Chapter 5166: FEDERAL MEDICAID WAIVER PROGRAMS

5166.01 Definitions.

As used in this chapter:

"Administrative agency" means, with respect to a home and community-based services medicaid waiver component, the department of medicaid or, if a state agency or political subdivision contracts with the department under section 5162.35 of the Revised Code to administer the component, that state agency or political subdivision.

"Dual eligible individual" has the same meaning as in section 5160.01 of the Revised Code.

"Home and community-based services medicaid waiver component" means a medicaid waiver component under which home and community-based services are provided as an alternative to hospital services, nursing facility services, or ICF/IID services.

"Hospital" has the same meaning as in section 3727.01 of the Revised Code.

"Hospital long-term care unit" has the same meaning as in section 5168.40 of the Revised Code.

"ICDS participant" has the same meaning as in section 5164.01 of the Revised Code.

"ICF/IID" and "ICF/IID services" have the same meanings as in section 5124.01 of the Revised Code.

"Integrated care delivery system" and "ICDS" have the same meanings as in section 5164.01 of the Revised Code.

"Level of care determination" means a determination of whether an individual needs the level of care provided by a hospital, nursing facility, or ICF/IID and whether the individual, if determined to need that level of care, would receive hospital services, nursing facility services, or ICF/IID services if not for a home and community-based services medicaid waiver component.

"Medicaid buy-in for workers with disabilities program" has the same meaning as in section 5163.01 of the Revised Code.

"Medicaid services" has the same meaning as in section 5164.01 of the Revised Code.

"Medicaid waiver component" means a component of the medicaid program authorized by a waiver granted by the United States department of health and human services under the "Social Security Act," section 1115 or 1915, 42 U.S.C. 1315 or 1396n. "Medicaid waiver component" does not include a care management system established under section 5167.03 of the Revised Code.

"Nursing facility" and "nursing facility services" have the same meanings as in section 5165.01 of the Revised Code.

"Ohio home care waiver program" means the home and community-based services medicaid waiver component that is known as Ohio home care and was created pursuant to section 5166.11 of the Revised Code.

"Ohio transitions II aging carve-out program" means the home and community-based services medicaid waiver component that is known as Ohio transitions II aging carve-out and was created pursuant to section 5166.11 of the Revised Code.

"Provider agreement" has the same meaning as in section 5164.01 of the Revised Code.

"Residential treatment facility" means a residential facility licensed by the department of mental health and addiction services under section 5119.34 of the Revised Code, or an institution certified by the department of job and family services under section 5103.03 of the Revised Code, that serves children and either has more than sixteen beds or is part of a campus of multiple facilities or institutions that, combined, have a total of more than sixteen beds.

"Skilled nursing facility" has the same meaning as in section 5165.01 of the Revised Code.

"Unified long-term services and support medicaid waiver component" means the medicaid waiver component authorized by section 5166.14 of the Revised Code.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5166.02 [Renumbered from 5111.85] Rules governing medicaid waiver components.

(A) The medicaid director shall adopt rules in accordance with Chapter 119. of the Revised Code governing medicaid waiver components . The rules may establish all of the following:

(1) Eligibility requirements for the medicaid waiver components;

(2) The type, amount, duration, and scope of medicaid services the medicaid waiver components cover;

(3) The conditions under which the medicaid waiver components cover medicaid services;

(4) The amounts the medicaid waiver components pay for medicaid services or the methods by which the amounts are determined;

(5) The manners in which the medicaid waiver components pay for medicaid services;

(6) Safeguards for the health and welfare of medicaid recipients receiving medicaid services under a medicaid waiver component;

(7) Procedures for prioritizing and approving for enrollment individuals who are eligible for a home and community-based services medicaid waiver component and choose to be enrolled in the component;

(8) Procedures for enforcing the rules, including establishing corrective action plans for, and imposing financial and administrative sanctions on, persons and government entities that violate the rules. Sanctions shall include terminating provider agreements. The procedures shall include due process protections.

(9) Other policies necessary for the efficient administration of the medicaid waiver components.

(B) The director may adopt different rules for the different medicaid waiver components. The rules shall be consistent with the terms of the waiver authorizing the medicaid waiver component.

(C) The following apply to procedures established under division (A)(7) of this section:

(1) Any such procedures established for the medicaid-funded component of the PASSPORT program shall be consistent with section 173.521 of the Revised Code.

(2) Any such procedures established for the medicaid-funded component of the assisted living program shall be consistent with section 173.542 of the Revised Code.

(3) Any such procedures established for the Ohio home care waiver program shall be consistent with section 5166.121 of the Revised Code.

(4) Any such procedures established for the unified long-term services and support medicaid waiver program shall be consistent with section 5166.141 of the Revised Code.

Renumbered from § 5111.85 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

Effective Date: 06-26-2003; 10-01-2005

5166.03 [Renumbered from 5111.84] Notice of intent to request medicaid waiver.

