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Rule 5123-9-01 | Home and community-based services waivers - enrollment, denial of enrollment, disenrollment, and reenrollment.
Effective:
November 19, 2020
(A) Purpose This rule establishes procedures for the
enrollment, denial of enrollment, disenrollment, and reenrollment of
individuals in home and community-based services waivers administered by the
Ohio department of developmental disabilities. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Alternative
services" means the various programs, services, and supports, regardless
of funding source, other than home and community-based services, that exist as
part of the developmental disabilities service system and other service systems
including, but not limited to: (a) Services provided directly by a county
board; (b) Services funded by a county board and delivered by
other providers; (c) Services provided and funded outside the developmental
disabilities service system; and (d) Services provided at the state level. (2) "County
board" means a county board of developmental disabilities or a person or
government entity, including a council of governments, with which a county
board has contracted for assistance with its medicaid local administrative
authority pursuant to section 5126.055 of the Revised Code. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Home and
community-based services" means medicaid-funded home and community-based
services provided under a medicaid component that the department administers
pursuant to section 5166.21 of the Revised Code. (5) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (6) "Intermediate
care facility for individuals with intellectual disabilities" has the same
meaning as in section 5124.01 of the Revised Code. (7) "Natural
supports" means the personal associations and relationships typically
developed in the community that enhance the quality of life for individuals.
Natural supports may include family members, friends, neighbors, and others in
the community or organizations that serve the general public who provide
voluntary support to help an individual achieve agreed upon outcomes through
the individual service plan development process. (8) "Prior
authorization" has the same meaning as in rule 5123-9-07 of the
Administrative Code. (9) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
redetermination date. (10) "Waiver
year" means the twelve-month period that begins on the date the waiver
takes effect and the twelve-month period following each subsequent anniversary
date of the waiver. (C) Requests for home and community-based
services When an individual who is not yet enrolled in
medicaid requests home and community-based services, the county board shall
submit or assist the individual with submission of Ohio department of medicaid
form 02399, "Request for Medicaid Home and Community-Based Services
Waiver" (revised August 2018), to the county department of job and family
services. The department shall accept notification of requests for home and
community-based services waiver enrollment that are referred by the county
department of job and family services. The department shall notify the
appropriate county board when it receives notification of a request from the
county department of job and family services. (D) Eligibility criteria for enrollment
in home and community-based services waivers To be eligible for enrollment in a home and
community-based services waiver administered by the department an individual
shall: (1) Be eligible for Ohio
medicaid in accordance with rule 5160:1-2-03 of the Administrative
Code; (2) Have a developmental
disabilities level of care in accordance with rule 5123-8-01 of the
Administrative Code; (3) Choose enrollment in
a home and community-based services waiver in lieu of an opportunity to reside
in an intermediate care facility for individuals with intellectual
disabilities; (4) Require, at a
minimum, one waiver service; (5) Participate in the
development of his or her individual service plan; and (6) Be able to have his
or her health and welfare needs met through waiver services at or below the
federally-approved cost limitation, and through a combination of informal and
formal supports including, but not limited to, waiver services, medicaid state
plan services, private health insurance plan benefits, non-waiver services,
and/or natural supports. (E) Responsibilities for
enrollment (1) A county board shall
enroll individuals in home and community-based services waivers in accordance
with rule 5123-9-04 of the Administrative Code. (2) When a county board
intends to enroll an individual in a home and community-based services waiver,
the county board shall request the department to authorize waiver capacity for
the individual to be enrolled. (3) Upon authorization by
the department to enroll an individual in a home and community-based services
waiver: (a) The county board shall complete the required
assessments of the individual in accordance with rule 5123-8-01 of the
Administrative Code and any other assessments specific to the waiver in which
the individual is seeking enrollment. (b) Within ninety calendar days of the department's
authorization to enroll an individual, the county board shall forward to the
department all necessary enrollment information, including a request for
developmental disabilities level of care determination with respect to the
individual. (c) The department shall determine whether the individual
meets the criteria for a developmental disabilities level of care in accordance
with rule 5123-8-01 of the Administrative Code. An individual determined to
have a developmental disabilities level of care who meets all other eligibility
criteria for home and community-based services waivers shall be eligible for
home and community-based services waiver enrollment. (d) The department shall send notification to the
individual upon completion of the level of care determination in accordance
with paragraph (J) of this rule. (e) The county board shall: (i) Submit a payment
authorization for waiver services to the department no later than the first
date of any planned service within an individual's waiver eligibility span
except when: (a) A delay is caused by failure of an entity other than
the county board to update an individual's record in the Ohio benefits
system, in which case, no later than fourteen calendar days after the
