(A) Initial contact: To determine if an
individual who applies for the medicaid-funded component of the assisted living
program meets all eligibility requirements for the program under rule
5160-33-03 of the Administrative Code, ODM's administrative agency shall
determine if the individual meets all medicaid financial eligibility
requirements required by that rule and ODA's designee shall determine if
the individual meets all non-financial eligibility required by that rule. An
individual may initially contact either ODM's administrative agency or
ODA's designee to begin the enrollment process. The two agencies shall
coordinate processing the request for enrollment into the medicaid-funded
component of the assisted living program:
(1) ODM's
administrative agency: An individual who makes initial contact with ODM's
administrative agency, shall apply for medicaid (unless already enrolled in
medicaid) and for the medicaid-funded component of the assisted living program
with the assistance of ODM's administrative agency. ODM's
administrative agency shall determine if the individual meets all financial
eligibility requirements and shall notify ODA's designee of the
individual's application. In response, ODA's designee shall initiate
contact with the individual to conduct an assessment to determine if the
individual meets all non-financial eligibility requirements. ODA's
designee may conduct the assessment by telephone, video conference, or in
person.
(2) ODA's
designee:
(a) An individual who makes initial contact with ODA's
designee shall apply for medicaid (unless already enrolled in medicaid) and for
the medicaid-funded component of the assisted living program with the
assistance of ODA's designee. ODA's designee shall conduct an
assessment to determine if the individual meets all non-financial eligibility
requirements. ODA's designee may conduct the assessment by telephone,
video conference, or in person.
(b) After the individual applies for the medicaid-funded
component of the assisted living program, ODA or its designee shall notify the
individual of the existence of the state-funded component of the assisted
living program in Chapter 173-51 of the Administrative Code and offer the
individual an opportunity to apply for enrollment in the state-funded component
of the program.
(B) If determined ineligible: If
ODM's administrative agency or ODA's designee determines the
individual does not meet all eligibility requirements for the program under
rule 5160-33-03 of the Administrative Code, ODA's designee shall not
enroll the individual in the program.
(1) ODM's
administrative agency: If ODM's administrative agency determines the
individual does not meet all financial eligibility requirements, it shall
notify ODA's designee and send the individual a notice of denial and
hearing rights under section 5101.35 of the Revised Code and division 5101:6 of
the Administrative Code.
(2) ODA's designee:
If ODA's designee determines the individual does not meet all
non-financial eligibility requirements, it shall notify ODM's
administrative agency and, in turn, ODM's administrative agency shall send
the individual a notice of denial and hearing rights under section 5101.35 of
the Revised Code and division 5101:6 of the Administrative Code.
(C) If determined eligible: If ODM's
administrative agency or ODA's designee determines the individual meets
all eligibility requirements for the medicaid-funded component of the assisted
living program under rule 5160-33-03 of the Administrative Code, ODA's
designee shall calculate the individual's medicaid waiver program
enrollment date according to paragraph (C)(1) of this rule and enroll the
individual into the program according to paragraph (C)(2) or (C)(3) of this
rule.
(1) Medicaid waiver
program enrollment date:
(a) According to paragraph (D)(1)(c) of rule 5160:1-2-03 of the
Administrative Code, ODA's designee shall establish the individual's
medicaid waiver program enrollment date.
(b) ODA's designee shall establish the individual's
medicaid waiver program enrollment date as the latest date that all the
following requirements are met:
(i) The individual's
basic medicaid effective date.
(ii) The date the
individual meets all level of care requirements to participate in the medicaid
waiver program.
(iii) The date the
individual meets all medicaid waiver program requirements listed in rule
5160-33-03 of the Administrative Code.
(iv) The date ODA's
designee approves the individual's person-centered services plan, which
includes at least one medicaid waiver service.
(v) The date the
individual began residing in an ODA-certified provider's RCF in one of the
following:
(a) A resident unit that
complies with rule 173-39-02.16 of the Administrative Code.
(b) A resident unit that
does not comply with rule 173-39-02.16 of the Administrative Code (a
non-compliant resident unit) if all of the following requirements are
met:
(i) The non-compliant
resident unit in which the individual lives includes a bathroom with a toilet,
a sink, and a shower/bathtub, all of which are in working order.
(ii) The provider has a
plan to succeed at one of the following before the deadline in paragraph
(C)(1)(b)(v)(b)(vi) of this rule:
(A) Bringing the
non-compliant resident unit in which the individual lives into compliance with
rule 173-39-02.16 of the Administrative Code and allow the individual to remain
in the resident unit once it is compliant.
