (ADL) and instrumental activities of daily living (IADL) needs. If the individual's person-centered services plan states that the service provided is to be personal care aide services, the service shall never be billed as a nursing service. If the provider cannot perform IADLs, the provider shall notify ODM or its designee, in writing, of the service limitations before inclusion on the individual's person-centered services plan. Personal care aide services include:

(a) Bathing, dressing, grooming, nail care, hair care, oral hygiene, shaving, deodorant application, skin care, foot care, feeding, toileting, assisting with ambulation, positioning in bed, transferring, range of motion exercises, and monitoring intake and output;

(b) General homemaking activities, including but not limited to: meal preparation and cleanup, laundry, bed-making, dusting, vacuuming, washing floors and waste disposal;

(c) Paying bills and assisting with personal correspondence as directed by the individual; and

(d) Accompanying or transporting the individual to Ohio home care waiver services, medical appointments, other community services, or running errands on behalf of that individual.

(2) Personal care aide services do not include tasks performed, or services provided as part of the home maintenance and chore services set forth in rule 5160-44-12 of the Administrative Code.

(3) Personal care aide services do not include services performed in excess of the number of hours approved pursuant to the person-centered services plan.

(4) Personal care aides shall not administer prescribed or over-the-counter medications to the individual, but may, unless otherwise prohibited by the provider's certification or accreditation status, pursuant to paragraph (C) of rule 4723-13-02 of the Administrative Code, help the individual self-administer medications by:

(a) Reminding the individual when to take the medication, and observing to ensure the individual follows the directions on the container;

(b) Assisting the individual by taking the medication in its container from where it is stored and handing the container to the individual;

(c) Opening the container for an individual who is physically unable to open the container;

(d) Assisting an individual who is physically-impaired, but mentally alert, in removing oral or topical medication from the container and in taking or applying the medication; and

(e) Assisting an individual who is physically unable to place a dose of medication in his or her mouth without spilling or dropping it by placing the dose in another container and placing that container to the mouth of the individual.

(5) Personal care aide services shall be delivered by one of the following:

(a) An employee of a medicare-certified, or otherwise-accredited home health agency; or

(b) A non-agency personal care aide.

(6) In order to be a provider and submit a claim for reimbursement, all personal care aide service providers shall meet the following:

(a) Comply with all applicable rules set forth in Chapters 5160-44, 5160-45 and 5160-46 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5160-46-06 of the Administrative Code.

(c) Be at least eighteen years of age.

(d) Be identified as the provider, and have specified, on the individual's person-centered services plan that is prior-approved by ODM or its designee, the number of hours for which the provider is authorized to furnish personal care aide services to the individual.

(e) Have a valid social security number, and one of the following forms of identification:

(i) Alien identification,

(ii) State of Ohio identification,

(iii) A valid driver's license, or

(iv) Other government-issued photo identification.

(f) Not be the individual's legally responsible family member as that term is defined in rule 5160-45-01 of the Administrative Code.

(g) Not be the foster caregiver of the individual.

(h) Be providing personal care aide services for one individual, or for up to three individuals in a group setting during a face-to-face visit.

(i) Comply with the additional applicable provider-specific requirements as specified in paragraph (A)( 7) or (A)( 8) of this rule.

(7) Medicare-certified and otherwise-accredited agencies shall ensure that personal care aides meet the following requirements:

(a) Before commencing service delivery, the personal care aide shall:

(i) Obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health under section 3721.31 of the Revised Code, or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.36 (as in effect on October 1, 2018), and

(ii) Obtain and maintain first aid certification from a program that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(b) Maintain evidence of the completion of twelve hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation. Continuing education shall be initiated immediately, and shall be completed annually thereafter.

(c) Receive supervision from an Ohio-licensed RN, or an Ohio-licensed LPN, at the direction of an RN in accordance with section 4723.01 of the Revised Code. The supervising RN, or LPN at the direction of an RN, shall:

(i) Conduct a face-to-face individual home visit explaining the expected activities of the personal care aide, and identifying the individual's personal care aide services to be provided.

(ii) Conduct a face-to-face individual home visit at least every sixty days while the personal care aide is present and providing care to evaluate the provision of personal care aide services, and the individual's satisfaction with care delivery and personal care aide performance. The visit shall be documented in the individual's record.

(iii) Discuss the evaluation of personal care aide services with the case manager.

