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

5160-51-01 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program: definitions.

The following definitions are applicable to Chapter 5101:3-51 of the Administrative Code:

(A) "Activities of daily living" are personal or self-care skills performed on a regular basis, with or without the use of adaptive and assistive devices that enable a consumer to meet basic life needs for food, hygiene and appearance as defined in rule 5101:3-3-06 of the Administrative Code.

(B) "Agency provider" is an agency that is eligible to participate in the HOME choice demonstration program.

(C) "All services plan" is the ODJFS-administered waiver service coordination and payment authorization document that identifies specific goals, objectives and measurable outcomes for consumer health and functioning expected as a result of services provided by both formal and informal caregivers, and that addresses the physical and medical conditions of the consumer.

(1) At a minimum, the all services plan shall include:

(a) Essential information needed to provide care to the consumer that assures the consumer's health and welfare;

(b) Billing authorization; and

(c) Signatures indicating the consumer's acceptance or rejection of the all services plan.

(2) The all services plan is not the same as the physician's plan of care.

(D) "Authorized representative"

(1) For a HOME choice demonstration program participant enrolled on an ODJFS-administered waiver, authorized representative has the same meaning as set forth in rule 5101:3-45-01 of the Administrative Code;

(2) For a HOME choice demonstration program participant enrolled on the ODA-administered choices waiver, authorized representative has the same meaning as set forth in rule 173-37-01 of the Administrative Code;

(3) For a HOME choice demonstration program participant enrolled on the ODA-administered PASSPORT waiver, authorized representative has the same meaning as set forth in rule 173-42-01 of the Administrative Code;

(4) For a HOME choice demonstration program participant enrolled on a DODD-administered waiver, authorized representative has the same meaning as set forth in rule 5101:1-2-01 of the Administrative Code; and

(5) For a HOME choice demonstration program participant who is not enrolled on an HCBS waiver, authorized representative has the same meaning as set forth in rule 5101:3-45-01 of the Administrative Code.

(E) "Case management agency" or "CMA" is the entity under contract with ODJFS that provides case management services to consumers enrolled on an ODJFS-administered waiver, and to HOME choice demonstration program participants who are not enrolled on an HCBS waiver.

(F) "Case manager" or "CM" is the CMA or PAA employee who provides a variety of case management services and care coordination activities for individuals enrolled on an ODJFS- or ODA-administered waiver, and to HOME choice demonstration program participants who are not enrolled on an HCBS waiver.

(G) "CDJFS" is a county department of job and family services.

(H) "Choices waiver program" or "choices" is the CMS-approved HCBS waiver program administered by ODA in accordance with Chapters 5101:3-31 and 173-37 of the Administrative Code.

(I) "Classroom rate" is the amount that HOME choice independent living skills training service 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 rule 5101:3-51-06 of the Administrative Code that is paid to a provider for furnishing HOME choice independent living skills training services to a single individual.

(J) "Classroom setting" is a situation in which a HOME choice independent living skills training service provider furnishes the same type of services to four or more individuals 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 service, or a combination of HOME choice independent living skills training services and similar independent living skills training services.

(K) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code, or a person or government entity, including a council of governments, with which a county board has contracted for assistance with its local medicaid administrative authority pursuant to division (E) of section 5126.055 of the Revised Code. The county board provides case management services to consumers enrolled on a DODD-administered waiver.

(L) "Demonstration services" are services available to the HOME choice demonstration program participant for up to three hundred sixty-five days beginning on the day a participant moves from an institutional setting into the community. Demonstration services include independent living skills training, community support coaching, social work/counseling, nutritional consultation, HOME choice nursing and respite services. Ohio is entitled to enhanced federal financial participation (FFP) from CMS for demonstration services.

(M) "DODD" is the Ohio department of developmental disabilities.

(N) "DODD-administered waiver" is a CMS-approved HCBS waiver administered by DODD in accordance with section 5111.871 of the Revised Code and Chapters 5101:3-40, 5101:3-42, 5123:2-8, 5123:2-9 and 5123:2-13 of the Administrative Code.

(O) "Financial management services" or "FMS" are federally-mandated administrative services that an ODJFS-designated governmental entity and/or another ODJFS-designated third-party entity perform on behalf of the HOME choice demonstration program participant.

(P) "Group rate" is the amount that HOME choice demonstration program nursing service providers, or HOME choice independent living skills training service 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 rule 5101:3-51-06 of the Administrative Code that is paid to a provider for delivering the HOME choice nursing services or HOME choice independent living skills training services to a single individual.

(Q) "Group setting" is a situation in which a HOME choice demonstration nursing service provider, or the HOME choice independent living skills training service provider furnishes the same type of services to two or three individuals 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.

(R) "Home and community-based services" or "HCBS" means medicaid-funded home and community-based services as set forth in Chapter 5111. of the Revised Code.

(S) "HOME choice demonstration program" means "Helping Ohioans Move, Expanding Choice."

(T) "HOME choice demonstration program application" is a formal request for a determination of HOME choice demonstration program eligibility that is made by an individual who is relocating from an institutional setting into the community. The ODJFS-approved application must be signed by the individual or the individual's authorized representative.

(U) "HOME choice demonstration program participant" is a person receiving HOME choice demonstration program services who may or may not be enrolled on a CMS-approved HCBS waiver.

(V) "HOME choice demonstration program period" is the three hundred sixty-five day period that begins the day an individual moves from an institutional setting into the community, and during which the HOME choice demonstration program participant is eligible for HOME choice demonstration program services.

(W) "HOME choice demonstration program services" are pre-transition, demonstration, qualified, and supplemental services available through the HOME choice demonstration program.

(X) "ICF-MR" is an intermediate care facility for persons with mental retardation.

(Y) "ICF-MR level of care" is the institutional level of care set forth in rule 5101:3-3-07 of the Administrative Code.

(Z) "Individual options waiver" or "IO waiver" is a CMS-approved HCBS waiver administered by the Ohio department developmental disabilities (DODD) in accordance with Chapters 5101:3-40, 5123:2-9 and 5123:2-13 of the Administrative Code.

(AA) "Individual service plan" or "ISP" is a written description of the services, supports and activities to be provided to a consumer enrolled on a DODD-administered waiver. The ISP is not the same as the physician's plan of care.

(BB) "Institutional level of care" is any of the levels of care set forth in rules 5101:3-3-05, 5101:3-3-06 and 5101:3-3-07 of the Administrative Code.

(CC) "Institutional setting" is any hospital, nursing facility (NF), residential treatment facility (RTF) or ICF-MR. Hospitals include institutions for mental diseases (IMD) only to the extent that medical assistance is available under the medicaid state plan for services provided by such institutions.

(DD) "Instrumental activity of daily living" is a community living skill performed on a regular basis, with or without the use of adaptive and assistive devices, that enables a consumer to independently manage his or her living arrangement as defined in rule 5101:3-3-08 of the Administrative Code.

(EE) "Intermediate level of care" or "ILOC" is the institutional level of care set forth in rule 5101:3-3-06 of the Administrative Code.

(FF) "Level one waiver" is a CMS-approved HCBS waiver administered by DODD in accordance with Chapters 5101:3-42, 5123:2-8 and 5123:2-9 of the Administrative Code.

(GG) "Medical necessity" and "medically necessary" have the same meaning as set forth in rule 5101:3-1-01 of the Administrative Code.

(HH) "Non-agency provider" is an independent provider who is not employed by an agency, and who is eligible to participate in the HOME choice demonstration program.

(II) "Non-waiver HOME choice demonstration program service plan" is the service coordination and payment authorization document that identifies the services, supports and activities to be provided to a HOME choice demonstration program participant who is not enrolled on an HCBS waiver. The non-waiver HOME choice demonstration program service plan is not the same as the physician's plan of care.