individual's enrollment in the waiver is reflected in the
department's information system; or (b) The individual funding level of an individual to be
enrolled in the individual options waiver exceeds the maximum value of the
funding range, in which case, no later than fourteen calendar days after prior
authorization is approved by the department. (ii) Submit an updated
payment authorization for waiver services to the department no later than
fourteen calendar days after authorizing a change to an individual's
services or revising an individual service plan, whichever is earlier. If
submission of the updated payment authorization for waiver services is rejected
by the department's information system due to discrepancies between
provider billing and service authorization, the payment authorization for
waiver services is to be submitted no later than fourteen calendar days after
the discrepancy has been successfully resolved. (iii) Correct an error to
a payment authorization for waiver services no later than fourteen calendar
days after identification of the error. (F) Continued enrollment and
disenrollment (1) The county board
shall submit a developmental disabilities level of care redetermination at
least annually to the department in accordance with rule 5123-8-01 of the
Administrative Code. (2) Subsequent to initial
enrollment of an individual in a home and community-based services waiver, the
county board shall evaluate the current needs and circumstances of the
individual in relationship to the services and activities described in the
individual's most recent individual service plan and recommend appropriate
action to the department, which may include a recommendation to disenroll the
individual from the home and community-based services waiver,
when: (a) There is a significant change of condition as defined
in rule 5123-8-01 of the Administrative Code; (b) The individual is admitted as an inpatient to a
hospital, nursing facility, intermediate care facility for individuals with
intellectual disabilities, or is incarcerated if such admission or
incarceration is reasonably anticipated to exceed ninety calendar
days; (c) The individual fails or refuses to use services in
accordance with his or her individual service plan; (d) The individual interferes with or otherwise refuses to
cooperate with the county board and such interference or refusal to cooperate
renders the county board unable to perform its medicaid local administrative
authority pursuant to section 5126.055 of the Revised Code; (e) The individual ceases to meet the eligibility criteria
for enrollment in the home and community-based services waiver; (f) The individual's health and welfare cannot be
assured in accordance with the requirements of paragraph (D)(6) of this rule;
or (g) The individual requests to be disenrolled from the home
and community-based services waiver. (3) When the cost of
waiver services for the individual exceeds the amount authorized by the centers
for medicare and medicaid services for the waiver in which the individual is
enrolled, the county board shall evaluate the individual, consider the measures
set forth in paragraphs (F)(3)(a) to (F)(3)(e) of this rule, and submit a
recommendation to the department regarding whether or not the individual can
remain enrolled in the waiver and have his or her health and welfare assured by
one or more of the following measures: (a) Adding more available natural supports; (b) Accessing available non-waiver services, other than
natural supports; (c) Accessing additional medicaid state plan
services; (d) Accessing private health insurance plan benefits;
and/or (e) Sharing supports and services, such as natural supports
and non-waiver services, by collaborating with other systems, organizations,
agencies, and people with and without disabilities. (4) Upon receipt of a
recommendation and necessary information from a county board in accordance with
paragraph (F)(2) or (F)(3) of this rule, the department shall within thirty
calendar days, make a determination as to the individual's continued
enrollment in the waiver, inform the county board accordingly, and take
whatever additional actions may be required by law. If the department
determines that the individual cannot continue to be enrolled in the waiver and
have his or her health and welfare assured by one or more of the measures set
forth in paragraph (F)(3) of this rule, the department shall propose to
disenroll the individual from the waiver and provide notice in accordance with
paragraph (J) of this rule. (5) When the department
proposes to disenroll an individual in accordance with paragraph (F)(2) or
(F)(3) of this rule, the county board shall: (a) Offer the individual the opportunity to apply for an
alternative home and community-based services waiver for which the individual
is eligible that may more adequately address the needs of the individual, to
the extent that such waiver openings exist; and (b) Assist the individual in identifying and obtaining
alternative services that are available and may more adequately address the
needs of the individual. (6) In the event that
options set forth in paragraphs (F)(5)(a) and (F)(5)(b) of this rule do not
meet the individual's needs, the county board may offer the individual an
opportunity to reside in an intermediate care facility for individuals with
intellectual disabilities. (G) Suspension of medicaid waiver
payment (1) In the event an
individual is admitted as an inpatient to a hospital, nursing facility, or
intermediate care facility for individuals with intellectual disabilities or is
incarcerated, the county board shall notify the department. (a) Upon receipt of notification, the department shall
suspend medicaid waiver payments for the individual for a period not to exceed
ninety calendar days during the time the individual is admitted as an inpatient
or is incarcerated. (b) When the individual continues to remain admitted as an
inpatient or incarcerated, the county board shall, prior to the ninety-first
calendar day after the date of admission as an inpatient or incarceration,
submit a recommendation to the department to disenroll the individual from the
home and community-based services waiver. (2) Upon receipt of a
recommendation and necessary information from a county board in accordance with
paragraph (G)(1)(b) of this rule, the department shall within thirty calendar