(d) Be able to read, write and understand English at a level that enables the provider to comply with all requirements set forth in the administrative rules governing the Ohio home care waiver.

(e) Be able to effectively communicate with the individual.

(8) Non-agency personal care aides shall meet the following requirements:

(a) Before commencing service delivery personal care aides shall have:

(i) Obtained a certificate of completion within the last twenty-four months for either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health in accordance with section 3721.31 of the Revised Code; or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.36 (as in effect on October 1, 2018); or other equivalent training program. The program shall include training in the following areas:

(a) Personal care aide services as defined in paragraph (A)(1) of this rule;

(b) Basic home safety; and

(c) Universal precautions for the prevention of disease transmission, including hand-washing and proper disposal of bodily waste and medical instruments that are sharp or may produce sharp pieces if broken.

(ii) Obtained and maintain first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(b) Complete twelve hours of in-service continuing education annually that shall occur on or before the anniversary date of their enrollment as a medicaid personal care aide provider. Continuing education topics include, but are not limited to, health and welfare of the individual, cardiopulmonary resuscitation (CPR), patient rights, emergency preparedness, communication skills, aging sensitivity, developmental stages, nutrition, transfer techniques, disease-specific trainings, and mental health issues.

(c) Comply with the individual's or the individual's authorized representative's specific personal care aide service instructions, and perform a return demonstration upon request of the individual or the case manager.

(d) Comply with ODM monitoring requirements in accordance with rule 5160-45-06 of the Administrative Code.

(e) Be able to read, write and understand English at a level that enables the provider to comply with all requirements set forth in the administrative rules governing the Ohio home care waiver.

(f) Be able to effectively communicate with the individual.

(9) All personal care aide providers shall maintain a clinical record for each individual served in a manner that protects the confidentiality of these records. Medicare-certified, or otherwise-accredited agencies, shall maintain the clinical records at their place of business. Non-agency personal care aides shall maintain the clinical records at their place of business, and maintain a copy in the individual's residence. For the purposes of this rule, the place of business shall be a location other than the individual's residence. At a minimum, the clinical record shall contain:

(a) Identifying information, including but not limited to: name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification numbers of the individual.

(b) The medical history of the individual.

(c) The name of individual's treating physician.

(d) A copy of the initial and all subsequent person-centered services plans.

(e) Documentation of all drug and food interactions, allergies and dietary restrictions.

(f) A copy of any advance directives including, but not limited to, DNR order or medical power of attorney, if they exist.

(g) Documentation of tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and individual or the individual's authorized representative, verifying the service delivery upon completion of service delivery. The individual or the individual's authorized representative's signature of choice shall be documented on the individual's person-centered services plan, and shall include any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(h) Progress notes signed and dated by the personal care aide, documenting all communications with the case manager, treating physician, other members of the multidisciplinary team, and documenting any unusual events occurring during the visit, and the general condition of the individual.

(i) A discharge summary, signed and dated by the departing non-agency personal care aide or the RN supervisor of an agency personal care aide, at the point the personal care aide is no longer going to provide services to the individual, or when the individual no longer needs personal care aide services. The summary should include documentation regarding progress made toward achievement of goals as specified on the individual's all services plan and indicate any recommended follow-ups or referrals.

(B) Adult day health center services.

(1) "Adult day health center services (ADHCS)" are regularly scheduled services delivered at an adult day health center to individuals who are age eighteen or older. A qualifying adult day health center must be a freestanding building or a space within another building that shall not be used for other purposes during the provision of ADHCS.

(a) An adult day health center shall provide:

(i) Waiver nursing services as set forth in rule 5160-44-22 of the Administrative Code, or personal care aide services as set forth in paragraph (A)(1) of this rule;

(ii) Recreational and educational activities; and

(iii) At least one meal, but no more than two meals, per day that meet the individual's dietary requirements.

(b) An adult day health center may also provide:

(i) Skilled therapy services as set forth in rule 5160-12-01 of the Administrative Code; and

(ii) Transportation of the individual to and from ADHCS.

(c) ADHCS are reimbursable at a full-day rate when five or more hours are provided to an individual in a day. ADHCS are reimbursable at a half-day rate when less than five hours are provided in a day.

(d) All of the services set forth in paragraphs (B)(1)(a) and (B)(1)(b) of this rule and delivered by an adult day health center shall not be reimbursed as separate services.

(2) ADHCS do not include services performed in excess of what is approved pursuant to, and specified on, the individual's person-centered services plan.