The medicaid director may not submit a request to the United States secretary of health and human services for a medicaid waiver under the "Social Security Act ," section 1115, 42 U.S.C. 1315, unless the director provides the speaker of the house of representatives and president of the senate written notice of the director's intent to submit the request at least ten days before the date the director submits the request to the United States secretary. The notice shall include a detailed explanation of the medicaid waiver the director proposes to seek.

Renumbered from § 5111.84 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 2007 HB119 09-29-2007

5166.04 [Renumbered from 5111.851] Home and community-based services medicaid waiver components.

The following requirements apply to each home and community-based services medicaid waiver component:

(A) Only an individual who qualifies for a component shall receive that component's medicaid services.

(B) A level of care determination shall be made as part of the process of determining whether an individual qualifies for a component and shall be made each year after the initial determination if, during such a subsequent year, the administrative agency determines there is a reasonable indication that the individual's needs have changed.

(C) A written plan of care or individual service plan based on an individual assessment of the medicaid services that an individual needs to avoid needing admission to a hospital, nursing facility, or ICF/IID shall be created for each individual determined eligible for a component.

(D) Each individual determined eligible for a component shall receive that component's medicaid services in accordance with the individual's level of care determination and written plan of care or individual service plan.

(E) No individual may receive medicaid services under a component while the individual is a hospital inpatient or resident of a skilled nursing facility, nursing facility, or ICF/IID.

(F) No individual may receive prevocational, educational, or supported employment services under a component if the individual is eligible for such services that are funded with federal funds provided under 29 U.S.C. 730 or the "Individuals with Disabilities Education Act," 111 Stat. 37 (1997), 20 U.S.C. 1400, as amended.

(G) Safeguards shall be taken to protect the health and welfare of individuals receiving medicaid services under a component, including safeguards established in rules adopted under section 5166.02 of the Revised Code and safeguards established by licensing and certification requirements that are applicable to the providers of that component's medicaid services.

(H) No medicaid services may be provided under a component by a provider that is subject to standards that the "Social Security Act," section 1616(e)(1), 42 U.S.C. 1382e(e)(1), requires be established if the provider fails to comply with the standards applicable to the provider.

(I) Individuals determined to be eligible for a component, or such individuals' representatives, shall be informed of that component's medicaid services, including any choices that the individual or representative may make regarding the component's medicaid services, and given the choice of either receiving medicaid services under that component or, as appropriate, hospital services, nursing facility services, or ICF/IID services.

(J) No individual shall lose eligibility for services under a component, or have the services reduced or otherwise disrupted, on the basis that the individual also receives services under the medicaid buy-in for workers with disabilities program.

(K) No individual shall lose eligibility for services under a component, or have the services reduced or otherwise disrupted, on the basis that the individual's income or resources increase to an amount above the eligibility limit for the component if the individual is participating in the medicaid buy-in for workers with disabilities program and the amount of the individual's income or resources does not exceed the eligibility limit for the medicaid buy-in for workers with disabilities program.

(L) No individual receiving services under a component shall be required to pay any cost sharing expenses for the services for any period during which the individual also participates in the medicaid buy-in for workers with disabilities program.

Renumbered from § 5111.851 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

Effective Date: 10-01-2005; 2007 HB119 09-29-2007

5166.05 [Renumbered from 5111.852] Review of plans of care and individual service plans.

The department of medicaid may review and approve, modify, or deny written plans of care and individual service plans that section 5166.04 of the Revised Code requires be created for individuals determined eligible for a home and community-based services medicaid waiver component. If a state agency or political subdivision contracts with the department under section 5162.35 of the Revised Code to administer a home and community-based services medicaid waiver component and approves, modifies, or denies a written plan of care or individual service plan pursuant to the agency's or subdivision's administration of the component, the department may review the agency's or subdivision's approval, modification, or denial and order the agency or subdivision to reverse or modify the approval, modification, or denial. The state agency or political subdivision shall comply with the department's order.

The department of medicaid shall be granted full and immediate access to any records the department needs to implement its duties under this section.

Renumbered from § 5111.852 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 10-01-2005

5166.06 [Renumbered from 5111.853] Agency records of costs of medicaid waiver components.

Each administrative agency shall maintain, for a period of time the department of medicaid shall specify, financial records documenting the costs of medicaid services provided under the home and community-based services medicaid waiver components that the agency administers, including records of independent audits. The administrative agency shall make the financial records available on request to the United States secretary of health and human services, United States comptroller general, and their designees.

Renumbered from § 5111.853 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 10-01-2005

5166.07 [Renumbered from 5111.854] Agency accountable for medicaid waiver components funds.

Each administrative agency is financially accountable for funds expended for medicaid services covered by the home and community-based services medicaid waiver components that the agency administers.

Renumbered from § 5111.854 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 10-01-2005

5166.08 [Renumbered from 5111.855] Agency contracting for medicaid waiver components; assurance of compliance.

Each state agency and political subdivision that enters into a contract with the department of medicaid under section 5162.35 of the Revised Code to administer a home and community-based services medicaid waiver component, or one or more aspects of such a component, shall provide the department a written assurance that the agency or subdivision will not violate any of the requirements of sections 5166.01 to 5166.07 of the Revised Code.