(JJ) "ODA" is the Ohio department of aging.

(KK) "ODA-administered waiver" is a CMS-approved HCBS waiver administered by ODA in accordance with Chapters 5101:3-31, 5101:3-32, 173-37 and 173-42 of the Administrative Code.

(LL) "ODJFS-administered waiver program" is the Ohio home care program benefit package that consists of CMS-approved HCBS waivers administered by ODJFS in accordance with Chapters 5101:3-45, 5101:3-46, 5101:3-47 and 5101:3-50 of the Administrative Code.

(MM) "ODMH" is the Ohio department of mental health.

(NN) "Ohio home care waiver" is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with Chapters 5101:3-45 and 5101:3-46 of the Administrative Code.

(OO) "PAA" means the local PASSPORT administrative agency that provides case management services to consumers enrolled on an ODA-administered waiver.

(PP) "Participant" means an individual who has been approved by ODJFS to participate in the HOME choice demonstration program.

(QQ) "PASSPORT waiver program" means the CMS-approved PASSPORT HCBS waiver program administered by ODA in accordance with Chapters 5101:31 and 173-42 of the Administrative Code.

(RR) "Plan of care" is the medical treatment plan that is established, approved and signed by the treating physician. The plan of care must be signed by the treating physician prior to when a provider requests reimbursement for a service. The plan of care is not the same as the all services plan, service plan or ISP, if the participant is enrolled on an ODJFS- , ODA- or DODD-administered waiver, respectively, or the non-waiver HOME choice demonstration program service plan if the HOME choice demonstration program participant is not enrolled on an HCBS waiver.

(SS) "Pre-transition services" are administrative activities and supplemental services that can be provided to a HOME choice demonstration program participant up to one hundred eighty days before the participant moves from a NF, ICF-MR, RTF or hospital into the community. Pre-transitional services and activities include transition coordination services and community transitions services.

(TT) "Qualified residence" is:

(1) A home owned or leased by the HOME choice demonstration program participant or the HOME choice demonstration program participant's family member;

(2) An apartment with an individual lease, that has lockable access and egress, and which includes living, sleeping, bathing and cooking areas over which the HOME choice demonstration program participant or the HOME choice demonstration program participant's family has domain and control. An apartment includes only the following:

(a) A private apartment,

(b) A public housing unit, or

(c) Residential care facility units designated for assisted living that meet the requirements of paragraph (RR)(2) of this rule; or

(3) A residence in a community-based residential setting in which no more than four unrelated individuals reside. A community-based residential setting only includes the following:

(a) Adult foster homes,

(b) Adult family homes,

(c) HCBS adult foster care certified by DODD,

(d) Supported living arrangements for individuals with a developmental disability who receive services through a DODD-administered waiver,

(e) Non-ICF-MR residential facilities licensed by DODD,

(f) Type 1 residential facilities licensed by the Ohio department of mental health (ODMH),

(g) Type 2 residential facilities licensed by ODMH,

(h) Foster homes for children that are certified by ODJFS,

(i) Medically fragile foster homes for children that are certified by ODJFS, or

(j) Group homes for children that are licensed or certified by ODJFS.

(UU) "Qualified home and community-based program" or "qualified HCB program" is the medicaid service package that shall be made available to a HOME choice demonstration program participant when the participant moves from an institutional setting into the community, and which will remain in effect at the conclusion of the HOME choice demonstration program. Qualified HCB programs include: HCBS waivers and the medicaid state plan.

(VV) "Qualified services" are existing waiver services, as well as the medicaid state plan services that have been determined by ODJFS to be non-acute, long term support services. They do not include demonstration and supplemental services.

(WW) "Residential treatment facility," for the purposes of the HOME choice demonstration program, is a facility greater than sixteen beds, or a facility located on a campus of multiple facilities that total more than sixteen beds, and that serves children and is licensed as a type 1 residential facility by ODMH in accordance with rule 5122-30-03 of the Administrative Code.

(XX) "Service and support administrator" or "SSA" is a county board of developmental disabilities employee who provides a variety of coordination activities for individuals enrolled on a DODD-administered waiver in accordance with section 5126.15 of the Revised Code.

(YY) "Service plan" is the written outline of an ODA-administered waiver consumer's services, including certified long term care services and all other services regardless of funding source. The service plan is not the same as the physician's plan of care.

(ZZ) "Skilled level of care" or "SLOC" is the institutional level of care set forth in rule 5101:3-3-05 of the Administrative Code.

(AAA) "Supplemental services" are HOME choice demonstration program services that are available to the HOME choice demonstration program participant during the three hundred sixty-five day demonstration period after a participant moves from an institution to the community that are not entitled to enhanced FFP. Supplemental services include:

(1) Communication aid services as set forth in paragraph (F) of rule 5101:3-51-04 of the Administrative Code; and

(2) Service animal services as set forth in paragraph (G) of rule 5101:3-51-04 of the Administrative Code.

(BBB) "Transitions Carve-Out Waiver" is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with Chapters 5101:3-45 and 5101:3-50 of the Administrative Code.

(CCC) "Transitions DD Waiver" is a CMS-approved HCBS waiver administered by ODJFS that serves consumers in accordance with Chapters 5101:3-45 and 5101:3-47 of the Administrative Code.

Effective: 09/09/2010
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85 , Section 309.30.90 of Am. Sub. H.B. 1, 128th G.A.
Prior Effective Dates: 7/1/2008

5160-51-02 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program: individual eligibility for services and participant hearing rights.

The HOME choice demonstration program is a multi-system demonstration funded through a CMS money follows the person (MFP) demonstration grant. The HOME choice demonstration program transitions qualifying individuals currently residing in nursing facilities, ICFs-MR, residential treatment facilities (RTF) and hospitals to a community setting. The HOME choice demonstration program provides additional services to enhance existing medicaid state plan and home and community-based services (HCBS) that will enable qualified consumers to safely and successfully integrate into community life. Open enrollment for the HOME choice demonstration program shall end on September 30, 2016. Any participant who qualifies prior to September 30, 2016 shall be entitled to receive HOME choice demonstration program services for three hundred sixty-five days beginning on the day the participant moves from an institutional setting into the community.

(A) To be eligible for the HOME choice demonstration program, an individual:

(1) Must continuously reside in a NF, ICF-MR, RTF and/or hospital, or a combination thereof, for a period of not less than ninety consecutive days, and in accordance with the federally-approved protocol and federal guidance. If the hospital is an institution for mental diseases, the individual must be under age twenty-one or over age sixty-five.

(2) Must be receiving medicaid benefits for inpatient services furnished by the institutional setting prior to discharge from the NF, ICF-MR, RTF or hospital.

(3) Must have an institutional level of care as defined in rule 5101:3-51-01 of the Administrative Code.

(4) Must be determined eligible for Ohio medicaid in accordance with rule 5101:1-38-01.6 of the Administrative Code.

(5) May be enrolled on an ODJFS- , ODA- or DODD-administered HCBS waiver.

(6) Must have available housing in a qualified residence in the community prior to leaving the institutional setting.

(7) Must agree to participate in the HOME choice demonstration program by signing an ODJFS-approved HOME choice demonstration program informed consent form.

(8) Must participate in the development and implementation of an all services plan, service plan or individual service plan (ISP) if the individual is enrolled on an ODJFS-, ODA- or DODD-administered HCBS waiver, respectively, or a non-waiver HOME choice service plan if the individual is not enrolled on an HCBS waiver.

(9) Must accept the all services plan, service plan, ISP or non-waiver HOME choice service plan, as appropriate, by signing and dating the plan.

(10) Must agree to participate in quality management and evaluation activities during the individual's tenure in the HOME choice demonstration program, and for up to one year after completion of the HOME choice demonstration period.