(3) In order to be a provider and submit a claim for reimbursement, providers of ADHCS shall:

(a) Comply with all applicable rules set forth in Chapters 5160-44, 5160-45 and 5160-46 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5160-46-06 of the Administrative Code.

(c) Be identified as the provider on the individual's person-centered services plan, that is prior-approved by ODM or its designee, the number of hours for which the provider is authorized to furnish adult day health center services to the individual.

(d) Operate the adult day health center in compliance with all applicable federal, state and local laws, rules and regulations.

(4) All providers of ADHCS shall:

(a) Comply with federal nondiscrimination regulations as set forth in 45 C.F.R. part 80 (as in effect on October 1, 2018).

(b) Provide for replacement coverage of a loss due to theft, property damage, and/or personal injury; and maintain a written procedure identifying the steps an individual takes to file a liability claim. Upon request, verification of coverage shall be provided to ODM or its designee.

(c) Maintain evidence of non-licensed direct care staff's completion of twelve hours of in-service training every twelve months.

(d) Ensure that any waiver nursing services provided are within the nurse's scope of practice as set forth in rule 5160-44-22 of the Administrative Code.

(e) Provide task-based instruction to direct care staff providing personal care aide services as set forth in paragraph (A)(1) of this rule.

(f) At all times, maintain a 1:6 ratio of paid direct care staff to individuals.

(5) Providers of ADHCS shall maintain a clinical record for each individual served in a manner that protects the confidentiality of these records. At a minimum, the clinical record shall contain the following:

(a) Identifying information, including but not limited to: name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers of the individual.

(b) The medical history of the individual.

(c) The name of the individual's treating physician.

(d) A copy of the initial and all subsequent all services plans.

(e) A copy of any advance directive including, but not limited to, DNR order or medical power of attorney, if they exist.

(f) Documentation of all drug and food interactions, allergies and dietary restrictions.

(g) Documentation that clearly shows the date of ADHCS delivery, including tasks performed or not performed, and the individual's arrival and departure times. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(h) A discharge summary, signed and dated by the departing ADHCS provider, at the point the ADHCS provider is no longer going to provide services to the individual, or when the individual no longer needs ADHCS. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups or referrals.

(i) Documentation of the information set forth in rule 5160-44-22 of the Administrative Code when the individual is provided waiver nursing and/ or skilled therapy services.

(C) Supplemental adaptive and assistive device services.

(1) "Supplemental adaptive and assistive device services" are medical equipment, supplies and devices, and vehicle modifications to a vehicle owned by the individual, or a family member, or someone who resides in the same household as the individual, that are not otherwise available through any other funding source and that are suitable to enable the individual to function with greater independence, avoid institutionalization, and reduce the need for human assistance. All supplemental adaptive and assistive device services shall be prior-approved by ODM or its designee. ODM or its designee shall only approve the lowest cost alternative that meets the individual's needs as determined during the assessment process.

(a) Reimbursement for medical equipment, supplies and vehicle modifications shall not exceed a combined total of ten thousand dollars within a calendar year per individual.

(b) ODM or its designee shall not approve the same type of medical equipment, supplies and devices for the same individual during the same calendar year, unless there is a documented need for ongoing medical equipment, supplies or devices as documented by a licensed health care professional, or a documented change in the individual's medical and/or physical condition requiring the replacement.

(c) ODM or its designee shall not approve the same type of vehicle modification for the same individual within the same three-year period, unless there is a documented change in the individual's medical and/or physical condition requiring the replacement.

(d) Supplemental adaptive and assistive device services do not include:

(i) Items considered by the federal food and drug administration as experimental or investigational;

(ii) Funding of down payments toward the purchase or lease of any supplemental adaptive and assistive device services;

(iii) Equipment, supplies or services furnished in excess of what is approved in the individual's person-centered services plan;

(iv) Replacement equipment or supplies or repair of previously approved equipment or supplies that have been damaged as a result of perceived misuse, abuse or negligence; and

(v) Activities described in paragraph (C)(2)(c) of this rule.

(2) Vehicle modifications.

(a) Reimbursable vehicle modifications include operating aids, raised and lowered floors, raised doors, raised roofs, wheelchair tie-downs, scooter/ wheelchair handling devices, transfer seats, remote devices, lifts, equipment repairs and/or replacements, and transfers of equipment from one vehicle to another for use by the same individual. Vehicle modifications may also include the itemized cost, and separate invoicing of vehicle adaptations associated with the purchase of a vehicle that has not been pre-owned or pre-leased.