Renumbered from § 5111.855 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 10-01-2005

5166.10 [Renumbered from 5111.856] Transfer of enrollee in one medicaid waiver component to another.

To the extent necessary for the efficient and economical administration of medicaid waiver components, the department of medicaid may transfer an individual enrolled in a medicaid waiver component administered by the department to another medicaid waiver component the department administers if the individual is eligible for the medicaid waiver component and the transfer does not jeopardize the individual's health or safety.

Renumbered from § 5111.856 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 10-01-2005

5166.11 [Renumbered from 5111.86] Creation of medicaid waiver components for home and community-based services programs.

(A) As used in this section , "Ohio home care program" means the program the department of medicaid administers that provides state plan services and medicaid waiver component services pursuant to rules adopted for the medicaid program and a medicaid waiver that went into effect July 1, 1998.

(B) The department of medicaid may create and administer two or more medicaid waiver components under which home and community-based services are provided to eligible individuals who need the level of care provided by a nursing facility or hospital. In administering the medicaid waiver components, the department may specify the following:

(1) The maximum number of individuals who may be enrolled in each of the medicaid waiver components ;

(2) The maximum amount the medicaid program may expend each year for each individual enrolled in the medicaid waiver components;

(3) The maximum amount the medicaid program may expend each year for all individuals enrolled in the medicaid waiver components;

(4) Any other requirements the department selects for the medicaid waiver components.

(C)

(D) After the first of any of the medicaid waiver components that the department administers under this section begins to enroll eligible individuals, the department may cease to enroll additional individuals in a medicaid waiver component of the Ohio home care program.

Renumbered from § 5111.86 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Effective Date: 06-05-2002; 10-01-2005

5166.12 [Renumbered from 5111.861] Determination regarding continuation of the Ohio home care waiver program.

If the unified long-term services and support medicaid waiver component is created, the departments of aging and medicaid shall collaborate to determine whether the Ohio home care waiver program should continue to operate as a separate medicaid waiver component or be terminated. If the departments determine that the Ohio home care waiver program should be terminated, the program shall cease to exist on a date the departments shall specify.

Renumbered from § 5111.861 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

5166.121 [Renumbered from 5111.862] Home first component for the Ohio home care waiver program.

(A) Unless the Ohio home care waiver program is terminated pursuant to section 5165.12 of the Revised Code, the department of medicaid shall establish a home first component for the Ohio home care waiver program. An individual is eligible for the Ohio home care waiver program's home first component if the individual has been determined to be eligible for the Ohio home care waiver program and at least one of the following applies:

(1) If the individual is under twenty-one years of age, the individual received inpatient hospital services for at least fourteen consecutive days, or had at least three inpatient hospital stays during the twelve months, immediately preceding the date the individual applies for the Ohio home care waiver program.

(2) If the individual is at least twenty-one but less than sixty years of age, the individual received inpatient hospital services for at least fourteen consecutive days immediately preceding the date the individual applies for the Ohio home care waiver program.

(3) The individual received private duty nursing services under the medicaid program for at least twelve consecutive months immediately preceding the date the individual applies for the Ohio home care waiver program.

(4) The individual does not reside in a nursing facility or hospital long-term care unit at the time the individual applies for the Ohio home care waiver program but is at risk of imminent admission to a nursing facility or hospital long-term care unit due to a documented loss of a primary caregiver.

(5) The individual resides in a nursing facility at the time the individual applies for the Ohio home care waiver program.

(6) At the time the individual applies for the Ohio home care waiver program, the individual participates in the money follows the person demonstration project authorized by section 6071 of the "Deficit Reduction Act of 2005," Pub. L. No. 109-171, as amended, and either resides in a residential treatment facility or inpatient hospital setting.

(B) An individual determined to be eligible for the home first component of the Ohio home care waiver program shall be enrolled in the program in accordance with rules adopted under section 5166.02 of the Revised Code.

Renumbered from § 5111.862 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.

Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

5166.13 [Renumbered from 5111.863] Determination regarding continuation of Ohio transitions II aging carve-out program.

If the unified long-term services and support medicaid waiver component is created, the departments of aging and medicaid shall collaborate to determine whether the Ohio transitions II aging carve-out program should continue to operate as a separate medicaid waiver component or be terminated. If the departments determine that the Ohio transitions II aging carve-out program should be terminated, the program shall cease to exist on a date the departments shall specify.

Renumbered from § 5111.863 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

5166.14 [Renumbered from 5111.864] Unified long-term services and support medicaid waiver component.

The department of medicaid shall create a unified long-term services and support medicaid waiver component to provide home and community-based services to eligible individuals of any age who require the level of care provided by nursing facilities. The department of medicaid shall collaborate with the department of aging in creating and implementing the component.

The medicaid director shall collaborate with the director of aging when adopting rules under section 5166.02 of the Revised Code to implement the component.

Renumbered from § 5111.864 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

5166.141 [Renumbered from 5111.865] Home first component for unified long-term services and support medicaid waiver program.

