Chapter 5160-51 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program

5160-51-01 Definitions for the helping Ohioans move, expanding choice (HOME choice) program.

(A) The definitions in this rule are applicable to the money follows the person (MFP) transition program known as the helping Ohioans move, expanding choice (HOME choice) program (hereafter referred to as HOME choice).

(B) Definitions.

(1) "Agency provider" means an entity that is eligible to provide services in the HOME choice program.

(2) "Case management agency" means the entity designated by the Ohio department of medicaid (ODM) to provide case management services to individuals enrolled on an ODM-administered waiver.

(3) "Case manager" means a registered nurse (RN), licensed social worker (LSW) or licensed independent social worker (LISW) employed by the case management agency who provides case management services to individuals enrolled on an ODM-administered waiver, an RN or LSW employed by the Ohio department of aging's (ODA) designee, a medicaid managed care plan, or mycare Ohio plan, who is responsible for the planning, coordinating, monitoring, evaluation, and authorization of medicaid waiver-funded community-based long-term care services and the non-medicaid waiver-funded PASSPORT program.

(4) "Demonstration period" means the three hundred sixty-five day period that begins the day a HOME choice participant is discharged from an institutional setting into a qualified residence in the community and during which the participant is eligible for HOME choice services.

(5) "Financial management services" are federally-mandated fiscal intermediary and administrative services that an ODM-designated entity provides for HOME choice participants.

(6) "Guardian" means, in accordance with section 2111.01 of the Revised Code, any person, association, or corporation appointed by the probate court to have the care and management of the person, the estate, or both of an individual who is incompetent or minor. When applicable, "guardian" includes, but is not limited to, a limited guardian, an interim guardian, a standby guardian, and an emergency guardian appointed pursuant to division (B) of section 2111.02 of the Revised Code. "Guardian" also includes an agency under contract with the Ohio department of developmental disabilities (DODD) for the provision of protective service under sections 5123.55 to 5123.59 of the Revised Code when appointed by the probate court to have the care and management of the person of an incompetent.

(7) "HOME choice application" means an official request for participation in the HOME choice program using the ODM 02361, "HOME Choice -Application" (rev. 7/2014).

(8) "HOME choice case management" means the provision of case management services to individuals participating in HOME choice who are not enrolled on a home and community based services (HCBS) waiver. These services are available immediately prior to a participant's enrollment in the program and continue through the participant's demonstration period.

(9) "HOME choice participant" or "participant" means a person who is receiving HOME choice services.

(10) "HOME choice service plan" means the plan that is approved by ODM that identifies and authorizes the HOME choice services, supports and activities to be provided to a HOME choice participant.

(11) "HOME choice services" means all services available to a HOME choice participant through the HOME choice program.

(12) "Institutional level of care" means any of the levels of care as described in rules 5160-3-07 and 5160-3-08 of the Administrative Code.

(13) "Institution" or "institutional setting" means a hospital, nursing facility, residential treatment facility, or an intermediate care facility for individuals with intellectual disabilities.

(14) "Legally responsible family member" means an individual's spouse, or in the case of a minor, the individual's birth or adoptive parent.

(15) "Money follows the person (MFP)" means the rebalancing demonstration program enacted by the Deficit Reduction Act of 2005. MFP is part of a comprehensive strategy to assist states in reforming long-term care support systems by reducing reliance on institutional care and developing community-based long-term care opportunities. The MFP rebalancing demonstration program in Ohio is titled HOME choice.

(16) "Non-agency provider" means a provider who is not employed by an agency, and who is eligible to provide services in the HOME choice program.

(17) "Plan of care" means the medical treatment plan that is established, approved, and signed by a treating physician prior to a provider requesting reimbursement for a service. The plan of care is not the same as an all services plan, service plan, individual service plan or HOME choice service plan.

(18) "Qualified residence" is a home which meets specific criteria to transition a participant safely into the community.

(a) A qualified residence must include:

(i) Lockable access and egress to the HOME choice participant's unit;

(ii) Sleeping, bathing, living and cooking areas over which a HOME choice participant or a HOME choice participant's family has domain and control;

(iii) A lease, rental agreement or other written verification of residency; and

(iv) No more than four unrelated individuals residing together.

(b) Examples of a qualified residence may include but are not limited to:

(i) A home owned or leased by a HOME choice participant or a HOME choice participant's family member or friend.

(ii) An adult foster home certified by an area agency on aging that the Ohio department of mental health and addiction services (OhioMHAS) contracts with in accordance with Chapter 5122-35 of the Administrative Code;

(iii) An adult family home licensed by OhioMHAS in accordance with section 5119.70 of the Revised Code and Chapter 5122-33 of the Administrative Code;

(iv) Type 1 residential facilities licensed by OhioMHAS in accordance with Chapter 5122-30 of the Administrative Code;

(v) Type 2 residential facilities licensed by OhioMHAS in accordance with Chapter 5122-30 of the Administrative Code;

(vi) Adult foster care where providers are certified by DODD in accordance with rule 5123:2-9-33 of the Administrative Code;

(vii) Non-intermediate care facilities for individuals with intellectual disabilities (ICF-IID) residential facilities licensed by DODD in accordance with section 5123.19 of the Revised Code and Chapter 5123:2-3 of the Administrative Code;

(viii) A supported living arrangement with a provider certified by DODD in accordance with agency 5123 of the Administrative Code for an individual with a developmental disability who is enrolled on an HCBS waiver that is administered by DODD;

(ix) Foster homes for children that are certified by the Ohio department of job and family services (ODJFS) in accordance with section 5103.03 of the Revised Code and Chapter 5101:2-7 of the Administrative code;

(x) Group homes for children that are licensed by ODJFS in accordance with Chapter 5101:2-5 of the Administrative Code, or certified by ODJFS in accordance with section 5103.03 of the Revised Code; or

(xi) Medically fragile foster homes for children that are certified by ODJFS in accordance with rule 5101:2-7-17 of the Administrative Code.

(xii) Any other community-based setting as approved by ODM.

(19) "Qualified services" means HCBS waiver services and medicaid state plan services that have been determined by ODM to be non-acute, long-term support services. Qualified services do not include HOME choice services. Qualified services are services that a participant would still receive at the end of the demonstration period when a recipient remains eligible for medicaid.

(20) "Residential treatment facility" means, in accordance with section 5166.01 of the Revised Code, a residential facility licensed by OhioMHAS under section 5119.34 of the Revised Code, or an institution certified by ODJFS under section 5103.03 of the Revised Code, that serves children and either has more than sixteen beds or is part of a campus of multiple facilities or institutions that, combined, have a total of more than sixteen beds.

(21) "Service and support administrator" means a provider employed by or under contract with a county board of developmental disabilities who provides a variety of coordination activities for an individual enrolled on an HCBS waiver that is administered by DODD in accordance with section 5126.15 of the Revised Code.

(22) "Transition coordination" is a service that helps a HOME choice participant plan for the move from an institutional setting into a qualified residence. The transition coordinator helps the participant locate benefits, secure housing, link with community services and make detailed plans for the services needed to move and remain in the community-based setting.

Replaces: 5160-51-01

Effective: 2/1/2015
Five Year Review (FYR) Dates: 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 119.03, 5164.02
Rule Amplifies: 5162.03, 5164.02, 5166.02, 5164.90
Prior Effective Dates: 7/1/2008, 9/9/2010

5160-51-02 Helping Ohioans move, expanding choice (HOME choice) program application process, participant eligibility, and enrollment.

(A) This rule describes the application process and the criteria for eligibility and enrollment of an individual into the helping Ohioans move, expanding choice program (hereafter referred to as HOME choice).

(B) The application process for the HOME choice program is completed when an individual submits the ODM 02361, "HOME Choice - Application" (rev. 7/2014) to the Ohio department of medicaid (ODM).