(b) Before the authorization of a vehicle modification, the individual and, if applicable, any other person(s) who will operate the vehicle shall provide ODM or its designee with documentation of:

(i) A valid driver's license, with appropriate restrictions, and if requested, evidence of the successful completion of driver training from a qualified driver rehabilitation specialist, or a written statement from a qualified driver rehabilitation specialist attesting to the driving ability and competency of the individual and/or other person(s) operating the vehicle;

(ii) Proof of ownership of the vehicle to be modified;

(iii) Vehicle owner's collision and liability insurance for the vehicle being modified; and

(iv) A written statement from a certified mechanic stating the vehicle is in good operating condition.

(c) Vehicle modifications do not include:

(i) Payment toward the purchase or lease of a vehicle, except as set forth in paragraph (C)(2)(a) of this rule;

(ii) Routine care and maintenance of vehicle modifications and devices;

(iii) Permanent modification of leased vehicles;

(iv) Vehicle inspection costs;

(v) Vehicle insurance costs;

(vi) New vehicle modifications or repair of previously approved modifications that have been damaged as a result of confirmed misuse, abuse or negligence; and

(vii) Services performed in excess of what is approved pursuant to, and specified on, the individual's all services plan.

(3) In order to be a provider and submit a claim for supplemental adaptive and assistive device services, the provider shall:

(a) Comply with all applicable rules set forth in Chapters 5160-44, 5160-45 and 5160-46 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5160-46-06 of the Administrative Code.

(c) Be identified as the provider, and have specified, on the individual's all services plan that is prior-approved by ODM or its designee, the supplemental adaptive and assistive device services the provider is authorized to furnish to the individual.

(d) Ensure all manufacturer's rebates have been deducted before requesting reimbursement for supplemental adaptive and assistive device services.

(e) Ensure the supplemental adaptive and assistive device was tested and is in proper working order, and is subject to warranty in accordance with industry standards.

(4) Providers of supplemental adaptive and assistive device services shall maintain a clinical record for each individual they serve in a manner that protects the confidentiality of these records. At a minimum, the clinical record shall include:

(a) Identifying information, including but not limited to name, address, age, date of birth, sex, race, marital status, significant phone numbers, and health insurance identification numbers of the individual.

(b) The name of the individual's treating physician.

(c) A copy of the initial and all subsequent person-centered services plans.

(d) Documentation that clearly shows the date the supplemental adaptive and assistive device service was provided. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(D) Supplemental transportation services.

(1) "Supplemental transportation services" are transportation services that are not available through any other resource that enable an individual to access waiver services and other community resources specified on the individual's person-centered services plan. Supplemental transportation services include, but are not limited to assistance in transferring the individual from the point of pickup to the vehicle and from the vehicle to the destination point.

(2) Supplemental transportation services do not include services performed in excess of what is approved pursuant to, and specified on, the individual's all services plan.

(3) In order to be a provider and submit a claim for supplemental transportation services, the provider shall:

(a) Comply with all applicable rules set forth in Chapters 5160-45 and 5160-46 of the Administrative Code.

(b) Request reimbursement for the provision of services in accordance with rule 5160-46-06 of the Administrative Code.

(c) Be identified as the provider, and have specified on the individual's person-centered services plan that is prior-approved by ODM or its designee, the amount of supplemental transportation services the provider is authorized to render to the individual.

(4) Agency supplemental transportation service providers shall:

(a) Maintain a current list of drivers.

(b) Ensure all drivers providing supplemental transportation services are age eighteen or older.

(c) Maintain a copy of the valid driver's license for each driver.

(d) Maintain collision and liability insurance for each vehicle and driver used to provide supplemental transportation services.

(e) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(f) Obtain and maintain a certificate of completion of a course in first aid for each driver used to provide supplemental transportation services that:

(i) Is not provided solely through the internet;

(ii) Includes hands-on training provided by a certified first aid instructor; and

(iii) Requires the individual to perform a successful return demonstration of what was learned in the course.

(g) Ensure drivers are not the individual's legally responsible family member, as that term is defined in rule 5160-45-01 of the Administrative Code.

(h) Ensure drivers are not the individual's foster caregivers.

(5) Non-agency supplemental transportation service providers shall:

(a) Be age eighteen or older.

(b) Possess a valid driver's license.