The department of medicaid shall establish a home first component for the unified long-term services and support medicaid waiver program. The home first component shall be similar to the home first component of the medicaid-funded component of the PASSPORT program established under section 173.521 of the Revised Code, the home first component of the medicaid-funded component of the assisted living program established under section 173.542 of the Revised Code, and the home first component of the Ohio home care waiver program established under section 5166.121 of the Revised Code.

Renumbered from § 5111.865 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

5166.16 Integrated care delivery system medicaid waiver.

(A) As used in this section, "ODA or MCD medicaid waiver component" means all of the following:

(1) The medicaid-funded component of the PASSPORT program, unless it is terminated pursuant to division (C) of section 173.52 of the Revised Code;

(2) The choices program, unless it is terminated pursuant to division (B) of section 173.53 of the Revised Code;

(3) The medicaid-funded component of the assisted living program, unless it is terminated pursuant to division (C) of section 173.54 of the Revised Code;

(4) The Ohio home care waiver program, unless it is terminated pursuant to section 5166.12 of the Revised Code;

(5) The Ohio transitions II aging carve-out program, unless it is terminated pursuant to section 5166.13 of the Revised Code.

(B) The medicaid director may create a home and community-based services medicaid waiver component as part of the integrated care delivery system. If the ICDS medicaid waiver component is created, both of the following apply:

(1) The department of medicaid shall administer it;

(2) When it begins to accept enrollments, no ICDS participant who is eligible for the ICDS medicaid waiver component shall be enrolled in an ODA or MCD medicaid waiver component regardless of whether the participant prefers to remain or be enrolled in an ODA or MCD medicaid waiver component.

(C) A dual eligible individual who is eligible for an ODA or MCD medicaid waiver component may enroll in the component before the individual becomes an ICDS participant. The dual eligible individual shall disenroll from the ODA or MCD medicaid waiver component and enroll in the ICDS medicaid waiver component once the individual becomes an ICDS participant and it is possible to enroll the individual in the ICDS medicaid waiver component. The disenrollment from the ODA or MCD medicaid waiver component and enrollment into the ICDS medicaid waiver component shall occur regardless of whether the individual prefers to remain enrolled in the ODA or MCD medicaid waiver component.

(D) An ICDS participant's disenrollment from an ODA or MCD medicaid waiver component and enrollment in the ICDS medicaid waiver component resulting from division (B)(2) or (C) of this section shall be accomplished without a disruption in the participant's services under the components.

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

5166.20 [Renumbered from 5111.87] Additional Medicaid waiver components for home and community-based services.

(A) The department of medicaid may create the following:

(1) One or more medicaid waiver components under which home and community-based services are provided to individuals with mental retardation or other developmental disability as an alternative to placement in ICFs/IID;

(2) One or more medicaid waiver components under which home and community-based services are provided in the form of any of the following:

(a) Early intervention and supportive services for children under three years of age who have developmental delays or disabilities the department determines are significant;

(b) Therapeutic services for children who have autism;

(c) Specialized habilitative services for individuals who are eighteen years of age or older and have autism.

(B) No medicaid waiver component created pursuant to division (A)(2)(b) or (c) of this section shall provide services that are available under another medicaid waiver component. No medicaid waiver component created pursuant to division (A)(2)(b) of this section shall provide services to an individual that the individual is eligible to receive through an individualized education program as defined in section 3323.01 of the Revised Code.

(C) The director of developmental disabilities and director of health may request that the department of medicaid create one or more medicaid waiver components under this section.

(D) Before creating a medicaid waiver component under this section, the department of medicaid shall seek, accept, and consider public comments.

Renumbered from § 5111.87 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 128th General Assemblych.28, SB 79, §1, eff. 10/6/2009.

Effective Date: 06-29-2004; 09-29-2005

5166.21 [Renumbered from 5111.871] Transitions developmental disabilities waiver.

The department of medicaid shall enter into a contract with the department of developmental disabilities under section 5162.35 of the Revised Code with regard to one or more of the medicaid waiver components created by the department of medicaid under section 5166.20 of the Revised Code. The contract shall include the medicaid waiver component known as the transitions developmental disabilities waiver. The contract shall provide for the department of developmental disabilities to administer the components in accordance with the terms of the federal medicaid waivers authorizing the components. The contract shall include a schedule for the department of developmental disabilities to begin administering the transitions developmental disabilities waiver.

If the department of developmental disabilities or the department of medicaid denies an individual's application for home and community-based services provided under any of these medicaid components, the department that denied the services shall give timely notice to the individual that the individual may appeal pursuant to section 5160.31 of the Revised Code.

The departments of developmental disabilities and medicaid may approve, reduce, deny, or terminate a medicaid service included in the individualized service plan developed for a medicaid recipient eligible for home and community-based services provided under any of these medicaid components. The departments shall consider the recommendations a county board of developmental disabilities makes under division (A)(1)(c) of section 5126.055 of the Revised Code. If either department approves, reduces, denies, or terminates a medicaid service, that department shall give timely notice to the medicaid recipient that the recipient may appeal pursuant to section 5160.31 of the Revised Code.