(C) To be eligible for participation in the HOME choice program, an individual must meet all of the following requirements:

(1) Continuously reside in an institutional setting such as a nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF-IID), residential treatment facility and/or hospital, or a combination thereof, for a period of not less than ninety consecutive days. If the hospital is an institution for mental diseases, the individual must be younger than age twenty-one or older than age sixty-five;

(2) Participate in an in-person meeting with a HOME choice pre-transition case manager to complete a HOME choice readiness assessment;

(3) Receive medicaid benefits for inpatient services furnished by the institutional setting prior to discharge;

(4) Have an institutional level of care;

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

(6) Have needs that can be safely met through the HOME choice program, as determined by the Ohio department of medicaid (ODM) or its designee;

(7) Agree to move into a qualified residence upon discharge from the institutional setting; and

(8) Agree to and sign the ODM 02362 "HOME Choice - Informed Consent" (rev. 7/2014).

(D) To be pre-enrolled and to maintain pre-enrollment status in the HOME choice program, the participant must:

(1) Be determined eligible for the HOME choice program in accordance with paragraph (C) of this rule;

(2) Be in compliance with the ODM 02362; and

(3) Work with a transition coordinator to develop a comprehensive transition plan based on the participant's needs to facilitate a smooth transition from the institutional setting into a qualified residence. Transition plans include but are not limited to locating suitable housing, benefits coordination, and linking to community resources.

(E) If an individual fails to meet any of the requirements set forth in paragraph (C) and/or paragraph (D) of this rule, the individual shall be denied pre-enrollment in the HOME choice program.

(F) Once pre-enrolled in the HOME choice program, if a participant no longer meets all of the requirements set forth in paragraph (C) and/or paragraph (D) of this rule, the participant's pre-enrollment status in the HOME choice program shall be terminated.

(G) If a participant is denied pre-enrollment in the HOME choice program, or the participant's pre-enrollment status is being terminated, the participant shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(H) A participant in pre-enrollment status is considered to be enrolled in the HOME choice program when he or she is discharged from the institutional setting into a qualified residence.

(I) If, at any time, a participant enrolled in the HOME choice program no longer meets all of the requirements set forth in paragraph (C) of this rule, or the requirements set forth in the ODM 02362, he or she shall be disenrolled from the HOME choice program.

(J) If a participant is denied enrollment in the HOME choice program, or is being disenrolled in the HOME choice program, the participant shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

Replaces: 5160-51-02

Effective: 2/1/2015
Five Year Review (FYR) Dates: 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 119.03, 5164.02
Rule Amplifies: 5162.03, 5164.02, 5166.02, 5164.90
Prior Effective Dates: 07/01/08, 09/09/10, 8/1/11

5160-51-03 Helping Ohioans move, expanding choice (HOME choice) program conditions of participation and enrollment for providers.

(A) This rule sets forth the conditions of participation and enrollment for providers furnishing services to participants in the helping Ohioans move, expanding choice (hereafter referred to as HOME choice) program.

(B) In order to enroll as a HOME choice service provider and maintain provider status, the provider shall:

(1) Submit a signed ODM 02216 "Ohio HOME Choice Demonstration Program Provider Enrollment Application/Time Limited Agreement" (rev. 11/2014) and applicable addendum, or another applicable HOME choice provider agreement;

(2) Meet all requirements in the applicable provider service specifications set forth in rule 5160-51-04 of the Administrative Code;

(3) As applicable, comply with the criminal records check requirements set forth in:

(a) Rules 5160-45-07, 5160-45-08 and 5160-45-11of the Administrative Code if the provider is approved by the Ohio department of medicaid (ODM);

(b) Rule 173-39-03 of the Administrative Code if the provider is certified by the Ohio department of aging (ODA);

(c) Rule 5123:2-2-01 of the Administrative Code if the provider is certified by the Ohio department of developmental disabilities (DODD); or

(d) Rules 5122-30-03 and 5122-30-04 of the Administrative Code, or rule 5122-26-06 of the Administrative Code, as applicable, if the provider is certified by the Ohio department of mental health and addiction services (OhioMHAS);

(4) Attend ODM-sponsored HOME choice program provider training sessions as required by ODM;

(5) Ensure participants receive HOME choice services in accordance with their HOME choice service plan;

(6) Upon request, and within the time frame prescribed in the request, provide all requested information to the state agency administering the home and community based services (HCBS) waiver on which the HOME choice participant is enrolled, or to ODM if the HOME choice participant is not enrolled on an HCBS waiver, to the centers for medicare and medicaid services (CMS) and to the entity under contract with ODM to provide HOME choice financial management services (FMS);

(7) Be knowledgeable about and comply with all federal and state privacy laws, including the health insurance portability and accountability act (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on the effective date of this rule), and the medicaid safeguarding of information requirements set forth in 42 C.F.R. 421.300 to 306 (as in effect on the effective date of this rule), along with section 5160.45 of the Revised Code;

(8) Retain all required documentation related to the services delivered during the contact or visit, including but not limited to: an individual-specific description and details of the tasks performed or not performed in accordance with the participant's approved HOME choice service plan and when required, the participant's plan of care;

(9) As directed by ODM, retain validation of service delivery including, but not limited to: the date and location of service delivery, arrival and departure times, and the dated signatures of the provider and the participant or his/her guardian. All signatures shall be obtained at the end of every visit or upon completion of the scheduled service. Acceptable signatures include, but are not limited to a handwritten signature, initials, a stamp or mark, or an electronic signature;

(10) Retain all records of service delivery and billing for a period of six years after the date of receipt of the payment based upon those records, or until any initiated audit is completed, whichever is longer;

(11) Cooperate with ODM and/or its designee during all provider monitoring activities by being available to answer questions during reviews, and by ensuring the availability and confidentiality of participant information and other documents that may be requested as part of provider monitoring activities;

(12) Notify the participant's case manager (CM), the service and support administrator (SSA) or HOME choice case manager, as appropriate, within twenty-four hours and provide written documentation within five calendar days when the provider is aware of issues that may affect service delivery to the participant. Issues may include, but are not limited to the following:

(a) The participant consistently declines services;

(b) The participant moves to another residential address;

(c) There are changes in the physical, mental and/or emotional status of the participant;

(d) There are changes in environmental conditions affecting the participant;

(e) The participant's caregiver status has changed;

(f) The participant no longer requires medically necessary services as defined in rule 5160-1-01 of the Administrative Code;

(g) Abuse or neglect of the participant is suspected, a referral has been made to a protective service agency on the participant's behalf, or an active protective services case is pending;

(h) The participant is behaving inappropriately toward the provider;

(i) Threatening actions were made toward the provider or the provider feels unsafe in the participant's environment;

(j) The participant is consistently non-compliant with physician orders, or is non-compliant with physician orders in a manner that may jeopardize the participant's health and welfare;

(k) The participant's requests consistently conflict with his/her approved HOME choice service plan or may jeopardize the participant's health and welfare;

(l) The participant has been hospitalized or visited the emergency room;

(m) The participant has been placed in an institutional setting;

(n) The participant is experiencing other health and welfare issues;

(13) Make arrangements to accept all correspondence sent by ODM, ODA, DODD, or OhioMHAS, as appropriate, or any of their designees, including but not limited to certified mail;

(14) Provide and maintain a current e-mail address to ODM and/or its designee in order to receive electronic notification of any rule adoption, amendment, or rescission, and any other communications from ODM or its designee;

(15) Submit written notification to the participant and ODM at least thirty calendar days prior to the anticipated last date of service if the provider is terminating the provision of HOME choice services to the participant. Exceptions to the thirty-day advance notification requirement are subject to oral notification within twenty-four hours of the last date of service, and written notification within five calendar days of the last date of service. Thirty-day advance notification may be waived by ODM upon request and on a case-by-case basis, including but not limited to, when the participant:

(a) Has been hospitalized for at least three days;

(b) Has been placed in an institutional setting;

(c) Has been incarcerated.

