5160:1-2-03 Medicaid: application for home and community-based (HCB) services.

(A) This rule sets forth the process for determining whether an individual is eligible for medicaid payments for services under the HCB services waivers set out in agency 5160 of the Administrative Code.

(B) Eligibility for HCB services. To receive HCB services, the individual shall:

(1) Be in receipt of medicaid, as described in Chapters 5160:1-1 to 5160:1-5 of the Administrative Code;

(2) Be in need of HCB services under a waiver described in agency 5160 of the Administrative Code; and

(3) Be enrolled in an HCB services waiver described in agency 5160 of the Administrative Code.

(C) Determination of eligibility for HCB services. The administrative agency shall approve HCB services for an individual in receipt of medicaid only upon:

(1) Approval by the HCB services waiver operational agency, as defined in rule 5160:1-1- 50.1 of the Administrative Code; and

(2) If services under the waiver are available only to a specific number of individuals, notification that the individual may be enrolled in the waiver from the Ohio department of medicaid (ODM), its designee, or a HCB services waiver operational agency.

(D) Coverage period. The HCB services coverage period can have a different beginning date or ending date from the medicaid eligibility period.

(1) HCB services cannot:

(a) Begin before an individual's medicaid eligibility period or before an individual's retroactive medicaid eligibility period;

(b) Extend beyond the termination date of an individual's medicaid coverage;

and

(c) Be provided during any period of medicaid ineligibility.

(2) Medicaid coverage of HCB services begins on the latest of the following dates:

(a) The process date for application for HCB services. The process date is:

(i) The date the administrative agency receives a signed application for HCB services from an individual; or

(ii) The signature date, if the administrative agency receives a signed and dated HCB services application from a waiver operational agency no more than five working days after the date of signature; or

(iii) The date the administrative agency receives the signed application for HCB services, if the application was received from a HCB services waiver operational agency more than five working days after the date of signature.

(b) The date the individual meets all criteria for coverage of an HCB services waiver described in agency 5160 of the Administrative Code.

(c) The date the individual is authorized, by the HCB services waiver operational agency, to receive HCB services.

(3) Medicaid coverage of HCB services terminates when either:

(a) The administrative agency determines the individual no longer meets medicaid conditions of eligibility as described in rule 5160:1-1-58 of the Administrative Code or the criteria for coverage of HCB services; or

(b) The HCB services waiver operational agency notifies the administrative agency that it no longer authorizes the individual to receive its HCB services.

(E) HCB services waiver operational agency responsibilities. HCB services waiver operational agencies shall:

(1) Submit a ODM 02399 "Request for Medicaid Home and Community-Based Services (HCBS)" (rev. 7/2014), signed by the individual, to the administrative agency within five days of the signature date, if assisting an individual with an application for HCB services.

(2) Determine, in accordance with this rule and agency 5160 of the Administrative Code, whether the individual requesting medicaid coverage of HCB services meets the requirements of the applicable HCB services waiver program.

(3) Provide written notification of determinations to individuals, including to whom any patient liability must be paid, if applicable.

(4) Notify the administrative agency of determinations and subsequent changes regarding approval of HCB services.

(F) Administrative agency responsibilities. The administrative agency shall:

(1) Determine an individual's eligibility for HCB services in accordance with this rule.

(a) If an individual who applies for HCB services is currently in receipt of medicaid, the administrative agency shall process the individual's application for HCB services.

(b) If an individual who applies for HCB services is not currently in receipt of medicaid, the administrative agency shall begin the application process described in rule 5160:1-1-51 of the Administrative Code.

(c) If the administrative agency determines that an individual who applies for HCB services is not eligible for any category of medical assistance, the administrative agency shall deny both medical assistance and HCB services for that individual.

(2) Notify the applicable HCB services waiver operational agency, within five days of the receipt of a signed ODM 02399, via the electronic eligibility system of the receipt of the application. If the HCB services waiver operational agency is not known or if multiple waiver agencies are indicated on the application, the administrative agency shall submit the ODM 02399 to ODM.

(3) Notify the applicable HCB services waiver operational agency of changes in the individual's eligibility for medicaid coverage of HCB services.

Replaces: 5160:1-2- 01.6

Effective: 3/23/2015
Five Year Review (FYR) Dates: 03/23/2020
Promulgated Under: 111.15
Statutory Authority: 5160.02, 5163.02, 5166.20, 5166.21
Rule Amplifies: 5160.02, 5163.02, 5166.21, 5162.35
Prior Effective Dates: 6/1/88 (Emer.), 8/1/88 (Emer.), 10/30/88, 1/1/90 (Emer.), 3/1/90 (Emer.), 3/30/90 (Emer.), 4/1/90, 6/29/90, 7/1/90, 10/1/90, 1/1/91 (Emer.), 4/1/91, 1/1/92 (Emer.), 3/20/92, 3/30/92, 5/1/92 (Emer.), 7/1/92, 8/14/92 (Emer.), 1/1/92, 5/1/93, 9/1/93, 7/1/94, 10/1/02, 10/1/04, 10/1/09