If supported living, as defined in section 5126.01 of the Revised Code, is to be provided as a medicaid service under any of these components, any person or government entity with a current, valid provider agreement and a current, valid certificate under section 5123.161 of the Revised Code may provide the medicaid service.

If a medicaid service is to be provided under any of these components by a residential facility, as defined in section 5123.19 of the Revised Code, any person or government entity with a current, valid provider agreement and a current, valid license under section 5123.19 of the Revised Code may provide the medicaid service.

Renumbered from § 5111.871 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Amended by 128th General Assemblych.28, SB 79, §1, eff. 10/6/2009.

Effective Date: 06-26-2003; 07-01-2005; 2007 HB119 06-30-2007

5166.22 [Renumbered from 5111.872] Allocating enrollment numbers to county board of developmental disabilities.

(A) Subject to division (B) of this section, when the department of developmental disabilities allocates enrollment numbers to a county board of developmental disabilities for home and community-based services specified in division (A)(1) of section 5166.20 of the Revised Code and provided under any of the medicaid waiver components that the department administers under section 5166.21 of the Revised Code, the department shall consider all of the following:

(1) The number of individuals with mental retardation or other developmental disability who are on a waiting list the county board establishes under section 5126.042 of the Revised Code for those services and are given priority on the waiting list;

(2) The implementation component required by division (A)(3) of section 5126.054 of the Revised Code of the county board's plan approved under section 5123.046 of the Revised Code;

(3) Anything else the department considers necessary to enable county boards to provide those services to individuals in accordance with the priority requirements for waiting lists established under section 5126.042 of the Revised Code for those services.

(B) Division (A) of this section applies to home and community-based services provided under the medicaid waiver component known as the transitions developmental disabilities waiver only to the extent, if any, provided by the contract required by section 5166.21 of the Revised Code regarding the component.

Renumbered from § 5111.872 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Amended by 128th General Assemblych.28, SB 79, §1, eff. 10/6/2009.

Effective Date: 06-26-2003; 2007 HB119 07-01-2007

5166.23 [Renumbered from 5111.873] Rules regarding payments for home and community-based services provided under medicaid component.

(A) Subject to division (D) of this section, the medicaid director shall adopt rules under section 5166.02 of the Revised Code establishing the payment amounts or the methods by which the payment amounts are to be determined for home and community-based services specified in division (A)(1) of section 5166.20 of the Revised Code and provided under the components of the medicaid program that the department of developmental disabilities administers under section 5166.21 of the Revised Code. With respect to these rules, all of the following apply:

(1) The rules shall establish procedures for the department of developmental disabilities to follow in arranging for the initial and ongoing collection of cost information from a comprehensive, statistically valid sample of persons and government entities providing the services at the time the information is obtained.

(2) The rules shall establish procedures for the collection of consumer-specific information through an assessment instrument the department of developmental disabilities shall provide to the department of medicaid.

(3) With the information collected pursuant to divisions (A)(1) and (2) of this section, an analysis of that information, and other information the director determines relevant, the rules shall establish payment standards that do all of the following:

(a) Assure that payment amounts are consistent with efficiency, economy, and quality of care;

(b) Consider the intensity of consumer resource need;

(c) Recognize variations in different geographic areas regarding the resources necessary to assure the health and welfare of consumers;

(d) Recognize variations in environmental supports available to consumers.

(B) As part of the process of adopting rules authorized by this section, the director shall consult with the director of developmental disabilities, representatives of county boards of developmental disabilities, persons who provide the home and community-based services, and other persons and government entities the director identifies.

(C) The medicaid director and director of developmental disabilities shall review the rules authorized by this section at times they determine are necessary to ensure that the payment amounts or the methods by which the payment amounts are to be determined continue to meet the payment standards established under division (A)(3) of this section.

(D) This section applies to home and community-based services provided under the medicaid waiver component known as the transitions developmental disabilities waiver only to the extent, if any, provided by the contract required by section 5166.21 of the Revised Code regarding the component.

Renumbered from § 5111.873 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01. See act for effective dates.

Amended by 128th General Assemblych.28, SB 79, §1, eff. 10/6/2009.

Effective Date: 06-26-2003

5166.30 [Renumbered from 5111.88] Coverage of home care attendant services.

(A) As used in sections 5166.30 to 5166.3010 of the Revised Code:

(1) "Adult" means an individual at least eighteen years of age.

(2) "Appropriate director" means the following:

(a) The medicaid director in the context of all of the following:

(i) The Ohio home care waiver program, unless it is terminated pursuant to section 5166.12 of the Revised Code;

(ii) The Ohio transitions II aging carve-out program, unless it is terminated pursuant to section 5166.13 of the Revised Code;

(iii) The integrated care delivery system medicaid waiver component authorized by section 5166.16 of the Revised Code.

(b) The director of aging in the context of the medicaid-funded component of the PASSPORT program, unless it is terminated pursuant to division (C) of section 173.52 of the Revised Code.