(B) If an individual fails to meet any of the required eligibility criteria set forth in paragraph (A) of this rule, the individual shall be denied enrollment on the HOME choice demonstration program. In such instances, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(C) Except for pre-transition services, an individual enrolled on the HOME choice demonstration program shall be eligible for qualified, demonstration and supplemental HOME choice demonstration program services for three hundred sixty-five days beginning on the day the individual moves from the institutional setting into the community.

(D) If, at any time, an individual enrolled on the HOME choice demonstration program ceases to meet any of the required eligibility criteria set forth in paragraph (A) of this rule, the individual shall be disenrolled from the HOME choice demonstration program. In such instances, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(E) If, at any time, an individual enrolled on the HOME choice demonstration program fails to meet the criteria for any HOME choice demonstration program service(s) established on his or her all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, and as those services are defined in rule 5101:3-51-04 of the Administrative Code, the individual shall be afforded notice and hearing rights in accordance with division 5101:6 of the Administrative Code.

(F) If an individual is enrolled on an HCBS waiver and fails to meet the criteria for HCBS waiver services and/or medicaid state plan services as established on his or her all services plan, service plan, or ISP, as appropriate, the individual shall be afforded notice and hearing rights in accordance with the procedures set forth by the state agency administering the specific HCBS waiver.

Effective: 08/01/2011
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02 , Section 309.33.80 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 07/01/2008, 09/09/2010

5160-51-03 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program: conditions of participation for providers.

This rule sets forth the conditions of participation for providers furnishing demonstration, supplemental and qualified services to HOME choice demonstration program participants.

(A) Demonstration and supplemental services.

(1) All providers of demonstration and supplemental services to participants enrolled on the HOME choice demonstration program shall:

(a) Meet all requirements in the applicable provider service specifications set forth in rule 5101:3-51-04 of the Administrative Code, and provider enrollment criteria set forth in rule 5101:3-51-05 of the Administrative Code.

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

(i) Rules 5101:3-45-07 and 5101:3-45-08 of the Administrative Code if the provider is approved by ODJFS;

(ii) Rule 173-41-01 of the Administrative Code if the provider is certified by the Ohio department of aging(ODA);

(iii) Rule 5123:2-1-05 or 5123:2-1-05.1 of the Administrative Code, as applicable, if the provider is certified by the Ohio department of developmental disabilities (DODD); or

(iv) 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(ODMH).

(c) Attend ODJFS-sponsored HOME choice demonstration program provider training sessions.

(d) Assure participants receive HOME choice demonstration program services in accordance with their all services plan, service plan, individual service plan (ISP) or non-waiver HOME choice demonstration service plan, as appropriate.

(e) Upon request and within the timeframe prescribed in the request, provide all information to the state agency administering the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or ODJFS if the HOME choice demonstration program participant is not enrolled on an HCBS waiver, and to CMS and the entity under contract with ODJFS to provide HOME choice financial management services (FMS).

(f) 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, 162 and 164 (as in effect on the effective date of this rule), and the medicaid confidentiality regulations as set forth in 42 C.F.R. 421.300 to 42 C.F.R. 306 (as in effect on the effective date of this rule), and sections 5101.26 to 5101.28 of the Revised Code.

(g) Maintain and retain all required documentation, including but not limited to, documentation of tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and the HOME choice participant or authorized representative verifying the service delivery upon completion of service delivery. Nothing shall prohibit the collection and maintenance of documentation through technology-based systems. The participant's or authorized representative's signature of choice shall be documented on the all services plan, service plan, ISP or non-waiver HOME choice demonstration service plan, as appropriate. It shall include, but not be limited to, any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(h) 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.

(i) Cooperate with ODJFS and the FMS provider under contract with ODJFS during all provider monitoring activities by being available to answer questions during reviews, and by assuring the availability and confidentiality of participant information and other documents that may be requested as part of provider monitoring activities.

(j) Notify the case manager (CM) or the service and support administrator (SSA) , 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:

(i) The participant consistently declines services.

(ii) The participant moves to another residential address.

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

(iv) There are changes in environmental conditions affecting the participant.

(v) The participant's caregiver status has changed.

(vi) The participant no longer requires medically necessary services as defined in rule 5101:3-1-01 of the Administrative Code.

(vii) A referral has been made to a protective service agency on the participant's behalf, or an active case is pending.

(viii) The participant is behaving inappropriately toward the provider.

(ix) The participant is consistently noncompliant with physician orders, or is noncompliant with physician orders in a manner that may jeopardize the participant's health and welfare.

(x) The participant's requests consistently conflict with the participant's approved all services plan, service plan, ISP or non-waiver HOME choice demonstration service plan.

(xi) The participant has been hospitalized or visited the emergency room.

(xii) The participant has been placed in an institutional setting.

(xiii) Abuse or neglect of the participant is suspected.

(xiv) The participant is experiencing other health and welfare issues.

(k) Make arrangements to accept all mail sent by ODJFS, ODA or DODD, as appropriate, or its designee, or the FMS, including but not limited to certified mail.

(l) Submit written notification to the participant and the FMS provider under contract with ODJFS, and the CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, at least thirty calendar days prior to the anticipated last date of the service if the provider is terminating the provision of HOME choice demonstration program services to the participant. Exceptions to the thirty-day advance notification requirement are set forth in paragraphs (A)(1)(l)(i) to (A)(1)(l)(iii) of this rule, and 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.

(i) Thirty-day advance notification is not required when the participant:

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

(b)Has been placed in an institutional setting;

(c)Has been incarcerated;

(d)Has died;

(e)Is terminating the services of the provider; or

(f)Is no longer eligible for medicaid.

(ii) Thirty-day advance notification is not required when the provider is furnishing services in an environment that places the provider in imminent danger.

(iii) The thirty-day advance notification may be waived for the provider by the CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate, on a case-by-case basis.

(iv) Advanced notification of service termination is not required if the participant is terminating the services of the provider.

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

(3) Providers furnishing HOME choice demonstration program 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), providers shall comply with the major unusual incident requirements set forth in rule 5123:2-17-02 of the Administrative Code.

(4) Providers furnishing HOME choice demonstration program services to participants enrolled on an ODJFS-administered waiver, providers shall comply with the consumer incident reporting requirements set forth in rule 5101:3-45-05 of the Administrative Code.

(5) Providers furnishing HOME choice demonstration program services to participants who are not enrolled on an HCBS waiver, or who are not eligible for services through a CBDD, providers shall comply with the consumer incident reporting requirements set forth in rule 5101:3-45-05 of the Administrative Code.

(6) Agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements.

(7) Non-agency providers shall pay applicable federal, state and local income and employment taxes in compliance with federal, state and local requirements. On an annual basis, non-agency providers must also submit an ODJFS-approved affidavit stating that they paid the applicable federal, state and local income and employment taxes.

(8) All providers shall deliver services professionally, respectfully, and legally, and shall not:

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

(b) Bring children, pets, friends, relatives, other HOME choice participants or anyone else to the participant's place of residence.

(c) Take the participant to the provider's place of residence.

(d) Use illegal drugs or chemical substances.

(e) Consume alcohol or take medications that may in any way impair the provider in the delivery of services to the participant.

(f) Provide services to the participant when the provider is medically, physically or emotionally unfit.

(g) Discuss religion or politics with the participant and others present in the care setting.

(h) Discuss personal issues with the participant and others in the care setting.

(i) Accept, obtain or attempt to obtain money or anything of value, including gifts or tips from the participant, household members and family members of the participant.

(j) Borrow money, credit cards or other items from the participant, household members and family members of the participant.

(k) Be designated on a financial account or credit card held by the participant, household members and family members of the participant.

(l) Use the property of the participant, household members and family members for personal gain.

