(A) To be eligible for enrollment in the MyCare Ohio waiver, a member must meet all of the following requirements:
(1) Be enrolled in the MyCare Ohio demonstration at the time of application for the MyCare Ohio waiver;
(2) Be determined to have a nursing facility -based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 or 5160-3-09 of the Administrative Code;
(3) In the absence of the MyCare Ohio waiver, require hospitalization or institutionalization in a nursing facility to meet his or her needs;
(4) Be determined to require at least one waiver service monthly that is otherwise unavailable through another source (including the medicaid state plan) and in an amount sufficient to meet the member's assessed needs;
(5) Reside in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and is not a hospital, nursing facility , intermediate care facility for individuals with intellectual disabilities (ICF-IID) or another licensed/certified facility, any facility covered by section 1616(e) of the Social Security Act (July 1, 2018), residential care facility (except an assisted living facility as described in rule 173-39-02.16 of the Administrative Code), adult foster home or another group living arrangement subject to state licensure or certification.
(6) Sign an agreement prior to waiver enrollment confirming that the member has been informed of service alternatives, choice of qualified providers available in the MyCare Ohio plan's provider panel and the options of institutional and community-based care, and he or she elects to receive MyCare Ohio waiver services; and
(7) Be able to have waiver services that can be identified in a person-centered services plan as described in rule 5160-44-02 of the Administrative Code that will safely meet his or her assessed needs.
(B) To be enrolled, and maintain enrollment in the MyCare Ohio waiver, a member must be determined by the MyCare Ohio plan to meet all of the following requirements:
(1) Be determined eligible for the MyCare Ohio waiver in accordance with paragraph (A) of this rule;
(2) Be able to have his or her health and welfare ensured through the waiver;
(3) Participate in the development and implementation of an integrated, individualized care plan that includes a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code, and sign and date the plan as a condition of its acceptance;
(4) Agree to receive waiver service coordination from the MyCare Ohio plan or its designee; and
(5) Agree to participate in quality management and evaluation activities during his or her enrollment on the MyCare Ohio waiver.
(C) If a member fails to meet any of the requirements set forth in paragraph (A) and/or paragraph (B) of this rule, the member shall be denied enrollment on the MyCare Ohio waiver.
(D) Once enrolled in the MyCare Ohio waiver, a member's level of care shall be reassessed at least annually, and more frequently if there is a significant change in the member's situation that may impact his or her health and welfare. If the reassessment determines the member no longer meets the requirements set forth in paragraph (A) or paragraph (B) of this rule, he or she shall be disenrolled from the MyCare Ohio waiver.
(E) If a member enrolled in the MyCare Ohio waiver does not receive at least one waiver service for ninety consecutive days, the MyCare Ohio plan shall, within ten days of the ninetieth day, reassess the member's need for waiver services. If it is determined the member no longer meets the requirements set forth in paragraph (A) or paragraph (B) of this rule, he or she shall be disenrolled from the MyCare Ohio waiver.
(F) If, at any other time, it is determined that a member enrolled in the MyCare Ohio waiver no longer meets the requirements set forth in paragraph (A) or paragraph (B) of this rule, he or she shall be disenrolled from the MyCare Ohio waiver.
(G) If a member is denied enrollment in the MyCare Ohio waiver pursuant to paragraph (C) of this rule, or is disenrolled from the waiver pursuant to paragraph (D), (E) or (F) of this rule, the Ohio department of medicaid or its designee shall afford the member notice and hearing rights in accordance with division 5101:6 of the Administrative Code.
Five Year Review (FYR) Dates: 9/26/2018 and 01/01/2024
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5166.02
Rule Amplifies: 5164.02, 5164.91, 5166.02 , 5166.16
Prior Effective Dates: 03/01/2014, 08/01/2016