(3) "Authorized representative" means the following:

(a) In the case of a consumer who is a minor, the consumer's parent, custodian, or guardian;

(b) In the case of a consumer who is an adult, an individual selected by the consumer pursuant to section 5166.3010 of the Revised Code to act on the consumer's behalf for purposes regarding home care attendant services.

(4) "Authorizing health care professional" means a health care professional who, pursuant to section 5166.307 of the Revised Code, authorizes a home care attendant to assist a consumer with self-administration of medication, nursing tasks, or both.

(5) "Consumer" means an individual to whom all of the following apply:

(a) The individual is enrolled in a participating medicaid waiver component.

(b) The individual has a medically determinable physical impairment to which both of the following apply:

(i) It is expected to last for a continuous period of not less than twelve months.

(ii) It causes the individual to require assistance with activities of daily living, self-care, and mobility, including either assistance with self-administration of medication or the performance of nursing tasks, or both.

(c) In the case of an individual who is an adult, the individual is mentally alert and is, or has an authorized representative who is, capable of selecting, directing the actions of, and dismissing a home care attendant.

(d) In the case of an individual who is a minor, the individual has an authorized representative who is capable of selecting, directing the actions of, and dismissing a home care attendant.

(6) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(7) "Custodian" has the same meaning as in section 2151.011 of the Revised Code.

(8) "Gastrostomy tube" means a percutaneously inserted catheter that terminates in the stomach.

(9) "Guardian" has the same meaning as in section 2111.01 of the Revised Code.

(10) "Health care professional" means a physician or registered nurse.

(11) "Home care attendant" means an individual holding a valid provider agreement in accordance with section 5166.301 of the Revised Code that authorizes the individual to provide home care attendant services to consumers.

(12) "Home care attendant services" means all of the following as provided by a home care attendant:

(a) Personal care aide services;

(b) Assistance with the self-administration of medication;

(c) Assistance with nursing tasks.

(13) "Jejunostomy tube" means a percutaneously inserted catheter that terminates in the jejunum.

(14) "Medication" means a drug as defined in section 4729.01 of the Revised Code.

(15) "Minor" means an individual under eighteen years of age.

(16) "Participating medicaid waiver component" means all of the following:

(a) The medicaid-funded component of the PASSPORT program, unless it is terminated pursuant to division (C) of section 173.52 of the Revised Code;

(b) The Ohio home care waiver program , unless it is terminated pursuant to section 5166.12 of the Revised Code;

(c) The Ohio transitions II aging carve-out program , unless it is terminated pursuant to section 5166.13 of the Revised Code;

(d) The integrated care delivery system medicaid waiver component authorized by section 5166.16 of the Revised Code.

(17) "Physician" means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(18) "Practice of nursing as a registered nurse," "practice of nursing as a licensed practical nurse," and "registered nurse" have the same meanings as in section 4723.01 of the Revised Code. "Registered nurse" includes an advanced practice registered nurse, as defined in section 4723.01 of the Revised Code.

(19) "Schedule II," "schedule III," "schedule IV," and "schedule V" have the same meanings as in section 3719.01 of the Revised Code.

(B) Participating medicaid waiver components may cover home care attendant services in accordance with sections 5166.30 to 5166.3010 of the Revised Code and rules adopted under section 5166.02 of the Revised Code.

Renumbered from § 5111.88 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.194, HB 303, §1, eff. 3/20/2013.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.301 [Renumbered from 5111.881] Home care attendant services providers.

The medicaid director shall enter into a provider agreement with an individual to authorize the individual to provide home care attendant services to consumers if the individual does both of the following:

(A) Agrees to comply with the requirements of sections 5166.30 to 5166.3010 and rules adopted under section 5166.02 of the Revised Code;

(B) Provides the director evidence satisfactory to the director of all of the following:

(1) That the individual either meets the personnel qualifications specified in 42 C.F.R. 484.4 for home health aides or has successfully completed at least one of the following:

(a) A competency evaluation program or training and competency evaluation program approved or conducted by the director of health under section 3721.31 of the Revised Code;

(b) A training program approved by the appropriate director that includes training in at least all of the following and provides training equivalent to a training and competency evaluation program specified in division (B)(1)(a) of this section or meets the requirements of 42 C.F.R. 484.36(a):

(i) Basic home safety;

(ii) Universal precautions for the prevention of disease transmission, including hand-washing and proper disposal of bodily waste and medical instruments that are sharp or may produce sharp pieces if broken;

(iii) Personal care aide services;

(iv) The labeling, counting, and storage requirements for schedule II, III, IV, and V medications.

(2) That the individual has obtained a certificate of completion of a course in first aid from a first aid course to which all of the following apply:

(a) It is not provided solely through the internet.

(b) It includes hands-on training provided by a first aid instructor who is qualified to provide such training according to standards set in rules adopted under section 5166.02 of the Revised Code.

(c) It requires the individual to demonstrate successfully that the individual has learned the first aid taught in the course.

(3) That the individual meets any other requirements for the medicaid provider agreement specified in rules adopted under section 5166.02 of the Revised Code.

Renumbered from § 5111.881 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.302 [Renumbered from 5111.882] Continuing education requirements for home care attendants.