(16) Providers furnishing HOME choice services to participants enrolled on an ODA-administered waiver shall comply with the incident reporting requirements set forth in rule 173-39-02 of the Administrative Code.

(17) Providers furnishing HOME choice services to participants enrolled on a DODD-administered waiver, or who are not enrolled on an HCBS waiver but are eligible for services through a county board of developmental disabilities (CBDD) shall comply with the major unusual incident requirements set forth in rule 5123:2-17-02 of the Administrative Code.

(18) Providers furnishing HOME choice services to participants enrolled on an ODM-administered waiver, shall comply with the incident reporting requirements set forth in rule 5160-45-05 of the Administrative Code.

(19) Providers furnishing HOME choice services to participants who are not enrolled on an HCBS waiver, or who are not eligible for services through a CBDD shall comply with the incident reporting requirements set forth in rule 5160-45-05 of the Administrative Code.

(20) Agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security.

(21) Non-agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. Federal employment taxes include medicare and social security. On an annual basis, non-agency providers must submit an ODM approved affidavit stating that they paid the applicable federal, state and local income and employment taxes.

(C) At no time shall HOME choice service providers:

(1) Engage in any behavior that causes or may cause physical, verbal, mental or emotional abuse or distress to the participant;

(2) Engage in any activity or behavior that may compromise the health and welfare of the participant;

(3) Engage in any activity or behavior that may take advantage of or manipulate the participant or his or her guardian, family or household members, that may result or appear to result in a conflict of interest, exploitation, or any other advantage for personal gain, as determined by ODM. This includes, but is not limited to:

(a) Misrepresentation;

(b) Accepting, obtaining, attempting to obtain, borrowing, or receiving money or anything of value including, but not limited to gifts, tips, credit cards or other items;

(c) Being designated on any financial account including, but not limited to bank accounts and credit cards;

(d) Using real or personal property of another;

(e) Using information of another;

(f) Lending or giving money or anything of value;

(g) Engaging in the sale or purchase of products, services or personal items;

(h) Engaging in any activity or behavior that takes advantage of or manipulates HOME choice program rules;

(i) Engaging in any other activity or behavior where the provider's personal or professional interests are potentially at odds with the best interests of the participant, as determined by ODM.

(4) Falsify the participant's signature, including using copies of the signature;

(5) Make fraudulent, deceptive or misleading statements in the advertising, solicitation, administration or billing of services;

(6) Submit a claim for HOME choice services rendered while the participant is hospitalized, institutionalized or incarcerated. The only exception is when the participant is receiving out-of-home respite as set forth on his or her service plan.

(D) While rendering services, HOME choice service providers shall not:

(1) Take the participant to the provider's place of residence;

(2) Bring children, animals, friends, relatives, other individuals or anyone else to the participant's place of residence;

(3) Provide care to persons other than the participant.

(4) Smoke without the consent of the participant;

(5) Sleep;

(6) Engage in any activity that is not related to the provision of services to the extent the activity distracts from, or interferes with, service delivery. Such activities include, but are not limited to the following:

(a) Using electronic devices for personal or entertainment purposes including, but not limited to watching television, using the computer or playing games;

(b) Making or receiving personal communications;

(c) Engaging in socialization with persons other than the individual;

(7) Deliver services when the provider is medically, physically or emotionally unfit;

(8) Use or be under the influence of the following while providing services:

(a) Alcohol;

(b) Illegal drugs;

(c) Chemical substances;

(d) Controlled substances that may adversely affect the provider's ability to furnish services;

(9) Engage in any activity or conduct that may reasonably be interpreted as sexual in nature, regardless of whether or not it is consensual;

(10) Engage in any behavior that may reasonably be interpreted as inappropriate involvement in the participant's personal beliefs or relationships including, but not limited to discussing religion, politics or personal issues;

(11) Consume the participant's food and/or drink without his or her offer and consent.

(E) HOME choice service providers shall not be designated to serve or make decisions for the participant in any capacity involving a declaration for mental health treatment, general power of attorney, health care power of attorney, financial power of attorney, guardianship pursuant to court order, as an authorized representative or a representative payee as that term is described in paragraph (E)(3) of this rule, except as provided in paragraphs (E)(1) to (E)(4) of this rule.

(1) A provider may be appointed by the court to serve as legal guardian for the participant pursuant to Chapter 2111. of the Revised Code if the provider is a family member.

(2) A provider may serve as an authorized representative or pursuant to a declaration for mental health treatment, general power of attorney, health care power of attorney, financial power of attorney or guardianship if the provider is the participant's parent or spouse.

(3) A provider may serve as the participant's representative payee if the provider is the participant's parent or spouse. For purposes of this rule, "representative payee" means a parent or spouse the participant designates to receive and manage payments that would otherwise be made directly to the participant.

(4) A provider may be designated as an authorized representative or pursuant to a declaration for mental health treatment, general power of attorney, health care power of attorney, financial power of attorney or guardianship for the participant if:

(a) The provider was serving in that capacity prior to October 1, 2008; and

(b) The provider was the participant's paid provider prior to October 1, 2008; and

(c) The designation is not otherwise prohibited by law.

(F) ODM shall not process a service provider application packet for a prospective HOME choice service provider if the application packet does not contain information necessary to complete the required verifications as listed on the checklist attachment to the ODM 02216. ODM shall notify the prospective service provider in writing of any missing information, and shall provide the applicant thirty calendar days to submit the required documentation. If the applicant does not submit the required documentation within thirty calendar days, the service provider application process shall be terminated.

(G) Failure to meet the requirements set forth in this rule and/or the applicable HOME choice provider agreement, may result in termination of the HOME choice provider's provider agreement.

Replaces: 5160-51-03, 5160-51-05

Effective: 2/1/2015
Five Year Review (FYR) Dates: 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 119.03, 5164.02
Rule Amplifies: 5162.03, 5164.02, 5166.02, 5164.90
Prior Effective Dates: 7/1/08, 9/9/10

5160-51-04 Helping Ohioans move, expanding choice (HOME choice) program definitions of covered services and provider qualifications.

(A) This rule sets forth the covered services available to a helping Ohioans move, expanding choice (hereafter referred to as HOME choice) program participant as well as provider requirements for those services.

(B) "Communication aid services" include devices, systems or services necessary to assist a HOME choice participant with hearing, speech or vision impairments to effectively communicate with others.

(1) Communication aid services include, but are not limited to:

(a) Augmentative communication devices or systems that transmit or produce a message or symbols in a manner that compensates for the participant's communication impairment;

(b) Computers and computer equipment;

(c) Other mechanical and electronic devices;

(d) Cable and internet access;

(e) The cost of installation, repair, maintenance and support of any covered communication aid;

(f) Interpreter services that support the HOME choice participant's integration into the community. Interpreter services refers to the process by which the interpreter conveys one person's message to another by incorporating both the message and the attitude of the communicator; and

(g) New technologies and any other devices that achieve the objective of the service.

(2) If the HOME choice participant is enrolled on a home and community based services (HCBS) waiver, the participant must exhaust similar waiver services that are available before utilizing communication aid services through HOME choice.

(3) A provider of communication aid services must be an agency provider who is:

(a) An Ohio department of medicaid (ODM)-approved provider of supplemental adaptive and assistive device services in accordance with rule 5160-46-04 or rule 5160-50-04 of the Administrative Code, as appropriate; or

(b) An Ohio department of developmental disabilities (DODD)-certified provider of adaptive and assistive equipment services in accordance with rule 5123:2-2-01 of the Administrative Code; or

(c) An Ohio department of aging (ODA)-certified long term care provider of home medical equipment and supplies in accordance with rule 173-39-03 of the Administrative Code.