days, make a determination as to the individual's continued enrollment in
the waiver, inform the county board accordingly, and take whatever additional
actions may be required by law, which may include, but are not limited to,
proposing to disenroll the individual from the waiver and providing notice in
accordance with paragraph (J) of this rule. If the department determines to
disenroll an individual based on a recommendation by the county board, the
county board may request reenrollment when the individual is discharged from
the hospital, nursing facility, or immediate care facility for individuals with
intellectual disabilities or is no longer incarcerated. (H) Reenrollment (1) When an individual
who has been disenrolled from a home and community-based services waiver
requests reenrollment within the same waiver year, the individual shall be
reenrolled in that waiver provided: (a) The circumstances leading to the individual's
disenrollment have been resolved; and (b) The individual meets the eligibility criteria for
enrollment in home and community-based services waivers in accordance with
paragraph (D) of this rule. (2) When an individual
who has been disenrolled from a home and community-based services waiver
requests reenrollment in a subsequent waiver year, the individual may be
reenrolled in a waiver: (a) Provided the individual meets the eligibility criteria
for enrollment in home and community-based services waivers in accordance with
paragraph (D) of this rule; and (b) In accordance with the process set forth in paragraph
(E) of this rule. (I) Waiver capacity In accordance with section 5126.054 of the
Revised Code, a county board shall annually inform the department of its waiver
capacity request. Based on the county board's request, the department may
authorize enrollment when the number of filled waivers for each year is less
than the number of waivers approved by the centers for medicare and medicaid
services for that year. The department shall provide notice of waiver capacity
to county boards. Within ninety calendar days from receipt of such notice from
the department, the county board shall submit the assessments and other
necessary enrollment information pursuant to paragraph (E) of this rule. The
county board may request and the department may grant for good cause, an
extension of the deadline referenced in this paragraph. Failure of the county
board to meet the requirements of this paragraph shall result in the department
providing the county board with prior notice of no less than fifteen calendar
days that the authorization to enroll pursuant to this rule is to be
withdrawn. (J) Required notices (1) The department shall
send written notice to an individual and the county board when the individual
is enrolled in a home and community-based services waiver. The notice shall
include the date on which waiver services may be initiated. (2) The department shall
send written notice to an individual and the county board when the individual
is disenrolled from a home and community-based services waiver. The notice
shall be made in accordance with paragraph (J)(3) of this rule. (3) When denial of
enrollment in or disenrollment from a home and community-based services waiver
is proposed, the individual shall receive notice of his or her right to a state
hearing in accordance with section 5160.31 of the Revised Code and rules
implementing that statute. (a) The department shall issue the notice
when: (i) Denial of enrollment
is based on a determination that the individual does not meet the criteria for
a developmental disabilities level of care; or (ii) The department
proposes disenrollment for any reason, including disenrollment based on the
county board's recommendation made in accordance with paragraph (F)(2),
(F)(3), or (G)(1)(b) of this rule. (b) The county board shall issue the notice when the county
board proposes to deny enrollment based on the individual's position on
the waiting list for home and community-based services waivers established in
accordance with rule 5123-9-04 of the Administrative Code. (K) Authority of director to suspend
provisions of this rule During the COVID-19 state of emergency declared
by the governor, the director of the department may suspend the disenrollment
criteria in paragraphs (F)(2)(a), (F)(2)(c), (F)(2)(d), (F)(2)(e), and/or
(F)(2)(f) of this rule.
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Rule 5123-9-02 | Home and community-based services waivers - ensuring the suitability of services and service settings.
Effective:
December 1, 2022
(A) Purpose This rule establishes standards to ensure that
home and community-based services waivers administered by the Ohio department
of developmental disabilities maximize opportunities for enrolled individuals
to access the benefits of community living and receive services in the most
integrated setting. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (5) "Immediate
family member" means a spouse, parent or stepparent, child or stepchild,
sibling or stepsibling, grandparent, or grandchild. (6) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (7) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (8) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (9) "Individual-specific expenses" means standard
monthly costs other than rent (e.g., household goods and supplies, food, minor
equipment, and medical equipment) that are not reimbursable through medicaid,
that are paid by the individual to a residential facility or provider of shared
living, and that have been identified as needed and requested by the individual
to be provided by the residential facility or provider of shared
living. (10) "Intermediate
care facility for individuals with intellectual disabilities" has the same
meaning as in section 5124.01 of the Revised Code. (11) "Landlord"
means the owner, lessor, or agent of the owner contracted by the owner to
manage the premises or to receive rent or room costs in accordance with a lease
or a residency agreement meeting the requirements set forth in paragraph (F) of
this rule. (12) "Lease"
means a written rental agreement meeting the requirements for rental agreements
set forth in Chapter 5321. of the Revised Code. (13) "Natural
supports" means the personal associations and relationships typically
developed in the community that enhance the quality of life for individuals.