(B) Bringing another
non-compliant resident unit into compliance with rule 173-39-02.16 of the
Administrative Code and allow the individual to transfer to that resident unit
once it is compliant.
(C) Transferring the
individual to a resident unit that complies with rule 173-39-02.16 of the
Administrative Code.
(iii) The provider
notifies the individual of both its plan under paragraph (C)(1)(b)(v)(b)(ii) of
this rule and the risks to the individual if the provider's plan does not
succeed before the deadline in paragraph (C)(1)(b)(v)(b)(vi) of this
rule.
(iv) The individual
agrees, in writing, to cooperate with the provider's plan under paragraph
(C)(1)(b)(v)(b)(ii) of this rule.
(v) The provider notifies the individual of its plan to bring the
resident unit into compliance with rule 173-39-02.16 of the Administrative Code
and the risks to the individual if the provider does not bring the resident
unit into compliance with rule 173-39-02.16 of the Administrative Code before
ODA's deadline in paragraph (C)(1)(b)(v)(b)(v) of this rule.
(vi) One of the following occurs no later than one hundred eighty
days after the date the individual began residing in the resident unit (or, if
the individual applied for the assisted living program after the individual
began residing in the resident unit, the date the latest of the dates in
paragraph (C)(1)(b)(ii), (C)(1)(b)(iii), or (C)(1)(b)(iv) of this rule), unless
ODA gives the provider an extended period of time to bring the resident unit
into compliance with rule 173-39-02.16 of the Administrative Code, which ODA
may do in thirty-day increments:
(A) ODA determines that
the resident unit in which the individual lives complies with rule 173-39-02.16
of the Administrative Code.
(B) The provider
transfers the resident to another resident unit in the RCF that complies with
rule 173-39-02.16 of the Administrative Code.
(c) The medicaid-funded component of the assisted living program
shall not pay for any service provided to an individual before ODA's
designee establishes the medicaid waiver program enrollment date according to
paragraph (C)(1)(b) of this rule.
(d) The individual's medicaid waiver program enrollment date
for the medicaid-funded component of the assisted living program may differ
from the basic medicaid effective date.
(2) Available slot: If a
waiver slot in the medicaid-funded component of the assisted living program is
available, and if ODA's designee has established the individual's
medicaid waiver program enrollment date, ODA's designee shall enroll the
individual into the program, if the individual continues to meet the
eligibility requirements for the program and continues to want to enroll into
the program. ODA's designee shall not place the individual on the unified
waiting list.
(3) No available slot: If
a waiver slot is not available in the medicaid-funded component of the assisted
living program, ODA's designee may enroll the eligible individual when a
waiver slot does become available by one of two means: the unified waiting list
or the home-first component of the medicaid-funded component of the assisted
living program:
(a) Unified waiting list: ODA's designee shall place the
individual on the unified waiting list according to rule 173-44-04 of the
Administrative Code, unless the individual qualifies for the home first
component of the medicaid-funded component of the assisted living program, as
addressed in paragraph (C)(3)(b) of this rule.
(b) Home first: If an individual meets all requirements for the
home first component of the assisted living program in section 173.542 of the
Revised Code, ODA's designee shall enroll the individual before enrolling
any individual from the unified waiting list.
(D) Reassessment: ODA's designee
shall reassess each individual enrolled into the medicaid-funded component of
the assisted living program no less often than one time each year after the
date the individual enrolled into the program. After ODA's designee
conducts each reassessment, if the individual continues to qualify for the
medicaid-funded component of the program, the individual shall decide if he or
she wishes to remain in the program. If the individual wishes to remain, the
individual shall sign form ODA1044 as a condition of continued enrollment.
ODA's designee may collect the individual's handwritten or electronic
signature on the form on a date later than the date the individual agrees to
continue in the program, but no later than the next reassessment of the
individual.
(E) An authorized representative may
represent an individual in the enrollment and reassessment
processes.
(F) Definitions for this
rule:
(1) "Basic medicaid
effective date" means the date an individual becomes eligible to receive
services under the medicaid state plan. Rule 5160:1-2-03 of the Administrative
Code establishes the basic medicaid effective date.
(2) "Form
ODA1044" means form ODA1044, "Annual Enrollment Agreement"
(March 2014). ODA publishes the form on www.aging.ohio.gov. It is available to
the general public at no cost.