(4) Reimbursement for communication aid services shall not exceed a total of five thousand dollars during the participant's demonstration period. The same type of communication aid equipment may be approved by ODM for the HOME choice participant when there is a documented need.

(5) In order to submit a claim and be reimbursed for communication aid services, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the communication aid service provider on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider.

(C) "Community support coaching" is a service provided for the purpose of guiding, educating and empowering a HOME choice participant, and the participant's guardian and family members, as applicable, before, during and after the participant's transition from an institution into the community.

(1) The community support coach shall:

(a) Communicate with and educate the participant about vital aspects of the transition process;

(b) Assist the HOME choice participant in:

(i) Making informed and independent choices,

(ii) Setting and achieving short-term and long-term goals,

(iii) Managing multiple tasks,

(iv) Identifying options and problem solving,

(v) Identifying community resources available to the participant, and

(vi) Connecting to potential employment opportunities before, during and after transition.

(c) Provide the case manager, service and support administrator, or HOME choice case manager, as appropriate, with written status reports during the participant's demonstration period, as prescribed by the HOME choice service plan.

(2) A provider of community support coaching services shall not be the same staff person, of a transition coordination agency, who provided transition coordination services to the same participant during their pre-transition period.

(3) Community support coaching shall not duplicate independent living skills training available through HOME choice, similar waiver services available to participants enrolled on an HCBS waiver, or services available through the medicaid state plan.

(4) A provider of community support coaching must:

(a) Be a non-agency provider, or

(b) Be an agency provider that is either:

(i) A community mental health provider certified by the Ohio department of mental health and addiction services (OhioMHAS) in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or

(ii) A non-profit agency provider.

(5) Non-agency providers of community support coaching services, and all staff members of agency providers of community support coaching services with direct participant contact must:

(a) Have either:

(i) A disability and has lived in an institution and successfully transitioned to the community, and/or

(ii) Experience transitioning individuals from an institution to the community.

(b) Be age eighteen or older;

(c) Possess a valid Ohio driver license and automobile liability insurance when providing transportation;

(d) Not be the participant's legally responsible family member; and

(e) Not be the participant's case manager or service and support administrator, as those terms are defined in rule 5160-51-01 of the Administrative Code.

(6) In order to a submit claim and be reimbursed for community support coaching, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the community support coach provider on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider.

(D) "Community transition services" are goods, services and support for the purpose of addressing an identified need in a participant's HOME choice service plan, including improving and maintaining the participant's opportunities for inclusion in the community.

(1) Community transition services are intended to:

(a) Decrease the need for formal support services and other medicaid services;

(b) Take into consideration the appropriateness and availability of a lower cost alternative for comparable services that meet the participant's needs;

(c) Promote community inclusion and family involvement;

(d) Improve the participant's health and welfare in the home and community;

(e) Be provided when the participant does not have the funds to purchase the services, or the services are not available through another source;

(f) Assist the participant in developing and maintaining personal, social, physical or work-related skills; and

(g) Assist the participant in living independently in the home and community.

(2) Community transition services include:

(a) Transportation expenses up to a maximum of five hundred dollars during the participant's pre-transition period and for thirty days after transitioning to the community;

(b) Initial transition expenses up to a maximum of two thousand dollars including, but not limited to the following:

(i) Security deposit and rent required to lease a qualified residence;

(ii) Essential household furnishings, including furniture, window coverings, food preparation items, and bed/bath linens;

(iii) Set-up fees or deposits for utility or service access, including telephone, electricity, heating and water;

(iv) Services necessary for the participant's health and welfare, such as pest control and one-time cleaning prior to moving in to the residence;

(v) Moving expenses;

(vi) Necessary home accessibility adaptations; and

(vii) Initial grocery purchase, i.e., food and household supplies.

(3) Community transition services do not include:

(a) Experimental or prohibited treatments;

(b) The ongoing cost of rent;

(c) Ongoing utility charges;

(d) Ongoing grocery expenses;

(e) Cigarettes and alcohol;

(f) Electronics and other household appliances or items that are intended to be used for entertainment or recreational purposes; and

(g) Cable and/or internet access.

(4) Community transition services shall not duplicate similar services available to a participant who is enrolled on an HCBS waiver except when the participant is enrolled on an ODA-administered waiver or ODM-administered waiver. Participants enrolled on an ODA-administered waiver or ODM-administered waiver shall use HOME choice community transition services in lieu of, but not in addition to, the community transition services available through the waiver.

(5) Reimbursement for community transition services shall not exceed a cumulative maximum of two thousand five hundred dollars for the items set forth in paragraph (D)(2) of this rule.

(6) In order to submit a claim and be reimbursed for community transition services:

(a) The specific goods and services purchased shall have been based upon the participant's needs; and

(b) The goods and/or services must have been identified on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date for which the provider is authorized to furnish community transition services to the participant. The provider will not be reimbursed for unauthorized community transition services including community transition services provided in excess of what is documented on the participant's service plan for that provider.

(7) During the HOME choice participant's demonstration period, the purchase of community transition services shall be coordinated by the participant's case manager, service and support administrator and/or HOME choice case manager as appropriate and as approved by ODM prior to submission for reimbursement to the ODM-designated HOME choice financial management service (FMS) provider.

(E) "HOME choice nursing services" are intermittent services provided to a HOME choice participant that require the skills of a registered nurse (RN) or licensed practical nurse (LPN) at the direction of an RN. All nurses providing HOME choice nursing services shall provide services within the nurse's scope of practice as set forth in Chapter 4723. of the Revised Code and rules of the Administrative Code adopted thereunder, and shall possess a current, valid and unrestricted license with the Ohio board of nursing.

(1) HOME choice nursing services do not include:

(a) Services delegated in accordance with Chapter 4723. of the Revised Code and rules of the Administrative Code adopted thereunder and to be performed by providers who are not licensed nurses;

(b) Services that require the skills of a psychiatric nurse;

(c) Visits performed for the purpose of conducting an RN assessment, including but not limited to an outcome and assessment information set (OASIS) assessment or any other assessment;

(d) Visits or communication performed by an RN either for the purpose of RN consultation or for the purpose of meeting supervisory requirements;

(e) Visits performed for the purpose of meeting the home care attendant service RN visit requirements set forth in rules 5160-46- 04.1 and 5160-50- 04.1 of the Administrative Code.

(2) HOME choice nursing services shall not duplicate similar waiver services available to participants enrolled on an HCBS waiver or available through medicaid state plan home health nursing or private duty nursing services.

(3) HOME choice nursing services may be provided on the same day as, but not concurrently with an RN assessment or an RN consultation.

(4) A provider of HOME choice nursing services must be a medicaid provider who is either:

(a) Employed by a medicare-certified, or otherwise-accredited home health agency; or

(b) An approved ODM-administered waiver non-agency nursing service provider in accordance with rule 5160-46-04 or 5160-50-04 of the Administrative Code.

(5) A provider of HOME Choice nursing services must not be:

(a) The participant's legally responsible family member unless the family member is employed by a medicare-certified, or otherwise-accredited home health agency; or

(b) The foster caregiver of the participant.