A home care attendant shall complete not less than twelve hours of in-service continuing education regarding home care attendant services each year and provide the appropriate director evidence satisfactory to the appropriate director that the attendant satisfied this requirement. The evidence shall be submitted to the appropriate director not later than the annual anniversary of the issuance of the home care attendant's initial provider agreement.

Renumbered from § 5111.882 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.303 [Renumbered from 5111.883] Responsibilities of home care attendants.

A home care attendant shall do all of the following:

(A) Maintain a clinical record for each consumer to whom the attendant provides home care attendant services in a manner that protects the consumer's privacy;

(B) Participate in a face-to-face visit every ninety days with all of the following to monitor the health and welfare of each of the consumers to whom the attendant provides home care attendant services:

(1) The consumer;

(2) The consumer's authorized representative, if any;

(3) A registered nurse who agrees to answer any questions that the attendant, consumer, or authorized representative has about consumer care needs, medications, and other issues.

(C) Document the activities of each visit required by division (B) of this section in the consumer's clinical record with the assistance of the registered nurse.

Renumbered from § 5111.883 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.304 [Renumbered from 5111.884] Nursing assistance by home care attendants.

(A) A home care attendant may assist a consumer with nursing tasks or self-administration of medication only after the attendant does both of the following:

(1) Subject to division (B) of this section, completes consumer-specific training in how to provide the assistance that the authorizing health care professional authorizes the attendant to provide to the consumer;

(2) At the request of the consumer, consumer's authorized representative, or authorizing health care professional, successfully demonstrates that the attendant has learned how to provide the authorized assistance to the consumer.

(B) The training required by division (A)(1) of this section shall be provided by either of the following:

(1) The authorizing health care professional;

(2) The consumer or consumer's authorized representative in cooperation with the authorizing health care professional.

Renumbered from § 5111.884 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.305 [Renumbered from 5111.885] Nursing assistance by home care attendants; consent and authorization.

A home care attendant shall comply with both of the following when assisting a consumer with nursing tasks or self-administration of medication:

(A) The written consent of the consumer or consumer's authorized representative provided to the appropriate director under section 5166.306 of the Revised Code;

(B) The authorizing health care professional's written authorization provided to the appropriate director under section 5166.307 of the Revised Code.

Renumbered from § 5111.885 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.306 [Renumbered from 5111.886] Nursing assistance by home care attendants; writtent statement providing consent.

To consent to a home care attendant assisting a consumer with nursing tasks or self-administration of medication, the consumer or consumer's authorized representative shall provide the appropriate director a written statement signed by the consumer or authorized representative under which the consumer or authorized representative consents to both of the following:

(A) Having the attendant assist the consumer with nursing tasks or self-administration of medication;

(B) Assuming responsibility for directing the attendant when the attendant assists the consumer with nursing tasks or self-administration of medication.

Renumbered from § 5111.886 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.307 [Renumbered from 5111.887] Nursing assistance by home care attendants; written statement of authorization.

To authorize a home care attendant to assist a consumer with nursing tasks or self-administration of medication, a health care professional shall provide the appropriate director a written statement signed by the health care professional that includes all of the following:

(A) The consumer's name and address;

(B) A description of the nursing tasks or self-administration of medication with which the attendant is to assist the consumer, including, in the case of assistance with self-administration of medication, the name and dosage of the medication;

(C) The times or intervals when the attendant is to assist the consumer with the self-administration of each dosage of the medication or nursing tasks;

(D) The dates the attendant is to begin and cease providing the assistance;

(E) A list of severe adverse reactions the attendant must report to the health care professional should the consumer experience one or more of the reactions;

(F) At least one telephone number at which the attendant can reach the health care professional in an emergency;

(G) Instructions the attendant is to follow when assisting the consumer with nursing tasks or self-administration of medication, including instructions for maintaining sterile conditions and for storage of task-related equipment and supplies;

(H) The health care professional's attestation of both of the following:

(1) That the consumer or consumer's authorized representative has demonstrated to the health care professional the ability to direct the attendant;

(2) That the attendant has demonstrated to the health care professional the ability to provide the consumer assistance with nursing tasks or self-administration of medication that the health care professional has specifically authorized the attendant to provide and that the consumer or consumer's authorized representative has indicated to the health care professional that the consumer or authorized representative is satisfied with the attendant's demonstration.

Renumbered from § 5111.887 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.308 [Renumbered from 5111.888] Nursing assistance by home care attendants; unauthorized actions.

When authorizing a home care attendant to assist a consumer with nursing tasks or self-administration of medication, a health care professional may not authorize a home care attendant to do any of the following:

(A) Perform a task that is outside of the health care professional's scope of practice;

(B) Assist the consumer with the self-administration of a medication, including a schedule II, schedule III, schedule IV, or schedule V drug unless both of the following apply:

(1) The medication is administered orally, topically, or via a gastrostomy tube or jejunostomy tube, including through any of the following:

(a) In the case of an oral medication, a metered dose inhaler;

(b) In the case of a topical medication, including a transdermal medication, either of the following:

(i) An eye, ear, or nose drop or spray;

(ii) A vaginal or rectal suppository.