Natural supports may include family members, friends, neighbors, and others in
the community or organizations that serve the general public who provide
voluntary support to help an individual achieve agreed upon outcomes through
the individual service plan development process. (14) "Provider-controlled residential setting"
means a residence where the landlord is: (a) An entity that is owned in whole or in part by the
individual's independent provider; (b) An immediate family member of the individual's
independent provider; (c) An immediate family member of an owner or a management
employee of the individual's agency provider; (d) Affiliated with the individual's agency provider,
meaning the landlord: (i) Employs a person who
is also an owner or a management employee of the agency provider;
or (ii) Has, serving as a
member of its board, a person who is also serving as a member of the board of
the agency provider; (e) An entity that is owned in whole or in part by an
owner, a management employee, or an immediate family member of the
individual's agency provider; or (f) An owner or a management employee of the
individual's agency provider. (15) "Related
to" means the caregiver is, by blood, marriage, or adoption, the
individual's: (a) Parent or stepparent; (b) Sibling or stepsibling; (c) Grandparent; (d) Aunt, uncle, nephew, or niece; (e) Cousin; or (f) Child or stepchild. (16) "Rent"
means the standard charge to the individual to cover the individual's use
of the property, living space, and structure, and where applicable, the
appliances, utilities, and furniture. (17) "Residency
agreement" means a written agreement between an individual and a
residential facility or provider of shared living which establishes or modifies
the terms, conditions, rules, or any other provisions concerning the use and
occupancy of a residence. (18) "Residential
facility" means a residential facility licensed by the department in
accordance with section 5123.19 of the Revised Code other than an intermediate
care facility for individuals with intellectual disabilities. (19) "Roommate"
means a person with whom one shares a bedroom. (20) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123:2-5-02 of the Administrative Code. (21) "Shared
living" has the same meaning as in rule 5123-9-33 of the Administrative
Code. (C) Home and community-based
services (1) The purpose of home
and community-based services is to support full community participation and
achievement of individual-specific outcomes. An individual receiving home and
community-based services shall have opportunities to access age-appropriate
activities, engage in meaningful employment and non-work activities, and pursue
activities with persons of the individual's choosing and in settings not
created exclusively for individuals with disabilities. (2) The service and
support administrator shall provide the individual with a description of all
services and service setting options available through the waiver in which the
individual is enrolled. Each individual shall be afforded the opportunity to
choose among services or a combination of services and settings that promote
the individual's autonomy and minimize the individual's dependency on
paid support staff. Services and service setting options (such as
technology-based supports, intermittent or drop-in staffing, shared living, and
integrated employment services) shall be considered to enable the individual to
live and work in settings which promote access to and participation in the
broader community. (3) The individual shall
receive home and community-based services that: (a) Are appropriate to meet the individual's assessed
needs and desired outcomes identified in the individual service
plan; (b) Supplement and not supplant existing natural
supports; (c) Support the individual in a cost-effective manner and
in the least restrictive manner available; and (d) Are not otherwise available through other resources,
including: (i) Unpaid
supports; (ii) Private
insurance; (iii) Community
resources; (iv) Special education or
related services as defined in section 602 of the Individuals with Disabilities
Education Improvement Act of 2004, 20 U.S.C. 1401, as in effect on the
effective date of this rule; (v) Vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this
rule; (vi) Medicare;
or (vii) The medicaid state
plan. (4) Home and
community-based services funds shall not be used to provide modifications to
the physical structure of a residential facility unless the modifications are
necessary to meet the needs of an established resident of the residential
facility or the modifications are portable and clearly identified as the
property of the individual. (5) Except for the
provision of short-term respite services as approved by the centers for
medicare and medicaid services, home and community-based services shall not be
provided in: (a) Hospitals; (b) Institutions for mental diseases; (c) Intermediate care facilities for individuals with
intellectual disabilities; (d) Nursing facilities; or (e) Other locations that have been determined by the
secretary of the United States department of health and human services or the
department as having the qualities of an institution and the effect of
isolating individuals from the broader community. (6) Absent a
determination by the centers for medicare and medicaid services that the
settings are suitable, home and community-based services shall not be provided
in: (a) Settings located in a building that is a
publicly-operated or privately-operated facility that also provides inpatient
institutional treatment; or (b) Settings located in a building on the grounds of or
immediately adjacent to a publicly-operated facility that provides inpatient
institutional treatment. (D) Requirements for providers of home
and community-based services A provider of home and community-based services
shall: (1) Meet the requirements
set forth in Chapter 5123-9 of the Administrative Code for the services