(6) Non-agency LPNs, at the direction of an RN, must:

(a) Meet with the directing RN at least every sixty days after the initial visit to evaluate the provision of HOME choice nursing services and the LPN's performance of those services, and to ensure that services are being provided in accordance with the approved plan of care and within the LPN's scope of practice; and

(b) Conduct an in-person visit with the participant and the directing RN before initiating services and at least once every one hundred twenty days for the purpose of evaluating the provision of HOME choice nursing services, the participant's satisfaction with care delivery and the LPN's performance, and to ensure that services are being provided in accordance with the approved plan of care and within the LPN's scope of practice

(7) All HOME choice nursing service providers must maintain a clinical record for each participant served in a manner that protects the confidentiality of these records. Medicare-certified, or otherwise-accredited home health agencies, must maintain the clinical records at their place of business. Non-agency HOME choice nursing service providers must maintain the clinical records at their place of business, and maintain a copy in the participant's residence. For the purposes of this rule, the place of business must be a location other than the participant's residence. At a minimum, the clinical record must include:

(a) Participant 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;

(b) The participant's medical history;

(c) Name of the participant's treating physician;

(d) A copy of the HOME choice service plan approved by ODM;

(e) A copy of the initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the nursing services being performed. When services are performed by an LPN at the direction of an RN, the clinical record shall include documentation that the RN has reviewed the plan of care with the LPN. The plan of care must be recertified by the treating physician every sixty days, or more frequently if there is a significant change in the participant's condition;

(f) Documentation of verbal orders given by the treating physician to the nurse. The nurse must document, in writing, the physician's verbal orders, the date and time the orders were given, and sign the entry in the clinical record. The nurse must subsequently secure documentation of the verbal orders, signed and dated by the treating physician;

(g) Clinical notes, signed and dated by the non-agency LPN, in all instances when a non-agency LPN is providing HOME choice nursing services. The LPN must maintain documentation of all consultations between the LPN and the directing RN, and the in-person visits between the LPN, the participant and the directing RN;

(h) Documentation of all drug and food interactions, allergies and dietary restrictions;

(i) A copy of any existing advanced directives including, but not limited to, do not resuscitate orders or medical powers of attorney;

(j) Clinical notes and other documentation of tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and the participant or their guardian verifying the service delivery upon completion of service delivery. The participant or their guardian's signature of choice shall be documented on the HOME choice service plan, and shall include, but not be limited to any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature;

(k) Clinical notes, signed and dated by the nurse, documenting all communications between the treating physician and other members of the multidisciplinary team; and

(l) A discharge summary, signed and dated by the nurse at the conclusion of the participant's demonstration period, or at the point the nurse is no longer going to provide services to the participant, or when the participant no longer needs HOME choice nursing services. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-up or referrals.

(8) In order to submit a claim and be reimbursed for HOME choice nursing services, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the HOME choice nursing services provider on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider;

(c) Be identified as the provider on, and be performing HOME choice nursing services pursuant to the participant's plan of care, as that term is defined in rule 5160-51-01 of the Administrative Code. The plan of care must be signed and dated by the participant's treating physician; and

(d) Have provided the services for one participant during an in-person visit, or for two or three participants in a group setting during an in-person visit.

(F) "Independent living skills training" is information, educational supports and resources provided to a HOME choice participant for the purpose of developing skills, knowledge or abilities needed to live more independently.

(1) Independent living skills training focuses on:

(a) Community living skills including, but not limited to:

(i) Identifying and accessing existing community resources,

(ii) Job training and seeking employment opportunities,

(iii) Linking to legal resources,

(iv) Negotiating transportation systems and arranging transportation,

(v) Safety in the community, and

(vi) Travel training.

(b) Financial management skills including, but not limited to:

(i) Budgeting,

(ii) Finding a bank and establishing an account,

(iii) Managing entitlements and insurance,

(iv) Paying bills and taxes,

(v) Understanding credit,

(vi) Understanding contracts,

(vii) Using a bank machine,

(c) Health management skills including, but not limited to:

(i) Assessing the need for, and accessing, adaptive and assistive devices,

(ii) Crisis care/recovery services,

(iii) Efficiently managing nutrition and diet,

(iv) Ensuring emergency preparedness,

(v) Linking to medical/dental services,

(vi) Managing and accessing medical supplies,

(vii) Managing medication,

(viii) Talking to the doctor, and

(ix) Training service providers;

(d) Home management skills including, but not limited to:

(i) Grocery shopping, cooking and meal planning,

(ii) Housekeeping and laundry,

(iii) Operating simple technology,

(iv) Personal shopping,

(v) Requesting and/or completing simple repairs, and

(vi) Safety at home;

(e) Personal skills including, but not limited to:

(i) Daily functions such as hygiene, dressing and undressing,

(ii) Scheduling, and

(iii) Utilization of leisure/education/physical/emotional activities; and

(f) Social skills development including, but not limited to:

(i) Building communication skills,

(ii) Knowing when and how to ask for help,

(iii) Learning how to be a good neighbor/roommate, and

(iv) Learning how to work with providers.

(2) Independent living skills training shall not duplicate community support coaching services available through HOME choice, similar waiver services available to participants enrolled on an HCBS waiver, or services available through the medicaid state plan.

(3) If the HOME choice participant is enrolled on a DODD-administered waiver, the participant must access homemaker/personal care in lieu of independent living skills training.

(4) The independent living skills training provider shall provide the case manager, service and support administrator, or HOME choice case manager, as appropriate, with written status reports as directed during the participant's demonstration period.

(5) A provider of independent living skills training must be either:

(a) A community mental health provider certified by OhioMHAS in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code; or

(b) A non-profit agency provider whose staff with direct participant contact:

(i) Have either:

(a) A disability and has lived in an institution and successfully transitioned to the community and/or;

(b) Experience transitioning individuals from an institution to the community, and

(ii) Must have knowledge and experience about:

(a) Local community resources,

(b) Applicable disability laws and regulations, and

(iii) Are age eighteen or older; and

(iv) Possess a valid Ohio driver license and automobile liability insurance when providing transportation.

(6) In order to submit a claim and be reimbursed for independent living skills training, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule;

(b) Be identified as the independent living skills training provider on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider; and

(c) Have provided the service to one participant, or to two or three participants in a group setting, or four or more participants in a classroom setting, during the same in-person visit.

(G) "Nutritional consultation services" are services that provide individualized guidance to a HOME choice participant who has special dietary needs. Nutritional consultation takes into consideration the participant's health, cultural, religious, ethnic and socio-economic background and dietary preferences and/or restrictions.

(1) Nutritional consultation services shall not duplicate similar waiver services available to participants enrolled on an HCBS waiver or services available through the medicaid state plan.

(2) A provider of nutritional consultation services must be:

(a) A medicaid provider of nutritional consultation services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, or an ODA-certified long term care provider of nutritional consultation services in accordance with rule 173-39- 02.10 of the Administrative Code; and,

(b) Be a dietitian who:

(i) Is registered by the commission on dietetic registration; and

(ii) Maintains a license in good standing with the Ohio board of dietetics;

(3) All providers of nutritional consultation services must:

(a) Conduct an initial individual assessment of the participant's nutritional needs, and subsequent assessments when necessary, using an assessment tool that identifies whether the participant is at nutritional risk or identifies a nutritional diagnosis that the dietitian will treat. The assessment must include:

(i) A history of the participant's height and weight;

(ii) An assessment of the participant's nutrient intake adequacy;

(iii) A review of the participant's medications, medical diagnoses and diagnostic test results;

(iv) An assessment of the participant's verbal, physical and motor skills that could be attributable to, or affect, nutrient needs;

(v) An assessment of caregiver and participant interactions during feeding; and

(vi) An assessment of the need for additional adaptive equipment and/or other community resources and/or services for the participant.

(b) Develop, implement, evaluate and revise, as necessary, a nutrition intervention plan with the assistance of the participant and/or their guardian, case manager and when applicable, the treating physician and other relevant service providers. The plan shall be used to prioritize and address the identified nutrition problems. It must include purposely planned actions designed to change nutrition-related behavior, risk factors, environmental conditions or health status, and at a minimum, it must address the following:

(i) Appropriate dietary restrictions and modifications;

(ii) Specific nutrients that may be required or limited;

(iii) Feeding modality;

(iv) Nutrition education and counseling; and

(v) Expected measurable indicators and outcomes related to the participant's nutrition goals.