(m) Lend or give the participant, household members and family members money or other personal items.

(n) Engage with the participant in sexual conduct, or in conduct that may reasonably be interpreted as sexual in nature, regardless of whether or not the contact is consensual.

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

(p) Engage in behavior that may reasonably be interpreted as inappropriate involvement in the participant's personal relationships.

(q) Leave the home for a purpose not related to the provision of services without notifying the agency supervisor, the participant's emergency contact person, identified caregiver and/or CM, SSA or ODJFS HOME choice demonstration program care coordinator, as appropriate.

(r) Use the participant's motor vehicle, unless solely for the benefit of the participant.

(s) Engage in activities that may distract from service delivery including, but not limited to:

(i) Watching television or playing computer or video games.

(ii) Making or receiving personal communications.

(iii) Engaging in non-care-related socialization with individuals other than the participant.

(iv) Providing care to individuals other than the participant.

(v) Smoking without the consent of the participant.

(vi) Sleeping.

(t) Sell to, or purchase from the participant, products or personal items unless the provider is a family member and the transaction occurs when the provider is not furnishing HOME choice services.

(u) Engage in behavior that takes advantage of or manipulates the participant, the participant's authorized representative or family, or the HOME choice demonstration program rules set forth in Chapter 5101:3-51 of the Administrative Code resulting in an advantage for personal gain.

(v) Use information about the participant or the participant's family for personal gain.

(9) HOME choice demonstration program providers shall not be designated to serve or make decisions for the participant in any capacity involving a declaration for mental health, durable power of attorney, financial power of attorney or guardianship pursuant to court order, or a representative payee. For the purpose of this rule, "representative payee" means a parent or spouse who the participant designates to receive and manage payments that would otherwise be made directly to the participant.

(B) Qualified services.

(1) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by DODD shall meet the assurances set forth in rules 5123:2-9-08 and 5123:2-2-01 of the Administrative Code.

(2) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODA shall meet the conditions of participation established for ODA-administered waivers set forth in rule 173-39-02 of the Administrative Code.

(3) Providers furnishing qualified services to HOME choice demonstration program participants enrolled on an HCBS waiver administered by ODJFS shall meet the conditions of participation established for ODJFS-administered waivers as set forth in rule 5101:3-45-10 of the Administrative Code.

(4) Providers furnishing qualified services to HOME choice demonstration program participants who are not enrolled on an HCBS waiver shall meet the same conditions of participation set forth for ODJFS-administered waiver service providers as described in rule 5101:3-45-10 of the Administrative Code.

(C) Failure to meet the requirements set forth in this rule may result in termination of the HOME choice demonstration program provider's provider agreement in accordance with rule 5101:3-1-17.6 of the Administrative Code. The provider shall be entitled to a hearing under Chapter 119. of the Revised Code in accordance with Chapter 5101:6-50 of the Administrative Code.

Effective: 09/09/2010
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85 , Section 309.30.90 of Am. Sub. H.B. 1, 128th G.A.
Prior Effective Dates: 7/1/2008

5160-51-04 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program: definitions of the covered services and program service limitations, provider qualifications and specifications.

This rule sets forth the definitions of the covered services and some program service limitations available to a HOME choice demonstration program participant. This rule also sets forth the provider requirements and specifications for the delivery of HOME choice demonstration program services. The HOME choice demonstration program participant shall have choice and control over the selection of his or her provider of services, and the direction over the provision of the services. HOME choice demonstration program services are reimbursed in accordance with rule 5101:3-51-06 of the Administrative Code.

(A) "Independent living skills training" is information and educational supports and resources provided to a HOME choice demonstration program participant or group of HOME choice demonstration program participants for the purpose of developing or increasing skills, knowledge or abilities needed to live more independently. Independent living skills training services can be furnished individually, or in a group setting or classroom setting as those terms are defined in rule 5101:3-51-01 of the Administrative Code.

(1) Training focuses on:

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

(i) Finding a bank and establishing an account,

(ii) How to pay bills and taxes,

(iii) Personal budgeting,

(iv) How to manage entitlements and insurance,

(v) How to use a bank machine,

(vi) Understanding credit, and

(vii) Understanding contracts;

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

(i) Communication skill building,

(ii) How to be a good neighbor/roommate,

(iii) How to work with providers, and

(iv) How to know when and how to ask for help;

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

(i) How to efficiently manage nutrition and diet,

(ii) How to talk to the doctor,

(iii) Training service providers,

(iv) Managing and accessing medical supplies,

(v) Crisis care/recovery services,

(vi) Linking to medical/dental services,

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

(viii) Continuing therapies,

(ix) Emergency preparedness, and

(x) Medication management;

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

(i) Personal shopping,

(ii) Housekeeping and laundry,

(iii) Grocery shopping, cooking and meal planning,

(iv) How to request and/or complete simple repairs,

(v) Safety skills at home, and

(vi) Operating simple technology;

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

(i) Travel training,

(ii) How to negotiate transportation systems and arrange transportation,

(iii) Identifying and accessing existing community resources,

(iv) Job training and seeking employment opportunities,

(v) Linking to legal resources, and

(vi) Safety skills in the community.

(2) Independent living skills training shall not duplicate community support coaching services available through the HOME choice demonstration program. In addition, independent living skills training shall not duplicate similar waiver or administrative services available on a home and community-based services (HCBS) waiver on which the HOME choice demonstration program participant is enrolled.

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

(4) The independent living skills training provider shall, as a function of the service, provide the entity responsible for assisting the HOME choice demonstration program participant with the development of his or her all services plan, service plan or non-waiver HOME choice demonstration program service plan, as appropriate, with written status reports during the HOME choice demonstration program participant's transition, as prescribed by the plan.

(5) In order to provide and submit a claim for reimbursement of independent living skills training, the independent living skills training provider delivering the service:

(a) Must be either a community mental health center certified by the Ohio department of mental health (ODMH) in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or a non-profit agency provider,

(i) Whose staff with direct participant contact:

(a) May have either:

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

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

(b) Must have knowledge and experience about:

(i) Local community resources,

(ii) Applicable disability laws and regulations, and

(c) Are age eighteen or older; and

(ii) Whose staff that provide transportation:

(a) Possess a valid Ohio driver's license, and

(b) Possess valid automobile liability insurance.

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(d) Must be identified as the provider, and have specified on the participant's all services plan, service plan or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish independent living skills training services to the participant.

(e) Must be providing the service to one individual, or to two or three individuals in a group setting, or four or more individuals in a classroom setting, during the same face-to-face visit.

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

(1) The community support coach shall:

(a) Communicate with and educate the HOME choice demonstration program participant in vital aspects of the transition process;

(b) Assist the HOME choice demonstration program participant in:

(i) Making informed and independent choices,

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

(iii) Managing multiple tasks, and

(iv) Identifying options and problem solving;

(c) Provide one-on-one coaching;

(d) Provide follow-up coaching during and after the transition;

(e) Inform and advise the HOME choice demonstration program participant in such a manner that empowers, but protects, the participant from being taken advantage of in the community;

(f) Assist with the identification of community resources and linkages to be used by the HOME choice demonstration program participant;

(g) Assist the HOME choice demonstration program participant in connecting to potential employment opportunities before, during and after transition; and

(h) Provide the entity responsible for assisting the HOME choice demonstration program participant with the development of his or her all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, with written status reports during the HOME choice demonstration program participant's transition, as prescribed by the all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan.

(2) Community support coaching shall include assistance after normal business hours when the HOME choice demonstration program participant is not enrolled on an HCBS waiver and is only receiving medicaid state plan services.

(3) Community support coaching shall not duplicate independent living skills training available through the HOME choice demonstration program. In addition, community support coaching shall not duplicate similar waiver or administrative services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled.