(c) Maintain collision and liability insurance for each vehicle used to provide supplemental transportation services.

(d) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(e) Obtain and maintain a certificate of completion of a course in first aid that:

(i) Is not provided solely through the internet;

(ii) Includes hands-on training provided by a certified first aid instructor; and

(iii) Requires the individual to perform a successful return demonstration of what was learned in the course.

(f) Not be the individual's legally responsible family member, as that term is defined in rule 5160-45-01 of the Administrative Code.

(g) Not be the individual's foster caregiver.

(6) All supplemental transportation service providers shall maintain documentation that, at a minimum, includes a log identifying the individual transported, the date of service, pick-up point, destination point, mileage for each trip, and the signature of the individual receiving supplemental transportation services, or the individual's authorized representative. The individual's or authorized representative's signature of choice shall be documented on the individual's person-centered services plan and shall include any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.



Effective: 7/1/2019
Five Year Review (FYR) Dates: 1/1/2024
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5162.03, 5166.02 , 5164.02
Prior Effective Dates: 03/30/1990 (Emer.), 06/29/1990, 07/01/1990, 03/12/1992 (Emer.), 06/01/1992, 07/31/1992 (Emer.), 10/30/1992, 07/01/1993 (Emer.), 07/30/1993, 09/01/1993, 01/01/1996, 07/01/1998, 07/01/2006, 10/25/2010, 07/01/2015, 11/03/2016, 01/01/2019

5160-46-04.1 [Rescinded] Ohio home care waiver program: home care attendant services.



Effective: 1/1/2019
Five Year Review (FYR) Dates: 10/15/2018
Promulgated Under: 119.03
Statutory Authority: 5166.30, 5166.02
Rule Amplifies: 5166.309, 5162.03, 5166.3010, 5166.308, 5166.307, 5166.306, 5166.305, 5166.304, 5166.303, 5166.302, 5166.301 , 5166.30, 5164.02
Prior Effective Dates: 07/01/2010, 08/01/2015

5160-46-05 [Rescinded] Ohio home care waiver program: calculation of the individual cost cap.



Effective: 07/03/2014
R.C. 119.032 review dates: 04/16/2014
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5162.03, 5164.02 and 5166.02
Prior Effective Dates: 7/1/98 and 2/15/07

5160-46-06 Ohio home care waiver program: reimbursement rates and billing procedures.

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

(1) "Base rate," as used in table A, column 3 of paragraph (B) of this rule, means the amount reimbursed by the Ohio department of medicaid (ODM) for the first thirty-five to sixty minutes of service delivered.

(2) "Bid rate," as used in table B, column 3 of paragraph (B) of this rule, means the per job bid rate negotiated between the provider and the individual's case manager.

(3) "Billing unit," as used in table B, column 3 of paragraph (B) of this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(4) "Caretaker relative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(5) "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.

(6) "Group setting" means a setting in which:

(a) A 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 ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(b) A waiver nursing service provider furnishes the same type of services to either:

(i) Two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(ii) Two to four individuals at the same address if all of the individuals receiving ODM-administered waiver nursing services are:

(a) Medically fragile children, and

(b) Siblings, and

(c) Residing together in the home of their caretaker relative. The services provided in the group setting must be ODM-administered waiver nursing services.

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

(a) For the billing codes in table B of paragraph (B) of this rule, the medicaid maximum rate is set forth in column (4).

(b) For the billing codes in table A of paragraph (B) of 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, or

(iii) The unit rate as defined in paragraph (A)(7)(b) of this rule.

(8) "Medically fragile child" means an individual who is under eighteen years of age, has intensive health care needs, and is considered blind or disabled under section 1614(a)(2) or (3) of the "Social Security Act," ( 42 U.S.C. 1382c(a)(2) or (3) ) (as in effect on January 1, 2018).

(9) "Modifier," as used in paragraph (D) 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.

(10) "Unit rate," as used in table A, column 4 of paragraph (B) of this rule, means the amount reimbursed by ODM for each fifteen minutes of service delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. ODM will reimburse a maximum of only one unit if the service is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(B) Billing code tables.