delivered; and (2) Deliver services in
accordance with each individual's choices, preferences, and needs and in a
manner that supports each individual's full participation in the community
as identified in the individual service plan. (E) Requirements for individuals enrolled
in home and community-based services waivers An individual enrolled in a home and
community-based services waiver shall: (1) Communicate, as
applicable, to the independent provider and/or assigned staff of the agency
provider and the agency provider management staff, personal preferences about
the duties, tasks, and procedures to be performed; (2) Communicate to the
service and support administrator any significant change that may affect the
provision of services or result in a need for more or fewer hours of service or
different types of service; (3) Use services in
accordance with the individual service plan; and (4) Cooperate with the
county board in the county board's performance of medicaid local
administrative authority in accordance with section 5126.055 of the Revised
Code. (F) Requirement for a lease or residency
agreement (1) A lease consented to
by both the individual and the landlord is required when an individual lives in
a provider-controlled residential setting. The lease shall
include: (a) A statement that the residence is a provider-controlled
residential setting and an explanation of the relationship between the landlord
and the provider of home and community-based services. (b) A statement that the individual may choose any provider
to deliver home and community-based services. (2) A residency agreement
consented to by both the individual and the landlord is required when an
individual lives in a residential facility or when an individual receives
shared living from a caregiver who is not related to the individual. The
residency agreement shall include: (a) Name and contact information of the
landlord. (b) A statement that the residence is, as applicable, a
residential facility or a shared living setting. (c) An explanation of the relationship between the landlord
and the provider of home and community-based services and a statement regarding
whether or not the individual may choose a provider other than the residential
facility or shared living provider to deliver home and community-based
services. (d) A statement that the landlord: (i) Is responsible for
maintaining in good working order all electrical, plumbing, sanitary, heating,
ventilating, and air conditioning systems; (ii) Shall ensure
barrier-free ingress and egress to and from the residence by individuals
residing in the residence; (iii) Is responsible for
keeping the residence in a safe condition that meets local health and safety
codes; and (iv) Has a right to
reasonable access to the residence in order to complete the terms of the
residency agreement. (e) Unless otherwise specified in the individual service
plan and implemented in accordance with rule 5123-2-06 of the Administrative
Code, a statement that the individual: (i) Has a right to select
the individual's roommates; (ii) Has a right to
privacy and security including locks and keys to the individual's
bedroom; (iii) Has a right to
decorate the individual's bedroom; (iv) Has a right to have
visitors of the individual's choosing at any time; (v) Has the freedom and
support to control the individual's schedule and activities;
and (vi) Has a right to
access food at any time. (f) A statement that the individual is responsible for
timely monthly payment of the rent or the individual's share of the rent,
as applicable, to the landlord. When determined to be appropriate by the
individual with the support of the team, the residency agreement may designate
a person or responsible party to ensure timely payment to the
landlord. (g) The rent amount which: (i) Shall be reasonable
and comparable to community standards; (ii) Shall be determined
based upon the accommodations provided and not upon an individual's
assets, resources, or ability to pay; (iii) In a residential
facility, shall include the cost of providing furnishings, equipment, and
supplies required by Chapter 5123-3 of the Administrative Code;
and (iv) Shall not include
items that are reimbursable under the medicaid program. (h) Individual-specific expenses: (i) Which reflect only
items that are available exclusively from the landlord and determined to be
needed by the individual with the support of the individual's
team; (ii) Which reflect only
items that the individual has been unable to access or utilize through other
available resources; and (iii) The cost of which
may be shared equally when two or more residents agree to share use of the
item. (i) A statement that the individual has a right to
terminate the residency agreement: (i) Without cause upon
thirty-day advance written notice to the landlord unless the individual and the
landlord mutually agree in writing to an alternative plan; or (ii) With cause upon
five-day advance written notice to the landlord if the landlord has breached an
obligation or failed to satisfy required conditions under the residency
agreement. (j) In a shared living setting, a statement that the
landlord has a right to terminate the residency agreement: (i) Without cause upon
thirty-day advance written notice to the individual unless the individual and
the landlord mutually agree in writing to an alternative plan; or (ii) With cause upon
five-day advance written notice to the individual if the individual has
breached an obligation or failed to satisfy required conditions under the
residency agreement or chooses to leave or otherwise vacates the residence
(e.g., upon incarceration). (k) In a residential facility, a statement that the
residential facility shall terminate services in accordance with rule 5123-3-05
of the Administrative Code.
Last updated December 1, 2022 at 10:47 AM
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Rule 5123-9-04 | Home and community-based services waivers - waiting list.