(4) In order to provide and submit a claim for reimbursement of community support coaching, the community support coach provider delivering the service:

(a) Must be:

(i) A non-agency provider who:

(a) May have either:

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

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

(b) Is age eighteen or older, and

(c) Possesses a valid Ohio driver's license, and

(d) Possesses valid automobile liability insurance, and

(e) Is not the participant's legally responsible family member as that term is defined in rule 5101:3-51-01 of the Administrative Code, and

(f) Is not the participant's case manager (CM) or service and support administrator (SSA), as those terms are defined in rule 5101:3-51-01 of the Administrative Code; or

(ii) Either a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or a non-profit agency provider,

(a) Whose staff with direct participant contact:

(i) May have either:

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

(B) Experience transitioning individuals from an institution to the community; and

(ii) Are age eighteen or older, and

(b) Whose staff that provide transportation:

(i) Possess a valid Ohio driver's license, and

(ii) Possess valid automobile liability insurance.

(b) Must not also be the transition coordination agency providing transition coordination services to the same participant during the pre-transition phase.

(c) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(d) Must meet the provider enrollment criteria set forth in paragraph (B), (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(e) Must be identified as the provider, and have specified on, the participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish community support coaching services to the participant.

(C) "HOME choice nursing services" are intermittent services provided to HOME choice demonstration program participants 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 individuals who are not licensed nurses in accordance with Chapter 4723. of the Revised Code;

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

(c) Visits performed for the sole purpose of conducting an "OASIS" (outcome and assessment information set) assessment or any other assessment; or

(d) Visits performed for the sole purpose of meeting the home care attendant service nurse consultation requirements set forth in rules 5101:3-46-04.1 and 5101:3-50-04.1 of the Administrative Code.

(e) Services performed in excess of the number of hours approved pursuant to the HOME choice demonstration program participant's service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(2) HOME choice nursing services shall not duplicate similar waiver or administrative services available on the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or medicaid state plan home health nursing and/or private duty nursing services.

(3) In order to provide and submit a claim for reimbursement of HOME choice nursing services, the RN, or LPN at the direction of an RN, delivering the service must meet all of the following requirements:

(a) Be employed by a medicare-certified, or otherwise-accredited home health agency, or be a non-agency home care nurse provider.

(b) Not be the participant's spouse, or in the case of a minor, the participant's birth or adoptive parent, unless the family member is employed by a medicare-certified, or otherwise-accredited home health agency.

(c) Not be the foster caregiver of the HOME choice demonstration program participant.

(d) Meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(e) Meet the provider enrollment criteria set forth in paragraph (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(f) Be identified as the provider, and have specified on, the participant's service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish HOME choice nursing services to the participant.

(g) 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 5101:3-51-01 of the Administrative Code. The plan of care must be signed and dated by the participant's treating physician.

(h) Be providing the service for one individual during a face-to-face visit, or for two or three individuals in a group setting during the same face-to-face visit.

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

(a) Conduct a face-to-face visit with the directing RN at least every sixty days after the initial visit to evaluate the provision of HOME choice nursing services and LPN performance, and to assure that HOME choice nursing services are being provided in accordance with the approved plan of care; and

(b) Conduct a face-to-face visit with the participant and the directing RN prior to 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 LPN performance, and to assure that HOME choice nursing services are being provided in accordance with the approved plan of care.

(5) 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 contain the information listed in paragraphs (C)(5)(a) to (C)(5)(l) 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 numbers.

(b) Participant medical history.

(c) Name of participant's treating physician.

(d) A copy of the initial and all subsequent service plans, ISPs or non-waiver HOME choice demonstration program service plans, as appropriate.

(e) A copy of the initial and all subsequent plans of care, specifying the type, frequency, scope and duration of the HOME choice 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) In all instances when the treating physician gives verbal orders to the nurse, the nurse must document, in writing, the physician's 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) In all instances when a non-agency LPN is providing HOME choice nursing services, the LPN must provide clinical notes, signed and dated by the LPN, documenting face-to-face visits between the LPN and the directing RN, and documenting the face-to-face visits between the LPN, the participant and the directing RN. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

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

(i) A copy of any advanced directives including, but not limited to, "do not resuscitate order" or medical power of attorney, if they exist.

(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 authorized representative verifying the service delivery upon completion of service delivery. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph. The participant or authorized representative's signature of choice shall be documented on the service plan, ISP or non-waiver HOME choice demonstration program 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. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(l) A discharge summary, signed and dated by the departing nurse at the conclusion of the three hundred sixty-five-day eligibility 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.

(D) "Social work/counseling services" are transitional services provided to the HOME choice demonstration program participant, authorized representative, 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 HOME choice demonstration program participant.

(1) Social work/counseling services can include crisis interventions, grief counseling and/or other social service interventions that support the HOME choice demonstration program participant's health and welfare.

(2) Social work/counseling services shall not:

(a) Take the place of case management services;

(b) Duplicate similar services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled; or

(c) Include services provided in excess of what is approved on the participant's all services plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(3) In order to provide and submit a claim for reimbursement of social work/counseling services, the social work/counseling service provider delivering the service:

(a) Must be either:

(i) A non-agency provider who shall:

(a) Be 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 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 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 , and

(b) Maintain documentation of licensure by the applicable Ohio licensure board and have at least one year of social work/counseling experience, or

(ii) An agency provider who shall:

(a) Assure that direct care staff include 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, or 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 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,

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

(c) 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.

(b) Must conduct an individual assessment to evaluate the HOME choice demonstration program participant's psycho-social, financial and environmental status.

(c) Must develop and revise, as necessary, with the assistance of the participant, and/or the participant's authorized representative, caregiver(s) and the CM or SSA, as appropriate, a treatment plan that includes the recommended method of treatment and the recommended number of counseling sessions.

(d) Must assure the treatment plan is implemented.

(e) Must furnish to either the CM or SSA, 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 authorized representative shall also be furnished with a copy of the individual assessment report and the treatment plan unless clinically indicated otherwise.

(f) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(g) Must meet the provider enrollment criteria set forth in paragraph (B), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(h) Must be identified as the provider, and have specified on the participant's all services plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish social work/counseling services to the participant.

(4) Providers of social work/counseling services must maintain a clinical record for each participant served. At a minimum, the clinical record must contain the information listed in paragraphs (D)(4)(a) to (D)(4)(j) 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 information.

(b) Participant medical history.

(c) Name of participant's treating physician.

(d) A copy of the initial and all subsequent all service plans, ISPs or non-waiver HOME choice demonstration program service plans, as appropriate.

(e) A copy of the initial and all subsequent individual assessments.

(f) A copy of the initial and all revised treatment plans.

(g) A copy of any advanced directives including, but not limited to, "do not resuscitate order" or medical power of attorney, if they exist.

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

(i) Documentation that clearly shows the date of social work/counseling service delivery. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(j) A discharge summary, signed and dated by the departing social work/counseling service provider at the conclusion of the three hundred sixty-five-day eligibility period, or at the point the service provider is no longer going to provide social work/counseling 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.

(E) "Nutritional consultation services" are services that provide individualized guidance to a HOME choice demonstration program 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:

(a) Duplicate similar HCBS waiver services a HOME choice demonstration program participant is receiving; or

(b) Include services provided in excess of what is approved on the participant's all services plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(2) In order to provide and submit a claim for reimbursement of nutritional consultation services, the nutritional consultation service provider delivering the service must meet all of the requirements set forth in paragraph (E)(2) of this rule.

(a) 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.

(b) Be providing 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 recertified by the treating physician every sixty days, or more frequently if there is a significant change in the participant's condition.