Table A

Column 1

Column 2

Column 3

Column 4

Billing code

Service

Base rate

Unit rate

T1002

Waiver nursing services provided by an agency RN

$ 47.40

$ 8.72

T1002

Waiver nursing services provided by a non-agency RN

$ 38.95

$ 7.03

T1002

Waiver nursing services provided by a non-agency RN (overtime)

$ 50.82

$ 10.01

T1003

Waiver nursing services provided by an agency LPN

$ 40.65

$ 7.37

T1003

Waiver nursing services provided by a non-agency LPN

$ 33.20

$ 5.88

T1003

Waiver nursing services provided by a non-agency LPN (overtime)

$ 43.00

$ 8.33

T1019

Personal care aide services provided by an agency personal care aide

$ 23.12

$ 3.84

T1019

Personal care aide services provided by a non-agency personal care aide

$ 18.64

$ 2.95

T1019

Personal care aide services provided by a non-agency personal care aide (overtime)

$ 22.59

$ 4.16

Table B

Column 1

Column 2

Column 3

Column 4

Billing code

Service

Billing unit

Medicaid maximum rate

H0045

Out-of-home respite services

Per day

$ 199.82

S0215

Supplemental transportation services

Per mile

$ 0.38

S5101

Adult day health center services

Per half day

$ 32.48

S5102

Adult day health center services

Per day

$ 64.94

S5160

Personal emergency response systems

Per installation and testing

$ 32.95

S5161

Personal emergency response systems

Per monthly fee

$ 32.95

S5165

Home modification services

Per item

Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year

T2029

Supplemental adaptive and assistive device services

Per item

Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year

S5170

Home delivered meal services - standard meal

Per meal

$ 6.50

S5170

Home delivered meal services - therapeutic or kosher meal

Per meal

$ 8.68

S5135

Community integration services

Per fifteen-minute unit

$ 3.50

T2038

Community transition services

Per job

$2,000 per waiver enrollment

S5121

Home maintenance and chore services

Per job

Amount prior-authorized on the person-centered services plan, not to exceed $10,000 in a twelve-month calendar year

(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 as a group rate shall be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "TU" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 and the entire claim is being billed as overtime.

(3) The "UA" modifier must be used when a provider submits a claim for billing code T1002, T1003 or T1019 and only a portion of the claim is being billed as overtime.

(4) The "U1" modifier must be used when a provider submits a claim for billing code T1002 and the individual enrolled on the Ohio home care waiver is receiving infusion therapy.

(5) 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 an individual enrolled on the Ohio home care waiver for the same date of service.

(6) 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 an individual enrolled on the Ohio home care waiver for the same date of service.

(7) 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.

(8) The "U6" modifier must be used when a provider submits a claim for billing code S5170 for a therapeutic or kosher home delivered meal.

(E) Claims shall be submitted to, and reimbursement shall be provided by, ODM in accordance with Chapter 5160-1 of the Administrative Code.



Effective: 7/1/2019
Five Year Review (FYR) Dates: 1/1/2022
Promulgated Under: 119.03
Statutory Authority: 5162.03, 5166.02
Rule Amplifies: 5162.03, 5164.70, 5164.77, 5166.01, 5166.02 , 5166.041
Prior Effective Dates: 01/01/2004, 07/01/2006, 07/01/2008, 01/01/2010, 04/01/2011, 10/01/2011, 07/01/2015, 01/01/2017, 01/01/2019

5160-46-06.1 Ohio home care waiver program: home care attendant services reimbursement rates and billing procedures.

(A) Definitions of terms used for billing and calculating home care attendant services (HCAS) rates.

(1) "Base rate," as set forth in column 3 of tables A and B of this rule, means the amount reimbursed by Ohio medicaid for the first thirty-five to sixty minutes of assistance with self-administration of medications and the performance of nursing tasks provided during a single visit.

(2) "Continuous nursing" means nursing services (waiver nursing and/or private duty nursing) that are more than four hours in length and during which personal care aide service tasks as described in paragraph (B)(1) of rule 5160-46-04 of the Administrative Code may be provided incidental to nursing services.

(3) "Group rate" means the amount that HCAS providers shall be reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation in which an HCAS provider furnishes HCAS in accordance with rule 5160-46-04.1 of the Administrative Code, and as authorized by the Ohio department of medicaid (ODM), to two or three individuals who reside at the same address.

(5) "HCAS visit" is a visit during which HCAS is provided in accordance with rule 5160-46-04.1 of the Administrative Code. An HCAS visit shall not exceed twelve hours or forty-eight units in duration.

(6) "Intermittent nursing" means nursing services (waiver nursing and/or home health nursing) that are four hours or less in length.