(c) Provide services pursuant to a plan of care for nutritional consultation services that is signed and dated by the treating physician. The plan of care for nutritional consultation services must be re certified by the treating physician every sixty days, or more frequently if there is a significant change in the participant's condition.

(d) Furnish the case manager, service support administrator, or HOME choice case manager, as appropriate, as well as the participant and/or the participant's guardian with a copy of the assessment and the nutrition intervention plan no later than seven working days after completion of the assessment.

(e) Furnish evidence, upon request, that the nutrition intervention plan was developed and services were delivered in accordance with professional licensure requirements.

(f) Maintain a clinical record for each participant served. At a minimum, the clinical record must include:

(i) Participant 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;

(ii) The participant's medical history;

(iii) Name of the participant's treating physician;

(iv) Treating physician's authorization for a nutritional assessment;

(v) A copy of the HOME choice service plan approved by ODM;

(vi) A copy of the initial and all subsequent individual assessments of the participant's nutritional needs;

(vii) A copy of the initial and all subsequent plans of care for nutritional consultation services specifying the type, frequency, scope and duration of the services being performed;

(viii) A copy of the initial and all subsequent nutrition intervention plans developed and implemented;

(ix) Documentation of all drug and food interactions, allergies and dietary restrictions;

(x) Documentation that clearly shows the date of nutritional consultation service delivery, including copies of all nutritional assessments conducted and all nutrition intervention plans developed and implemented; and

(xi) A discharge summary, signed and dated by the nutritional consultation provider at the conclusion of the participant's demonstration period, or at the point the dietitian is no longer going to provide services to the participant, or when the participant no longer needs nutritional consultation services. The summary shall include progress made to date toward goal achievement and nutritional outcomes, and any recommended follow-ups and/or referrals.

(4) In order to submit a claim and be reimbursed for nutritional consultation services, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the nutritional consultation services provider on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider.

(H) "Respite services" are services provided on a short-term basis to a HOME choice participant who is not enrolled on an HCBS waiver, and who is unable to care for himself or herself, due to the temporary absence of or periodic relief for the primary caregiver. Respite services include all of the necessary care that the primary caregiver would normally provide during that period. Respite services may be provided in-home, out-of-home or in a day camp setting in accordance with the participant's HOME choice service plan.

(1) In-home respite services are services provided in the participant's place of residence and shall include, but not be limited to:

(a) General supervision of the participant;

(b) Homemaker services to assist with housekeeping chores, meal preparation and shopping;

(c) Personal care services to assist with bathing, dressing and exercise;

(d) Skilled nursing services to assist with medical needs;

(e) Accompanying the participant to community outings; and

(f) Other related services.

(2) Out-of-home respite services are services provided in an out-of-home setting that meets the requirements set forth in paragraph (H)(4)(b) of this rule, and that require an overnight stay. Out-of-home respite services shall include, but not be limited to:

(a) Personal care services;

(b) Skilled nursing services; and

(c) Three meals per day that meet the participant's dietary needs.

(3) Day camp respite services are provided by a day camp that is licensed or certified by a recognized, accredited entity. Day camp respite services shall:

(a) Be provided for the purpose of therapeutic intervention that will meet the emotional and behavioral needs of the HOME choice participant;

(b) Include, but not be limited to:

(i) Personal care services;

(ii) Skilled nursing services; and

(iii) Meal services commensurate with the camp respite setting that meet the participant's dietary needs; and

(c) Not be provided in the HOME choice participant's place of residence.

(4) A provider of respite services must be one of the following:

(a) An in-home respite provider who is:

(i) A homemaker/personal care provider certified by DODD in accordance with rules 5123:2-9-30 and 5123:2-2-01 or rule 5123:2-3-19 of the Administrative Code, as applicable; or

(ii) An approved ODM-administered waiver personal care aide service provider or nursing service provider in accordance with rule 5160-46-04 or 5160-50-04 of the Administrative Code; or

(b) An out-of-home respite provider that is:

(i) Approved by ODM in accordance with rule 5160-45-04 of the Administrative Code; or

(ii) An intermediate care facility for individuals with intellectual disabilities (ICF-IID) that meets the requirements set forth in rules 5160-3-02 and 5160-3- 02.3 of the Administrative Code; or

(iii) A non-ICF-IID entity (i.e., a group home) licensed by DODD in accordance with rule 5123:2-3-02 of the Administrative Code; or

(iv) A nursing facility that meets the requirements set forth in rules 5160-3-02 and 5160-3- 02.3 of the Administrative Code; or

(v) Another licensed setting approved by ODM or its designee, including but not limited to, a hospice or hospital; or

(c) A camp respite provider that is licensed or certified by a recognized, accredited entity that includes, but is not limited to, the American camping association.

(5) All providers of in-home respite services must:

(a) Maintain evidence of the completion of twelve hours of in-service training within a twelve-month period, excluding agency and program-specific orientation. Agency providers must maintain evidence of non-licensed direct care staff's completion of the same requirements. In order to maintain ongoing provider status, in-service training must be initiated immediately after the non-licensed direct care staff's first anniversary of employment with the provider, and must be completed annually thereafter;

(b) Not be the participant's legally responsible family member;

(c) Ensure that any skilled nursing services provided are within the nurse's scope of practice as set forth in Chapter 4723. of the Revised Code; and

(d) Provide care as specified by task-based instruction for the provision of personal care services. Agency providers must provide such task-based instruction to direct care staff providing personal care services. Non-agency providers will receive instruction regarding their necessary care from the participant and/or their guardian and as documented in their plan of care.

(6) All providers of out-of-home respite services must:

(a) Provide insurance coverage of a participant's loss due to theft, property damage or personal injury, and maintain a written procedure identifying the steps a participant takes to file a liability claim. Documentation verifying the coverage shall be provided to ODM upon request;

(b) Maintain evidence of non-licensed direct care staff's completion of twelve hours of in-service training within a twelve-month period, excluding agency and program-specific orientation. In order to maintain ongoing provider status, in-service training must be initiated immediately after the non-licensed direct care staff's first anniversary of employment with the provider, and must be completed annually thereafter;

(c) Ensure that any skilled nursing services provided are within the nurse's scope of practice as set forth in Chapter 4723. of the Revised Code; and

(d) Provide task-based instruction to direct care staff providing personal care services.

(7) All respite service providers must maintain a record for each participant served in a manner that protects the confidentiality of the records. Providers of in-home respite must ensure at a minimum the record contains the information set forth in paragraphs (H)(7)(a) to (H)(7)(g) of this rule. At a minimum, providers of out-of-home respite must ensure the record contains the information set forth in paragraphs (H)(7)(a) to (H)(7)(h) of this rule.

(a) Participant identifying information including, but not limited to, name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification number;

(b) The participant's medical history;

(c) A copy of the initial and all subsequent HOME choice service plans;

(d) A copy of any existing advance directives including, but not limited to, do not resuscitate orders or medical powers of attorney;

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

(f) Documentation including, but not limited to, case notes clearly showing the date and outcome of respite service delivery, including tasks performed or not performed;

(g) Documentation required for providers of ODM administered waiver nursing services as set forth in rule 5160-46-04 or 5160-50-04 of the Administrative Code when skilled nursing services are provided during respite services;

(h) A discharge summary, signed and dated by the respite service provider, at the point the provider is no longer going to furnish respite services to the participant, or when the participant no longer needs respite services. The summary should indicate any recommended follow-ups or referrals.

(8) In order to submit a claim and be reimbursed for respite services the provider must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the respite services provider on the participant's HOME choice service plan as approved by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider.

(I) "Service animals" are animals that are trained to perform tasks for HOME choice participants that the participants are unable to perform for themselves.