(c) In the case of a gastrostomy tube or jejunostomy tube, only through a pre-programmed pump.

(2) The medication is in its original container and the label attached to the container displays all of the following:

(a) The consumer's full name in print;

(b) The medication's dispensing date, which must not be more than twelve months before the date the attendant assists the consumer with self-administration of the medication;

(c) The exact dosage and means of administration that match the health care professional's authorization to the attendant.

(C) Assist the consumer with the self-administration of a schedule II, schedule III, schedule IV, or schedule V medication unless, in addition to meeting the requirements of division (B) of this section, all of the following apply:

(1) The medication has a warning label on its container.

(2) The attendant counts the medication in the consumer's or authorized representative's presence when the medication is administered to the consumer and records the count on a form used for the count as specified in rules adopted under section 5166.02 of the Revised Code.

(3) The attendant recounts the medication in the consumer's or authorized representative's presence at least monthly and reconciles the recount on a log located in the consumer's clinical record.

(4) The medication is stored separately from all other medications and is secured and locked at all times when not being administered to the consumer to prevent unauthorized access.

(D) Perform an intramuscular injection;

(E) Perform a subcutaneous injection unless it is for a routine dose of insulin;

(F) Program a pump used to deliver a medication unless the pump is used to deliver a routine dose of insulin;

(G) Insert, remove, or discontinue an intravenous access device;

(H) Engage in intravenous medication administration;

(I) Insert or initiate an infusion therapy;

(J) Perform a central line dressing change.

Renumbered from § 5111.888 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.309 [Renumbered from 5111.889] Practice of nursing as registered nurse or licensed practical nurse not allowed by home care attendants.

A home care attendant who provides home care attendant services to a consumer in accordance with the authorizing health care professional's authorization does not engage in the practice of nursing as a registered nurse or in the practice of nursing as a licensed practical nurse in violation of section 4723.03 of the Revised Code.

A consumer or the consumer's authorized representative shall report to the appropriate director if a home care attendant engages in the practice of nursing as a registered nurse or the practice of nursing as a licensed practical nurse beyond the authorizing health care professional's authorization. The appropriate director shall forward a copy of each report to the board of nursing.

Renumbered from § 5111.889 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.3010 [Renumbered from 5111.8810] Authorized representative.

A consumer who is an adult may select an individual to act on the consumer's behalf for purposes regarding home care attendant services by submitting a written notice of the consumer's selection of an authorized representative to the appropriate director . The notice shall specifically identify the individual the consumer selects as authorized representative and may limit what the authorized representative may do on the consumer's behalf regarding home care attendant services. A consumer may not select the consumer's home care attendant to be the consumer's authorized representative.

Renumbered from § 5111.8810 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.

5166.35 [Renumbered from 5111.97] Ohio access success project.

(A) The medicaid director may establish the Ohio access success project to help medicaid recipients make the transition from residing in nursing facilities to residing in community settings. The project may be established as a separate nonmedicaid program or integrated into a new or existing home and community-based services medicaid waiver component. The director shall permit any medicaid recipient receiving nursing facility services to apply for participation in the project, but may limit the number of project participants.

The director shall ensure that an assessment of an applicant is conducted as soon as practicable to determine whether the applicant is eligible for participation in the project. To the maximum extent possible, the assessment and eligibility determination shall be completed not later than the date that occurs six months after the applicant begins to receive nursing facility services.

(B) To be eligible for benefits under the project, a medicaid recipient must satisfy all of the following requirements:

(1) The medicaid recipient must be receiving nursing facility services at the time of applying for the project benefits.

(2) If the project is established as a nonmedicaid program, the medicaid recipient must be able to remain in the community as a result of receiving project benefits and the projected cost of the benefits to the project does not exceed eighty per cent of the average monthly medicaid cost of a medicaid recipient in a nursing facility.

(3) If the project is integrated into a home and community-based services medicaid waiver component, the medicaid recipient must meet the waiver component's enrollment criteria.

(C) If the director establishes the Ohio access success project, the benefits provided under the project may include payment of all of the following:

(1) The first month's rent in a community setting;

(2) Rental deposits;

(3) Utility deposits;

(4) Moving expenses;

(5) Other expenses not covered by the medicaid program that facilitate a medicaid recipient's move from a nursing facility to a community setting.

(D) If the project is established as a nonmedicaid program, no participant may receive more than two thousand dollars' worth of benefits under the project.

(E) If the department of medicaid enters into a contract with an entity to provide fiscal management services regarding the project, the contract may provide for a portion of a participant's benefits under the project to be paid to the contracting entity. The contract shall specify the portion to be paid to the contracting entity.

(F) The director may adopt rules in accordance with Chapter 119. of the Revised Code for the administration and operation of the project. If the project is integrated into a home and community-based services medicaid waiver component, the rules shall be adopted under section 5166.02 of the Revised Code.

Renumbered from § 5111.97 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.

Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.

Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.

Effective Date: 10-01-2005