(7) "Medicaid maximum rate" means the maximum amount that shall be paid by the Ohio medicaid program for the service rendered. The base rate in column 3 and the unit rate in column 4 of table A of this rule, and the base rate in column 3 and the unit rates in column 5 of table B of this rule represent the medicaid maximum rates for HCAS.

(8) "Modifier" means the additional two-alpha-numeric-digit billing code set forth in paragraph (G) of this rule that HCAS providers shall use to provide additional information regarding service delivery.

(9) "Unit rate," as set forth in column 4 of table A of this rule and column 5 of table B of this rule, means the amount reimbursed by Ohio medicaid for each fifteen minutes of HCAS delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. Ohio medicaid will reimburse a maximum of only one unit if HCAS is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(B) Providers shall bill for reimbursement using table A when HCAS is provided in lieu of continuous nursing as described in paragraph (A)(2) of this rule. Personal care aide tasks are included in the unit rate.

Table A

Column 1

Column 2

Column 3

Column 4

Billing code

Home care attendant service description

Base rate

Unit rate

S5125

Assistance with self-administration of medications and/or the performance of nursing tasks (HCAS/N)

$ 25.95

$ 4.43 per fifteen minute unit of HCAS/N delivered during visit

(C) Providers shall bill for reimbursement using table B when HCAS is provided in lieu of intermittent nursing as described in paragraph (A)(6) of this rule. The first four units of HCAS shall be billed for at the base rate. Beginning with the fifth unit of HCAS, assistance with self-administration of medications and the performance of nursing tasks (HCAS/N) shall be billed at the HCAS/N unit rate; and personal care aide service tasks (HCAS/PC) shall be billed at the HCAS/PC unit rate using the U8 modifier.

Table B

Column 1

Column 2

Column 3

Column 4

Column 5

Billing code

Home care attendant service description

Base rate

Modifier

Unit rate

S5125

HCAS/N

$ 25.95

N/A

$ 4.43 per fifteen minute unit of HCAS/N delivered during the visit

S5125

HCAS/PC

N/A

U8

$ 2.95 per fifteen minute of HCAS/PC delivered during the visit

S5125

HCAS/PC (overtime)

$ 33.09

TU or UA

$ 4.16

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

(E) When HCAS/N and HCAS/PC are provided during an uninterrupted period of time, the visit shall be considered a single HCAS visit. An HCAS provider is entitled to only one base rate during an HCAS visit.

(F) HCAS providers shall be limited to a maximum of twelve hours or forty-eight units of HCAS during a twenty-four-hour period, regardless of the number of individuals enrolled on an ODM-administered waiver who are served.

(G) Required modifiers.

(1) The "HQ" modifier must be used when a provider submits a claim if HCAS 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 rate.

(2) The "TU" modifier must be used when a provider submits a claim for billing code S5125 and the entire claim is being billed as overtime.

(3) The "UA" modifier must be used when a provider submits a claim for billing code S5125 and only a portion of the claim is being billed as overtime.

(4) The "U2" modifier must be used when a provider submits a claim for a second HCAS visit to an individual enrolled on the Ohio home care waiver for the same date of service.

(5) The "U3" modifier must be used when the same provider submits a claim for three or more HCAS visits to an individual enrolled on the Ohio home care waiver for the same date of service.

(6) The "U8" modifier must be used when a provider submits a claim for an HCAS visit that is in lieu of intermittent nursing as described in paragraph (A)(6) of this rule, and for units of service that are HCAS/PC.

(H) Claims shall be submitted to, and reimbursement shall be provided by, the ODM in accordance with Chapter 5160-1 of the Administrative Code.



Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/14/2016 and 01/01/2022
Promulgated Under: 119.03
Statutory Authority: 5166.02, 5166.30
Rule Amplifies: 5162.03, 5164.02, 5166.30 , 5166.301, 5166.302, 5166.303, 5166.304, 5166.305, 5166.306, 5166.307, 5166.308, 5166.309, 5166.3010
Prior Effective Dates: 7/1/10, 10/1/11, 8/1/15

5160-46-07 [Rescinded] Ohio home care waiver: enrollment and waiting list process.



Effective: 12/1/2014
Five Year Review (FYR) Dates: 09/05/2014
Promulgated Under: 119.03
Statutory Authority: 5166.02
Rule Amplifies: 5162.03, 5164.02, 5166.02
Prior Effective Dates: 8/1/01, 3/1/02 (Emer), 5/30/02, 7/1/06, 02/08/09