(1) Tasks performed by service animals include, but are not limited to:

(a) Guiding people who are blind;

(b) Alerting people who are deaf;

(c) Pulling wheelchairs;

(d) Alerting and protecting participants who are having a seizure;

(e) Carrying and picking up things for participants with mobility impairments; and

(f) Assisting participants with mobility impairments with balance.

(2) Service animals may include, but are not limited to:

(a) Seeing eye dogs;

(b) Hearing dogs; and

(c) Service monkeys.

(3) Expenses related to the use of service animals include, but are not limited to:

(a) First-year costs associated with the raising of the animal;

(b) Housing, feeding, upkeep and medical care of the animal during training;

(c) Actual training of the animal, participant orientation and related transportation, room/board and administrative activities;

(d) Equipment and supplies;

(e) Animal health insurance; and

(f) Transportation to the veterinarian.

(4) If the HOME choice participant is enrolled on a DODD-administered waiver, the participant must exhaust similar waiver services that are available before utilizing the service animal service through HOME choice.

(5) A provider of service animal services must be an agency provider of adaptive and assistive equipment services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code.

(6) Reimbursement for service animal expenses shall not exceed a total of eight thousand dollars during the participant's demonstration period.

(7) In order to submit a claim and be reimbursed for service animal services, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the service animal service provider on the participant's HOME choice service plan as authorized by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider.

(J) "Social work/counseling services" are transitional services provided to a HOME choice participant, their guardian, caregiver and/or family member on a short-term basis to promote the participant's physical, social and emotional well-being. Social work/counseling services promote the development and maintenance of a stable and supportive environment for the participant.

(1) Social work/counseling services can include, but are not limited to, crisis interventions, grief counseling and/or other social service interventions that support the participant's health and welfare.

(2) Social work/counseling services shall not:

(a) Take the place of case management services; or

(b) Duplicate similar waiver services available to participants enrolled on an HCBS waiver or through the medicaid state plan.

(3) A provider of social work/counseling services must be either:

(a) A non-agency provider who shall maintain documentation of licensure by the applicable Ohio licensure board and have at least one year of social work/counseling experience, and is:

(i) A licensed professional clinical counselor (LPCC), licensed independent social worker (LISW), or independent marriage and family therapist (IMFT) who holds a current, valid and unrestricted license to practice issued by the counselor, social worker, and marriage and family therapist board in accordance with Chapter 4757. of the Revised Code; or

(ii) A psychologist who holds a current, valid and unrestricted license to practice issued by the state board of psychology of Ohio in accordance with Chapter 4732. of the Revised Code; or

(iii) An RN who holds a current, valid and unrestricted license to practice issued by the Ohio board of nursing in accordance with Chapter 4723. of the Revised Code and holds a masters degree in nursing (MSN) with a specialization or concentration in psychiatric or mental health nursing; or

(b) An agency provider who shall maintain documentation that all direct care social work/counseling staff are licensed by the applicable Ohio licensure board, and have at least one year of social work/counseling experience, and:

(i) Is a medicaid provider of social work counseling services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, or as certified by OhioMHAS in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or is an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39- 02.12 of the Administrative Code; and

(ii) Ensures that staff providing direct care is one of the following:

(a) An LPCC, licensed professional counselor (LPC), LISW, licensed social worker (LSW), marriage and family therapist (MFT), or IMFT who holds a current, valid and unrestricted license to practice issued by the counselor, social worker, and marriage and family therapist board in accordance with Chapter 4757. of the Revised Code;

(b) A psychologist who holds a current, valid and unrestricted license to practice issued by the state board of psychology of Ohio in accordance with Chapter 4732. of the Revised Code; or

(c) An individual who holds a current, valid and unrestricted license as an RN from the Ohio board of nursing accordance to Chapter 4723. of the Revised Code, and holds an MSN with a specialization or concentration in psychiatric or mental health nursing; and

(iii) Ensures that LSWs, LPCs and MFTs are supervised in accordance with Chapter 4757. of the Revised Code, and that the supervisor of an LSW, LPC or MFT co-signs all initial assessments and social work/counseling intervention plans prepared by the LSW, LPC, MFT or MSN.

(4) A provider of social work/counseling services must:

(a) Conduct individual assessments in order to evaluate the HOME choice participant's psycho-social, financial and environmental status;

(b) Develop and revise, as necessary, with the assistance of the participant, and/or the participant's guardian, caregiver(s) and the case manager or service and support administrator, as appropriate, a treatment plan that includes the recommended method of treatment and the recommended number of counseling sessions;

(c) Ensure that the treatment plan is implemented; and

(d) Furnish to the case manager, service and support administrator, or HOME choice case manager, a copy of the individual assessment report and the treatment plan no later than seven working days after completion of the individual assessment. The participant and/or the participant's guardian shall also be furnished with a copy of the individual assessment report and the treatment plan unless otherwise specified by the treatment plan.

(e) Maintain a clinical record for each participant served. At a minimum, the clinical record must include:

(i) Participant identifying information, including but not limited to name, address, age, date of birth, sex, race, marital status, significant phone numbers and health insurance identification information;

(ii) The participant's medical history;

(iii) Name of the participant's treating physician;

(iv) A copy of the HOME choice service plan approved by ODM;

(v) A copy of the initial and all subsequent individual assessments;

(vi) A copy of the initial and all revised treatment plans;

(vii) A copy of any existing advanced directives including, but not limited to, do not resuscitate orders or medical powers of attorney;

(viii) Documentation of all drug and food interactions, allergies and dietary restrictions;

(ix) Documentation that clearly shows the date of social work/counseling service delivery;

(x) A discharge summary, signed and dated by the social work/counseling service provider at the conclusion of the participant's demonstration period, or at the point the provider is no longer going to provide services to the participant, or when the participant no longer needs social work/counseling services. The summary should include documentation regarding service outcomes and progress made toward goal achievement and indicate any recommended follow-ups and/or referrals.

(5) In order to submit a claim and be reimbursed for social work/counseling services, the provider delivering the service must:

(a) Meet the conditions of participation and enrollment criteria set forth in rule 5160-51-03 of the Administrative Code, as well as all applicable provider qualifications set forth in this rule; and

(b) Be identified as the social work/counseling services provider on the participant's HOME choice service plan as approved by ODM. The authorized service plan will indicate the service begin date and the number of units/hours for which the provider is authorized to furnish services to the participant. The provider will not be reimbursed for unauthorized services including services provided in excess of what is documented on the participant's service plan for that provider.

Replaces: 5160-51-04, 5160-51-05

Effective: 2/1/2015
Five Year Review (FYR) Dates: 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 119.03, 5164.02
Rule Amplifies: 5162.03, 5164.02, 5166.02, 5164.90
Prior Effective Dates: 7/1/08, 6/1/09, 9/9/10, 8/1/11

5160-51-05 [Rescinded] HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program: process for enrolling service providers.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/20/2014
Promulgated Under: 119.03
Statutory Authority: 119.03, 5164.02
Rule Amplifies: 5162.03, 5164.02, 5166.02, 5164.90
Prior Effective Dates: 7/1/08, 9/9/10

5160-51-06 Helping Ohioans move, expanding choice (HOME choice) program definitions of billing terms, reimbursement rates and billing procedures for providers of covered services.

(A) This rule sets forth the helping Ohioans move, expanding choice (hereafter referred to as HOME choice) program definitions of billing terms, reimbursement rates and billing procedures for providers of covered services.

(B) Definitions of HOME choice billing terms:

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

(2) "Billing unit," as used in paragraph ( C) , table (B) of this rule, means a single fixed item or amount of time.

(3) "Classroom rate" is the amount that HOME choice independent living skills training providers are reimbursed when the service is provided in a classroom setting. The rate is equivalent to fifty per cent of the reimbursement rate set forth in paragraph ( C), table (B) of this rule that is paid to a provider for furnishing HOME choice independent living skills training services to a single participant.

