Chapter 5160-49 Ohio Access Success Project

5160-49-01 Non-medicaid-funded Ohio access success project.

(A) This rule sets forth the eligibility requirements and benefit limitations for the non-medicaid-funded Ohio access success project.

(B) Definitions:

(1) "Fiscal year" is defined as the fiscal year of this state, as specified in section 9.34 of the Revised Code.

(2) "HOME choice demonstration program" is Ohio's money follows the person (MFP) demonstration project funded by the centers for medicare and medicaid services (CMS).

(3) "Individual" is defined as a medicaid recipient who is residing in a nursing facility (NF) and is seeking non-medicaid Ohio access success project benefits.

(4) "Nursing Facility" and "NF" are defined as a facility or a distinct part of a facility as defined in division (M) of section 5111.20 of the Revised Code.

(5) "Non-medicaid-funded Ohio access success project" is defined as the portion of the Ohio access success project that is authorized to pay for relocation expenses with non-medicaid program funds.

(6) "ODJFS" is defined as the Ohio department of job and family services.

(7) "ODA" is defined as the Ohio department of aging.

(8) "Relocation" is defined as transition from a NF into the community as set forth in section 5111.97 of the Revised Code.

(C) The non-medicaid-funded Ohio access success project benefit shall be used to purchase goods and services to assist in the relocation of an individual from a NF to a community setting. Goods and services include, but are not limited to rental deposits, utility deposits, moving expenses, home modifications, debts and other expenses not covered by the medicaid program that facilitate a medicaid recipient's move from a NF to a community setting. No participant may receive more than two thousand dollars worth of goods and services under the non-medicaid-funded Ohio access success project, and part of the participant's allocation shall, if appropriate, be paid to a contractor for costs associated with the administration of the benefit.

(D) The application process for the non-medicaid-funded Ohio access success project requires:

(1) Completion of the "non-medicaid Ohio access success project referral"; and

(2) An assessment of the consumer's care needs in the community.

(E) In order to qualify for non-medicaid-funded Ohio access success project benefits an individual must meet all of the criteria set forth in this rule:

(1) Be a medicaid recipient of medicaid-funded NF services at the time of application .

(2) Be able to remain in the community as a result of receiving project benefits .

(3) Receive a determination from ODJFS or its designee that the individual's projected cost of services as described in paragraph (E)(3)(a) of this rule shall not exceed eighty per cent of the state average monthly medicaid cost of care for a medicaid recipient residing in a NF as described in paragraph (E)(3)(b) of this rule.

(a) The calculation of projected monthly service costs for the individual in the community shall include all of the following:

(i) The average medicaid per member per month costs for hospital, physician and pharmacy services as determined by ODJFS; and

(ii) The individual's assessed monthly need for medicaid covered services.

(b) The calculation of average monthly costs for an individual residing in a NF shall be the sum of all of the following:

(i) The average medicaid per diem paid to all NFs on the first date of the state fiscal year in which the participant's eligibility for the non-medicaid-funded Ohio access success project is being determined; and

(ii) The average per member per month medicaid costs for medicaid services not covered in paragraph (E)(3)(b)(i) of this rule for a NF resident.

(4) Not qualify for similar services that are reimbursable by medicaid .

(5) Have been determined ineligible for the HOME choice demonstration program as set forth in Chapter 5101:3-51 of the Administrative Code.

(F) An individual applying for, or a participant receiving, benefits under the non-medicaid Ohio access success project shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(G) ODJFS has the authority to limit the number of participants in the non-medicaid Ohio access success project to the extent funds are available. ODJFS may direct the available funds toward the relocation of individuals at the greatest risk of remaining in the NF.

Effective: 10/01/2011
R.C. 119.032 review dates: 07/14/2011 and 10/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.97
Rule Amplifies: 5111.97
Prior Effective Dates: 7/1/04, 10/1/05, 12/10/09