(c) Meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(d) Meet the provider enrollment criteria set forth in paragraph (B), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(e) Be identified as the provider, and have specified on the participant's all services plan, ISP or non-waiver HOME choice demonstration program service plan, the number of hours for which the provider is authorized to furnish nutritional consultation services to the participant.

(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 a tool that identifies whether the participant is at nutritional risk or identifies a nutritional diagnosis that the dietitian will treat. The tool must include the following:

(i) An assessment of height and weight history;

(ii) An assessment of adequacy of nutrient intake;

(iii) A review of medications, medical diagnoses and diagnostic test results;

(iv) An assessment of 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.

(b) Develop, implement, evaluate and revise, as necessary, a nutrition intervention plan with the assistance of the participant and/or authorized representative, 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) Furnish the CM or SSA, as appropriate, the participant and/or the participant's authorized representative with a copy of the assessment and the nutrition intervention plan no later than seven working days after completion of the assessment.

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

(4) Providers of nutritional consultation services must maintain a clinical record for each HOME choice demonstration program participant served. Nothing shall prohibit the use of technology-based systems in the collection and maintenance of the documentation required by this paragraph. At a minimum, the clinical record must contain all of the information listed in paragraphs (E)(4)(a) to (E)(4)(k) 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 numbers.

(b) Participant medical history.

(c) Name of participant's treating physician.

(d) Treating physician's authorization for a nutritional assessment.

(e) A copy of the initial and all subsequent all service plans, ISPs or non-waiver HOME choice demonstration program service plans, as appropriate.

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

(g) 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.

(h) A copy of the initial and all subsequent nutrition intervention plans developed and implemented.

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

(j) 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. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(k) A discharge summary, signed and dated by the departing nutritional consultation service provider at the conclusion of the three hundred sixty-five-day eligibility period, 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 that have been made.

(F) "Communication aids" are devices, systems or services necessary to assist the HOME choice demonstration program participant with hearing, speech or vision impairments to effectively communicate with service providers, family, friends and the general public.

(1) Communication aids 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 HOME choice demonstration program participant's communication impairment;

(b) Computers and computer equipment;

(c) Other mechanical and electronic devices;

(d) Cable and internet access; and

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

(2) Communication aids may also include:

(a) Interpreter services that support the HOME choice demonstration program participant's integration into the community. Interpreter services refer 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.

(b) New technologies and any other devices so long as the technologies and devices achieve the objective of the service.

(3) Reimbursement for communication aids shall not exceed a total of five thousand dollars within the three hundred sixty-five day HOME choice demonstration program eligibility period per participant. The CM or SSA, as appropriate, shall not approve the same type of communication aid equipment for the same HOME choice demonstration program participant more than once unless there is a documented need for ongoing communication aid services or a change in the HOME choice demonstration program participant's medical and/or physical condition requiring the replacement.

(4) If the HOME choice demonstration program participant is enrolled on an HCBS waiver, then the participant must exhaust similar waiver services that are available to the participant before utilizing communication aid services. Communication aid service costs are not included in the cost of HCBS waiver services.

(5) In order to provide and submit a claim for reimbursement of communication aid services, the communication aid service provider delivering the service:

(a) Must be an agency provider.

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(d) Must be identified as the provider, and have specified on the participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish communication aid services to the participant.

(G) "Service animals" are animals that are individually trained to perform tasks for HOME choice demonstration program participants that the participants are unable to perform for themselves. They also assist people with disabilities in their day-to-day activities.

(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) Activities 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, student training and related transportation, room/board and administrative activities;

(d) Equipment and supplies;

(e) Home care, including cooking/food, housekeeping, laundry for students in training;

(f) Animal health insurance; and

(g) Transportation to the veterinarian.

(4) Reimbursement for service animals shall not exceed a total of eight thousand dollars within the three hundred sixty-five day HOME choice demonstration program eligibility period per participant. The CM or SSA, as appropriate, shall not approve the same type of service animal services for the same HOME choice demonstration program participant more than once unless there is a documented need for ongoing service animal services or a change in the HOME choice demonstration program participant's medical and/or physical condition requiring the replacement.

(5) If the HOME choice demonstration program participant is enrolled on a DODD-administered waiver, then the participant must exhaust similar waiver services that are available to the participant before utilizing the service animal service. Service animal costs are not included in the cost of waiver services.

(6) In order to provide and submit a claim for reimbursement of service animal services, the service animal service provider delivering the service:

(a) Must be an agency provider.

(b) Must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(c) Must meet the provider enrollment criteria set forth in paragraph (B), (C), (D) or (E) of rule 5101:3-51-05 of the Administrative Code, as applicable.

(d) Must be identified as the provider, and have specified on, the participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, the number of hours for which the provider is authorized to furnish service animal services to the participant.

(H) "Community transition services" are services providing goods, services and support for the purpose of addressing an identified need in the HOME choice demonstration program participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate, including improving and maintaining the HOME choice demonstration program participant's opportunities for membership in the community.

(1) Community transition services are intended to meet the following criteria:

(a) The goods and services will decrease the need for formal support services and other medicaid services;

(b) The goods and services will take into consideration the appropriateness and availability of a lower cost alternative for comparable services that meet the HOME choice demonstration program participant's needs;

(c) The goods and services will promote community inclusion and family involvement;

(d) The goods and services will improve the HOME choice demonstration program participant's health and welfare in the home and/or community;

(e) The HOME choice demonstration program participant does not have the funds to purchase the goods and services, or the goods and services are not available through another source;

(f) The goods and services will assist the HOME choice demonstration program participant in developing and maintaining personal, social, physical or work-related skills; and

(g) The goods and services will assist the HOME choice demonstration program participant in living independently in the home and community.

(2) Allowable community transition expense and service limitations are as follows:

(a) A maximum of five hundred dollars for pre-transition (i.e., up to, but not including, the actual date of transition) transportation expenses that may include, but are not limited to, visits to potential housing, and to local agencies for the purpose of establishing benefits; and

(b) A maximum of two thousand dollars for pre- and post-transition expenses including, but not limited to, the following, and except as limited by paragraph (H)(3) of this rule:

(i) Post-transition (i.e., on or after the actual date of transition) transportation expenses,

(ii) Security deposits that are required to obtain a lease on an apartment or home ,

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

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

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

(vi) Moving expenses ,

(vii) Necessary home accessibility adaptations , and

(viii) Start-up groceries, i.e., food and household supplies.

(3) Community transition services do not include:

(a) Experimental or prohibited treatments;

(b) The ongoing cost of room and board;

(c) Regular utility charges;

(d) Ongoing grocery expenses;

(e) Cigarettes and alcohol;

(f) Uniforms and memberships;

(g) Electronics and other household appliances or items that are used for entertainment or recreational purposes; and

(h) Cable/internet access.

(4) Reimbursement for community transition services shall not exceed a cumulative maximum of two thousand five hundred dollars for the items set forth in paragraph (H)(2) of this rule. The CM or SSA, as appropriate, shall not approve the same type of community transition services for the same HOME choice demonstration program participant unless there is a documented need for ongoing community transition services or a change in the HOME choice demonstration program participant's medical and/or physical condition requiring the replacement.

(5) Except as provided for in paragraph (H)(6) of this rule, community transition services shall not duplicate similar waiver or administrative services available on an HCBS waiver on which the HOME choice demonstration program participant is enrolled.

(6) When the HOME choice demonstration program participant is enrolling on an ODA-administered waiver, the participant may use HOME choice community transition services in lieu of, but not in addition to, the community transition service available through the ODA-administered waiver.

(7) In order for a provider to provide and submit a claim for reimbursement of community transition services,

(a) The specific goods and services to be purchased shall be:

(i) Determined by the HOME choice demonstration program participant in conjunction with his or her CM or SSA, as appropriate,

(ii) Based upon the HOME choice demonstration program participant's established need, and

(iii) Specified on the participant's all service plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(b) During the HOME choice demonstration period, the purchase of community transition services shall be coordinated by the participant's CM or SSA, as appropriate, in conjunction with the ODJFS-designated HOME choice financial management service (FMS) provider.