(4) "Classroom setting" is a situation in which a HOME choice independent living skills training provider furnishes the same type of services to four or more participants at the same address, during the same visit. The services provided in the classroom setting can be either the same type of HOME choice independent living skills training , or a combination of HOME choice independent living skills training services and similar independent living skills training services.

(5) "Group rate," as used in paragraph ( F)(1) of this rule, is the amount that HOME choice nursing providers, or HOME choice independent living skills training providers are reimbursed when the service is provided in a group setting. The rate is equivalent to seventy-five per cent of the reimbursement rate set forth in paragraph ( C), table (A) of this rule for HOME choice nursing services, and in paragraph ( C), table (B) of this rule for HOME choice independent living skills training services that is paid to a provider for delivering the HOME choice nursing services or HOME choice independent living skills training services to a single participant.

(6) "Group setting" is a situation in which a HOME choice nursing, service provider, or independent living skills training provider furnishes the same type of services to two or three participants at the same address, during the same visit. The services provided in the group setting can be either the same type of HOME choice nursing service or HOME choice independent living skills training service, or a combination of HOME choice nursing services and similar nursing services, or HOME choice independent living skills training services and similar independent living skills training services.

(7) "Maximum usage amounts," as used in paragraph ( C) , table (B) of this rule, means the maximum number of hours, or the maximum dollar amount that a HOME choice service can be reimbursed, as set forth on the HOME choice participant's HOME choice service plan.

(8) "Maximum hours per month," as used in paragraph ( C) , table (A) of this rule, means the maximum number of hours that a HOME choice service can be reimbursed per month, as set forth on the HOME choice participant's HOME choice service plan.

(9) "Maximum rate" means the maximum amount that will be paid for the HOME choice service rendered.

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

(b) For the billing codes in paragraph ( C) , table (A) of this rule, the HOME choice maximum rate is:

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

(ii) The base rate as defined in paragraph ( B)(1) of this rule plus the unit rate as defined in paragraph ( B)( 11) of this rule for each additional unit of service delivered.

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

(11) "Unit rate," as used in paragraph ( C) , table (A) of this rule, and in paragraph ( C) , table (B) of this rule, means the amount paid for each fifteen minute unit following the base rate paid for the first four units of service provided.

(C) Billing code tables.

Table A

Column 1

Column 2

Column 3

Column 4

Column 5

Billing code

Service

Base rate

Unit rate

Maximum hours per month

HC001

HOME choice nursing provided by an RN

$ 56.65

$ 5.87

44 hours per month

HC002

HOME choice nursing provided by an LPN

$ 56.65

$ 5.87

44 hours per month

Table B

Column 1

Column 2

Column 3

Column 4

Column 5

Column 6

Billing code

Service

Billing unit

Maximum rate

Unit rate

Maximum usage amounts

HC003

Independent living skills training

15 minutes

$ 30.00 per hour

$ 7.50

144 hours during the 365-day demonstration period

HC004

Community support coaching

15 minutes

$ 25.00 per hour

$ 6.25

72 hours during the pre-transition and 365-day demonstration periods, combined

HC005

Social work/ counseling services

15 minutes

$ 64.12 per hour

$ 16.03

36 hours during the 365-day demonstration period

HC006

Nutritional consultation services

15 minutes

$ 52.56 per hour

$ 13.14

36 hours during the 365-day demonstration period

HC007

Communication aids

Per item

A maximum of $5, 000.00 for all items

N/A

$5,000 during the 365-day demonstration period

HC008

Service animals

Per item

A maximum of $8, 000.00 for all items

N/A

$8,000 during the 365-day demonstration period

HC009

Community transition services

Per item

A maximum of $2, 500.00 for all items (included in this is a maximum of $500 for pre-transition transportation expenses)

N/A

A maximum of $2,500 for all items (included in this is a maximum of $500 for pre-transition transportation expenses, and for all other approved community transition services, a maximum of $2,000 during the pre-transition and 365-day demonstration periods, combined)

HC012

In-home respite services

15 minutes

$ 9.00 per hour

$ 2.25

$2,000 for in-home, out-of-home and camp respite services, combined, during the 365-day demonstration period

HC013

Out-of-home respite services

Per day with overnight stay

$ 200.00 per day

N/A

$2,000 for in-home, out-of-home and camp respite services, combined, during the 365-day demonstration period

HC014

Camp respite services

Per day

A maximum of $625 per week

$125

$2,000 for in-home, out-of-home and camp respite services, combined, during the 365-day demonstration period, and including a maximum of $625/week for camp respite

(D) In order for a provider to submit a claim for reimbusement of HOME choice services, the services must be provided in accordance with Chapter 5160-51 of the Administrative Code.

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

(F) Required modifiers.

(1) The "GS" modifier must be used when a provider submits a claim for HOME choice nursing services, or HOME choice independent living skills training services, 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 HOME choice program maximum for the specific service.

(2) The "CS" modifier must be used when a provider submits a claim for HOME choice independent living skills training services if the service was delivered in a classroom setting. Reimbursement as a classroom rate shall be the lesser of the provider's billed charge or fifty per cent of the HOME choice program maximum.

(3) The "N2" modifier must be used when the same provider submits a claim for HOME choice nursing services for a second visit to a participant for the same date of service.

(4) The "N3" modifier must be used when the same provider submits a claim for HOME choice nursing services for three or more visits to a participant for the same date of service.

(5) The "N4" modifier must be used when a provider submits a claim for HOME choice nursing services for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(G) Reimbursement will be provided in accordance with the following:

(1) Except as stated in paragraph ( G)(2) of this rule, claims must be received by the financial management service (FMS) provider within ninety calendar days of the actual date the HOME choice service was provided.

(2) Reimbursement requests for community transition services must be received by the FMS provider within thirty calendar days of the actual date goods and services were purchased. Reimbursement requests must be in the form of either an invoice, a receipt or a purchase order.

(3) The payment for a covered HOME choice service constitutes payment-in-full and shall not be construed as a partial payment when the reimbursement amount is less than the provider's charge. The provider may not collect and/or bill the participant for any difference between the HOME choice payment and the provider's charge, or request the participant to share in the cost through a deductible, coinsurance, co-payment or other similar charge.

(4) Except as stated in paragraphs ( G)(5) and ( G)(6) of this rule, HOME choice providers shall not be reimbursed for non-covered services, or for otherwise covered services which are available either through the home and community based services (HCBS) waiver on which the HOME choice participant is enrolled, or through the medicaid state plan.

(5) When the HOME choice participant is enrolled on an HCBS waiver, HOME choice reimbursement is available for communication aid services only after the participant has received and exhausted same or similar waiver services.

(6) When the HOME choice participant is enrolled on an ODA-administered waiver or ODM-administered waiver, the participant shall use HOME choice community transition services in lieu of, but not in addition to, community transition services available through the waiver.

(7) Reimbursement is made only for those HOME choice services that are authorized on the participant's HOME choice service plan. The amount of payment is determined in accordance with federal and state laws and regulations. In establishing HOME choice maximums, ODM must assure that the maximum reimbursement is consistent with efficiency, economy and quality of care.

(H) ODM or its designee may recoup any overpayment by deducting that amount from a current or future payment or by another method prescribed by ODM. Overpayments include, but are not limited to payments made in error, payments for services that were not authorized, payments for services that were authorized but not provided, and payments that were made as a result of inaccurate billing.

Effective: 2/1/2015
Five Year Review (FYR) Dates: 10/20/2014 and 02/01/2020
Promulgated Under: 119.03
Statutory Authority: 119.03, 5164.02
Rule Amplifies: 5162.03, 5164.02, 5166.02, 5164.90
Prior Effective Dates: 7/1/08, 6/1/09, 9/9/10, 8/1/11