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

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