Effective:
November 19, 2018
(A) Purpose This rule sets forth requirements for the waiting
list established pursuant to section 5126.042 of the Revised Code when a county
board determines that available resources are insufficient to enroll
individuals who are assessed to need and who choose home and community-based
services in department-administered home and community-based services
waivers. (B) Definitions (1) "Adult"
means an individual who is eighteen years of age or older. (2) "Alternative services"
means the various programs, funding mechanisms, services, and supports, other
than home and community-based services, that exist as part of the developmental
disabilities service system and other service systems. "Alternative
services" includes, but is not limited to, services offered through
Ohio's medicaid state plan such as home health services and services
available at an intermediate care facility for individuals with intellectual
disabilities. (3) "Community-based
alternative services" means alternative services in a setting other than a
hospital, an intermediate care facility for individuals with intellectual
disabilities, or a nursing facility. (4) "County board" means a
county board of developmental disabilities. (5) "Current need" means an
unmet need for home and community-based services within twelve months, as
determined by a county board based upon assessment of the individual using the
waiting list assessment tool. Situations that give rise to current need
include: (a) An individual is likely to be at risk of substantial harm due
to: (i) The primary
caregiver's declining or chronic physical or psychiatric condition that
significantly limits his or her ability to care for the
individual; (ii) Insufficient
availability of caregivers to provide necessary supports to the individual;
or (iii) The
individual's declining skills resulting from a lack of
supports. (b) An individual has an ongoing need for limited or intermittent
supports to address behavioral, physical, or medical needs, in order to sustain
existing caregivers and maintain the viability of the individual's current
living arrangement. (c) An individual has an ongoing need for continuous supports to
address significant behavioral, physical, or medical needs. (d) An individual is aging out of or being emancipated from
children's services and has needs that cannot be addressed through
community-based alternative services. (e) An individual requires waiver funding for adult day services
or employment-related supports that are not otherwise available as vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this rule, or as
special education or related services as those terms are defined in section 602
of the Individuals with Disabilities Education Improvement Act of 2004, 20
U.S.C. 1401, as in effect on the effective date of this rule. (f) An individual is living in an intermediate care
facility for individuals with intellectual disabilities or a nursing facility
and has a viable discharge plan. (6) "Date of request" means the
earliest date and time of any written or otherwise documented request for home
and community-based services made prior to September 1, 2018. (7) "Department" means the Ohio
department of developmental disabilities. (8) "Home and community-based
services" has the same meaning as in section 5123.01 of the Revised
Code. (9) "Immediate need" means a
situation that creates a risk of substantial harm to an individual, caregiver,
or another person if action is not taken within thirty calendar days to reduce
the risk. Situations that give rise to immediate need include: (a) A resident of an intermediate care facility for individuals
with intellectual disabilities has received notice of termination of services
in accordance with rule 5123:2-3-05 of the Administrative Code. (b) A resident of a nursing facility has received thirty-day
notice of intent to discharge in accordance with Chapter 5160-3 of the
Administrative Code. (c) A resident of a nursing facility has received an adverse
determination in accordance with rule 5123:2-14-01 of the Administrative
Code. (d) An adult is losing his or her primary caregiver due to the
primary caregiver's declining or chronic physical or psychiatric condition
or due to other unforeseen circumstances (such as military deployment or
incarceration) that significantly limit the primary caregiver's ability to
care for the individual when: (i) Impending loss of the
caregiver creates a risk of substantial harm to the individual;
and (ii) There are no other
caregivers available to provide necessary supports to the
individual. (e) An adult or child is engaging in documented behavior that
creates a risk of substantial harm to the individual, caregiver, or another
person. (f) There is impending risk of substantial harm to the individual
or caregiver as a result of: (i) The individual's
significant care needs (i.e., bathing, lifting, high-demand, or
twenty-four-hour care); or (ii) The
individual's significant or life-threatening medical needs. (g) An adult has been subjected to abuse, neglect, or
exploitation and requires additional supports to reduce a risk of substantial
harm to the individual. (10) Individual" means a person with
a developmental disability. (11) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (12) "Locally-funded home and
community-based services waiver" means the county board pays the entire
nonfederal share of medicaid expenditures in accordance with sections 5126.059
and 5126.0510 of the Revised Code. (13) "Nursing facility" has the
same meaning as in section 5165.01 of the Revised Code. (14) "Service and support
administration" means the duties performed by a service and support
administrator pursuant to section 5126.15 of the Revised Code. (15) "State-funded home and
community-based services waiver" means the department pays, in whole or in
part, the nonfederal share of medicaid expenditures associated with an
individual's enrollment in the waiver. (16) "Status date" means the
date on which the individual is determined to have a current need based on
completion of an assessment of the individual using the waiting list assessment
tool. (17) "Transitional list of
individuals waiting for home and community-based services" means the list
maintained in the department's web-based individual data system which
shall include the name and date of request for each individual on a list of
individuals waiting for home and community-based services on August 31, 2018
established in accordance with rule 5123:2-1-08 of the Administrative Code as
that rule existed on August 31, 2018. (18) "Waiting list assessment
tool" means the Ohio assessment for immediate need and current need
contained in the appendix to this rule, which shall be used for purposes of
making a determination of an individual's eligibility to be added to the
waiting list for home and community-based services defined in paragraph (B)(20)
of this rule and administered by persons who successfully complete training