(c) Community transition services shall be reimbursed in accordance with rule 5101:3-51-06 of the Administrative Code, the requirements set forth in the FMS contract and established HOME choice demonstration program policies and procedures. At ODJFS's discretion, community transition services may also be reimbursed through a debit card, an electronic benefit transfer (EBT) card or another similar financial instrument.

(I) "Respite services" are services provided on a short-term basis to a HOME choice demonstration program participant who is not enrolled on an HCBS waiver, and who is unable to care for himself or herself, and because of the absence of, or the temporary 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 an in-home, out-of-home or day camp setting in accordance with the participant's non-waiver HOME choice demonstration program service plan.

(1) In-home respite services are services provided in the HOME choice demonstration program participant's place of residence during the day or overnight.

(a) In-home respite services shall include, but not be limited to:

(i) General supervision of the participant;

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

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

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

(v) Accompanying the participant to community outings; and

(vi) Other related services.

(b) Nothing shall preclude a non-legally responsible family member from being an in-home respite service provider if the family member meets the requirements set forth in paragraph (I) (4) of this rule.

(2) Out-of-home respite services are services provided in an approved out-of-home setting that require an overnight stay. Out-of-home respite services shall:

(a) Include, but not be limited to:

(i) Personal care services;

(ii) Skilled nursing services; and

(iii) Three meals per day that meet the participant's dietary needs; and

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

(3) Day camp respite services are services 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 interventions that will meet the emotional and behavioral needs of the HOME choice demonstration program 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 demonstration program participant's place of residence.

(4) In order to provide and submit a claim for reimbursement of respite services,

(a) The provider must:

(i) Be an in-home respite provider who is:

(a) A homemaker/personal care provider certified by DODD in accordance with rule 5123:2-13-04 , 5123:2-8-03 or 5123:2-8-10 of the Administrative Code; or

(b) An approved ODJFS-administered waiver personal care aide service provider or nursing service provider in accordance with rule 5101:3-46-04, 5101:3-47-04 or 5101:3-50-04 of the Administrative Code; or

(ii) Be an out-of-home respite provider that is:

(a) An ICF-MR facility licensed in accordance with rules 5101:3-3-02 and 5101:3-3-02.3 of the Administrative Code; or

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

(c) A nursing facility (NF) licensed in accordance with rules 5101:3-3-02 and 5101:3-3-02.3 of the Administrative Code; or

(d) Another licensed setting approved by ODJFS or its designated CMA, including, but not limited to, a hospice or hospital; or

(iii) Be 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.

(b) Meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code.

(c) Must meet the provider enrollment criteria set forth in paragraph (E) of rule 5101:3-51-05 of the Administrative Code.

(d) Must be identified as the provider, and have specified on the participant's non-waiver HOME choice demonstration program service plan the number of hours for which the provider is authorized to furnish respite services to the participant. Respite services shall not exceed the service and cost limitations specified on the participant's non-waiver HOME choice demonstration program service plan.

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

(i) 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-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.

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

(iii) Receive task-based instruction regarding the provision of personal care services. Agency providers must provide such task-based instruction to direct care staff providing personal care services.

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

(i) Comply with federal nondiscrimination regulations as set forth in 42 C.F.R. 80 (as in effect on the effective date of this rule).

(ii) Provide for 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. Additionally, upon request, provide documentation to the designated CMA verifying the coverage.

(iii) 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-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.

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

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

(5) 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 assure the record contains the information set forth in paragraphs (I)(5)(a) to (I)(5)(g) of this rule. At a minimum, providers of out-of-home respite must assure the record contains the information set forth in paragraphs (I)(5)(a) to (I)(5)(h) of this rule.

(a) Participant's 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) Participant medical history.

(c) A copy of the initial and all subsequent non-waiver HOME choice demonstration program service plans.

(d) A copy of any advance directives including, but not limited to, "do not resuscitate order" or "medical power of attorney," if they exist.

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

(f) Documentation including, but not limited to, case notes clearly show the date and outcome of respite service delivery, including tasks performed or not performed. Nothing shall prohibit the use of technology-based systems in collecting and maintaining the documentation required by this paragraph.

(g) Documentation required for providers of ODJFS-administered waiver nursing services as set forth in rule 5101:3-46-04, 5101:3-47-04 or 5101:3-50-04 of the Administrative Code when skilled nursing services are provided during respite services.

(h) A discharge summary, signed and dated by the departing 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.

Effective: 08/01/2011
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02 , Section 309.33.80 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 07/01/2008, 06/01/2009, 09/09/2010

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

(A) All providers of HOME choice demonstration program services must meet the conditions of participation set forth in rule 5101:3-51-03 of the Administrative Code, as appropriate, and the provider requirements and specifications set forth in rule 5101:3-51-04 of the Administrative Code prior to furnishing services to a consumer.

(B) A prospective provider intending to furnish HOME choice demonstration program services to a participant enrolled on a home and community-based services (HCBS) waiver administered by ODJFS must meet the requirements set forth in this paragraph. The provider must submit a signed statement affirming that the provider received and read all rules of the Administrative Code governing the HOME choice demonstration program and the ODJFS-administered waiver on which the participant is enrolled.

(1) For qualified services, the provider shall:

(a) Be a provider as approved by ODJFS in accordance with rule 5101:3-45-04 of the Administrative Code, and the ODJFS-administered waiver service provider specifications set forth in rule 5101:3-46-04, 5101:3-47-04 or 5101:3-50-04 of the Administrative Code, as appropriate, for the specific waiver service to be furnished.

(b) Be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a medicaid provider of nutritional consultation services as certified by the Ohio department of developmental disabilities (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, if the provider is furnishing nutritional consultation as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be 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 ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or be an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39-02.12 of the Administrative Code, if the provider is furnishing social work counseling as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a provider of community support coaching as approved by ODJFS in accordance with rule 5101:3-45-04 of the Administrative Code, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(d) Be a provider of independent living skills training as approved by ODJFS in accordance with rule 5101:3-45-04 of the Administrative Code, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing independent living skills training as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall:

(a) Be a:

(i) Medicaid provider of supplementary adaptive and assistive device services as approved by ODJFS in accordance with rule 5101:3-45-04 of the Administrative Code, and rule 5101:3-46-04, 5101:3-47-04 or 5101:3-50-04 of the Administrative Code, as appropriate, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(ii) Provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of adaptive and assistive equipment services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(C) A prospective provider intending to furnish HOME choice demonstration program services to a participant enrolled on an HCBS waiver administered by ODA must meet the requirements set forth in this paragraph.

(1) For qualified services, the provider shall:

(a) Be an ODA-certified long term care provider in accordance with rule 173-39-02 of the Administrative Code.

(b) Be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a provider of HOME choice nursing services as approved by ODJFS in accordance with rule 5101:3-51-04 of the Administrative Code, if the provider is furnishing HOME choice nursing services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a provider of community support coaching as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a provider of independent living skills training as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing independent living skills training as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall:

(a) Be:

(i) An ODA-certified long term care provider of specialized medical equipment and supplies in accordance with rule 173-39-02.7 of the Administrative Code, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(ii) A provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of adaptive and assistive equipment services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(D) A prospective provider intending to furnish HOME choice demonstration program services to a participant enrolled on an HCBS waiver administered by DODD must meet the requirements set forth in this paragraph. The provider must submit a signed statement affirming that the provider received and read all rules of the Administrative Code governing the HOME choice demonstration program.

(1) For qualified services, the provider shall:

(a) Be a medicaid provider as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code for the specific waiver service to be furnished.