developed by the department. (19) "Waiting list date" means,
as applicable, either: (a) The date of request for an individual whose name is included
on the transitional list of individuals waiting for home and community-based
services; or (b) The earliest status date for an individual whose name is not
included on the transitional list of individuals waiting for home and
community-based services. (20) "Waiting list for home and
community-based services" means the list established by county boards and
maintained in the department's web-based waiting list management system
which shall include the name, status date, date of request (as applicable),
waiting list date, and the criteria for current need by which an individual is
eligible based on administration of the waiting list assessment tool, for each
individual determined to have a current need on or after September 1,
2018. (C) Planning for locally-funded home and
community-based services waivers A county board shall, in conjunction with
development of its plan described in section 5126.054 of the Revised Code and
its strategic plan described in rule 5123-4-01 of the Administrative Code,
identify how many individuals the county board plans to enroll in each type of
locally-funded home and community-based services waiver during each calendar
year, based on projected funds available to the county board to pay the
nonfederal share of medicaid expenditures and the assessed needs of the
county's residents on the waiting list for home and community-based
services. This information shall be made available to any interested person
upon request. (D) Waiting list for home and
community-based services (1) An individual or the
individual's guardian, as applicable, who thinks the individual has an
immediate need or a current need may contact the county board in the
individual's county of residence to request an assessment of the
individual using the waiting list assessment tool. The county board shall
initiate an assessment of the individual using the waiting list assessment tool
within thirty calendar days. An individual or the individual's guardian,
as applicable, shall have access to the individual's completed waiting
list assessment tool maintained in the department's web-based waiting list
management system and upon request, shall be provided a copy by the county
board. (2) The county board
shall place an individual's name on the waiting list for home and
community-based services when, based on assessment of the individual using the
waiting list assessment tool, the individual: (a) Has been determined to have a condition that is: (i) Attributable to a
mental or physical impairment or combination of mental and physical
impairments, other than an impairment caused solely by mental
illness; (ii) Manifested before
the individual is age twenty-two; and (iii) Likely to continue
indefinitely; and (b) Has a current need which cannot be met by community-based
alternative services in the county where the individual resides (including a
situation in which an individual has a current need despite the
individual's enrollment in a home and community-based services
waiver). (3) The county board
shall not place an individual's name on the waiting list for home and
community-based services when the individual: (a) Is a child who is subject to a determination under section
121.38 of the Revised Code and requires home and community-based services;
or (b) Has an immediate need, in which case the county board shall
take action necessary to ensure the immediate need is met. The county board
shall provide the individual or the individual's guardian, as applicable,
with the option of having the individual's needs met in an intermediate
care facility for individuals with intellectual disabilities or through
community-based alternative services. Once an individual or individual's
guardian chooses the setting in which he or she prefers to receive services,
the county board shall take action to ensure the individual's immediate
need is met, including by enrollment in a home and community-based services
waiver, if necessary. Such action may also include assisting the individual or
the individual's guardian, as applicable, in identifying and accessing
alternative services that are available to meet the individual's
needs. (4) When a county board
places an individual's name on the waiting list for home and
community-based services, the county board shall: (a) Record, in the department's web-based waiting list
management system: (i) The individual's
status date; and (ii) For an individual
included in the transitional list of individuals waiting for home and
community-based services defined in paragraph (B)(17) of this rule, the
individual's date of request. (b) Notify the individual or the individual's guardian, as
applicable, that the individual's name has been placed on the waiting list
for home and community-based services. (c) Provide contact information to the individual or the
individual's guardian, as applicable, for a person at the county board who
can assist in identifying and accessing alternative services that address, to
the extent possible, the individual's needs. (5) Annually, a county
board shall: (a) Review the waiting list assessment tool and service needs of
each individual whose name is included on the waiting list for home and
community-based services with the individual and the individual's
guardian, as applicable; and (b) Assist the individual or the individual's guardian, as
applicable, in identifying and accessing alternative services. (6) Under any
circumstances, when a county board determines an individual's status has
changed with regard to having an immediate need and/or having a current need or
an individual's status date has changed, the county board shall update the
individual's record in the department's web-based waiting list
management system. (E) Order for enrolling individuals in
locally-funded home and community-based services waivers (1) Individuals shall be
selected for enrollment in locally-funded home and community-based services
waivers in this order: (a) Individuals with immediate need who require waiver funding to
address the immediate need. (b) Individuals who have met multiple criteria for current need
for twelve or more consecutive months and who were not offered enrollment in a
home and community-based services waiver in the prior calendar year. When two
or more individuals meet the same number of criteria for current need, the
individual with the earliest of either the status date or date of request shall
be selected for enrollment. (c) Individuals who have met multiple criteria for current need
for less than twelve consecutive months. When two or more individuals meet the
same number of criteria for current need, the individual with the earliest of
either the status date or date of request shall be selected for
enrollment. (d) Individuals who meet a single criterion for current need.