(b) Be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be 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, if the provider is furnishing nutritional consultation as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be 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 ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or be an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39-02.12 of the Administrative Code, if the provider is furnishing social work counseling as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be a provider of HOME choice nursing services as approved by ODJFS in accordance with rule 5101:3-51-04 of the Administrative Code, if the provider is furnishing HOME choice nursing services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(d) Be a provider of community support coaching as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall be:

(a) A medicaid provider of adaptive and assistive equipment or specialized medical equipment as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(b) A provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; and

(c) Be a medicaid provider of adaptive and assistive equipment services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(E) A prospective provider intending to furnish HOME choice demonstration program services to a participant who is not enrolled on an HCBS waiver must meet the requirements set forth in this paragraph.

(1) For qualified medicaid state plan services, the provider shall be a medicaid state plan service provider as approved by ODJFS in accordance with division 5101:3 of the Administrative Code, as appropriate for the specific medicaid state plan service to be furnished.

(2) For demonstration services, the provider shall:

(a) Be a provider of HOME choice nursing services as approved by ODJFS in accordance with rule 5101:3-51-04 of the Administrative Code, if the provider is furnishing HOME choice nursing services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be 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, if the provider is furnishing nutritional consultation as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(c) Be 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 ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, or be an ODA-certified long term care provider of social work counseling services in accordance with rule 173-39-02.12 of the Administrative Code, if the provider is furnishing social work counseling as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(d) Be a provider of community support coaching as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing community support coaching as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(e) Be a provider of independent living skills training as approved by ODJFS, or a community mental health center certified by ODMH in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code, if the provider is furnishing independent living skills training as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(f) Be a provider of out-of-home respite services as approved by ODJFS in accordance with rule 5101:3-45-04 of the Administrative Code, or day camp respite as approved by ODJFS, if the provider is furnishing respite services as that service is set forth in rule 5101:3-51-04 of the Administrative Code.

(3) For supplemental services, the provider shall:

(a) Be:

(i) A medicaid provider of durable medical equipment as approved by ODJFS in accordance with rule 5101:3-10-01 of the Administrative Code, if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code; or

(ii) A provider of communication aid services as approved by ODJFS if the provider is furnishing communication aid services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(b) Be a medicaid provider of adaptive and assistive equipment services as certified by DODD in accordance with rule 5123:2-2-01 of the Administrative Code, if the provider is furnishing service animal services as those services are set forth in rule 5101:3-51-04 of the Administrative Code.

(F) ODJFS shall not process a service provider application packet for prospective providers of HOME choice nursing, community support coaching, independent living skills training, or communication aid services if the packet does not contain information necessary to complete the required verifications.

(1) ODJFS shall not process a service provider application packet for prospective providers of HOME choice nursing, community support coaching, independent living skills training or communication aid services if the provider does not submit the signed statement as required by paragraphs (B) and (D) of this rule.

(2) ODJFS shall notify the service provider in writing of any missing information, and shall provide the applicant thirty calendar days to submit the required documentation. If the provider does not submit the required documentation within thirty calendar days, the service provider application process shall be terminated.

(3) ODJFS shall review all information and make a determination regarding the prospective service provider's eligibility for enrollment. If ODJFS determines the provider is ineligible for enrollment as a provider of HOME choice demonstration program services, the provider shall be entitled to a hearing under Chapter 119. of the Revised Code in accordance with Chapter 5101:6-50 of the Administrative Code.

Effective: 09/09/2010
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.85
Rule Amplifies: 5111.01 , 5111.02 , 5111.85 , Section 309.30.90 of Am. Sub. H.B. 1, 128th G.A.
Prior Effective Dates: 7/1/2008

5160-51-06 HOME choice ("Helping Ohioans Move, Expanding Choice") demonstration program: reimbursement rates and billing procedures.

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

(1) "Base rate," as used in table A, column 3 of paragraph (B) of this rule, means the amount paid for up to the first four units of service delivered.

(2) "Billing unit," as used in table B, column 3 of paragraph (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 service 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 (B), table (B) of this rule that is paid to a provider for furnishing HOME choice independent living skills training services to a single individual.

(4) "Classroom setting" is a situation in which a HOME choice independent living skills training service provider furnishes the same type of services to four or more individuals 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 service, 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 (E)(1) of this rule, is the amount that HOME choice nursing providers, or HOME choice independent living skills training services 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 (B), table (A) of this rule for HOME choice nursing services, and in paragraph (B), 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 individual.

(6) "Group setting" is a situation in which a HOME choice nursing, service provider, or a HOME choice independent living skills training service provider furnishes the same type of services to two or three individuals 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 table B, column 6 of paragraph (B) of this rule, means the maximum number of hours, or the maximum dollar amount that a HOME choice demonstration program service can be reimbursed, and as set forth on the HOME choice demonstration program participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

(8) "Maximum hours per month," as used in table A, column 5 of paragraph (B) of this rule, means the maximum number of hours that a HOME choice demonstration program service can be reimbursed per month, and as set forth on the HOME choice participant's all services plan, service plan, ISP or non-waiver HOME choice demonstration program service plan, as appropriate.

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

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

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

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

(ii) The base rate as defined in paragraph (A)(1) of this rule plus the unit rate as defined in paragraph (A)(10) of this rule for each additional unit of service delivered.

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

(11) "Unit rate," as used in table A, column 4 of paragraph (B) of this rule, and in table B, column 5 of paragraph (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.

(B) 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 $ 30.00per hour $ 7.50 144 hours during the 365-day demonstration period
HC004 Community support coaching 15 minutes $ 25.00per hour $ 6.25 72 hours during the pre-transition and 365-day demonstration periods, combined
HC005 Social work/ counseling services 15 minutes $ 64.12per hour $ 16.03 36 hours during the 365-day demonstration period
HC006 Nutritional consultation services 15 minutes $ 52.56per 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, 500.00for 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 $ 9.00per 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 $ 200.00per 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

(C) In order for a provider to submit a claim for HOME choice demonstration program services, the services must be provided in accordance with Chapter 5101:3-51 of the Administrative Code.

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

(E) 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 demonstration 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 demonstration 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.

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

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

(2) Reimbursement requests for community transition services must be received by the FMS within fourteen 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 demonstration program 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 demonstration program 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 for as stated in paragraphs (F)(5) and (F)(6) of this rule, HOME choice demonstration program reimbursement is not available for non-covered services, or for similar waiver or administrative services available on the HCBS waiver on which the HOME choice demonstration program participant is enrolled, or the medicaid state plan.

(5) When the HOME choice demonstration program participant is enrolled on an HCBS waiver, HOME choice demonstration program 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 demonstration program participant is enrolling on an ODA-administered waiver, the participant may use HOME choice community transition services in lieu of, but not in addition to, the community transition service available through the ODA-administered waiver.

(7) Reimbursement is made only for those HOME choice demonstration program services that are set forth in the participant's all services plan, service plan, individual service plan or non-waiver HOME choice demonstration program service plan, as appropriate. The amount of payment is determined in accordance with federal and state laws and regulations. In establishing HOME choice demonstration program maximums, ODJFS must assure that the maximum reimbursement is consistent with efficiency, economy and quality of care.

(8) The state's appropriation determines the total amount of funds that may be expended for HOME choice demonstration program services. The maximums used by ODJFS may be less than the maximums permitted under federal law for same or similar services, but may not be more. Providers are expected to bill the FMS provider their usual and customary charge (i.e., the amount the provider charges the general public). If the amount billed to the FMS exceeds the maximum set forth in this rule, the amount paid will automatically be reduced to the maximum permitted.

Effective: 08/01/2011
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02 , Section 309.33.80 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 07/01/2008, 06/01/2009, 09/09/2010