When two or more individuals meet a single criterion for current need, the
individual with the earliest of either the status date or date of request shall
be selected for enrollment. (2) Individuals with
immediate need and individuals with current need may be enrolled in
locally-funded home and community-based services waivers
concurrently. (3) Meeting the criteria
for immediate need and/or current need does not guarantee enrollment in a
locally-funded home and community-based services waiver within a specific
timeframe. (4) When an individual is
identified as next to be enrolled in a locally-funded home and community-based
services waiver, the county board shall determine the individual's
eligibility for enrollment in a home and community-based services waiver. When
the county board determines an individual is eligible for enrollment in a home
and community-based services waiver, the county board shall determine which
type of locally-funded home and community-based services waiver is sufficient
to meet the individual's needs in the most cost-effective
manner. (F) Order for enrolling individuals in
state-funded home and community-based services waivers (1) The department shall
determine the order for enrolling individuals in state-funded home and
community-based services waivers. (2) Meeting the criteria
for immediate need and/or current need does not guarantee enrollment in a
state-funded home and community-based services waiver within a specific
timeframe. (G) Change in an individual's county
of residence When an individual on the waiting list for home
and community-based services moves from one county to another and the
individual or the individual's guardian, as applicable, notifies the
receiving county board, the receiving county board shall within ninety calendar
days of receiving notice, review the individual's waiting list assessment
tool. (1) When the receiving
county board determines that the individual has a current need which cannot be
met by community-based alternative services in the receiving county (including
a situation in which an individual has a current need despite the
individual's enrollment in a home and community-based services waiver),
the receiving county board shall update the individual's county of
residence in the department's web-based waiting list management system
without changing the status date or date of request assigned by the previous
county board. (2) When the receiving
county board determines that the individual has a current need which can be met
by community-based alternative services in the receiving county, the receiving
county board shall assist the individual or the individual's guardian, as
applicable, in identifying and accessing those services. (H) Removal from waiting list for home
and community-based services A county board shall remove an individual's
name from the waiting list for home and community-based services: (1) When the county board
determines that the individual no longer has a condition described in paragraph
(D)(2)(a) of this rule; (2) When the county board
determines that the individual no longer has a current need; (3) Upon request of the
individual or the individual's guardian, as applicable; (4) Upon enrollment of
the individual in a home and community-based services waiver that meets the
individual's needs; (5) If the individual or
the individual's guardian, as applicable, declines enrollment in a home
and community-based services waiver or community-based alternative services
that are sufficient to meet the individual's needs; (6) If the individual or
the individual's guardian, as applicable, fails to respond to attempts by
the county board to contact the individual or the individual's guardian by
at least two different methods, one of which shall be certified mail to the
last known address of the individual or the individual's guardian, as
applicable; (7) When the county board
determines the individual does not have a developmental disabilities level of
care in accordance with rule 5123:2-8-01 of the Administrative
Code; (8) When the individual
is no longer a resident of Ohio; or (9) Upon the
individual's death. (I) Advancement from transitional list of
individuals waiting for home and community-based services to waiting list for
home and community-based services (1) The department shall
maintain the transitional list of individuals waiting for home and
community-based services as defined in paragraph (B)(17) of this rule until
December 31, 2020. (2) A county board shall
administer the waiting list assessment tool to each individual residing in the
county whose name is included on the transitional list of individuals waiting
for home and community-based services. (a) The county board shall administer the waiting list assessment
tool to each individual residing in the county whose name is included on the
transitional list of individuals waiting for home and community-based services
who receives service and support administration when the individual service
plan is next scheduled for review following September 1, 2018. (b) The county board shall administer the waiting list assessment
tool to each individual residing in the county whose name is included on the
transitional list of individuals waiting for home and community-based services
who does not receive service and support administration no later than December
31, 2020. A county board may request and the department may provide assistance
to identify, locate, contact, or administer the waiting list assessment tool to
individuals residing in the county but unknown to the county
board. (c) There are three possible outcomes of administration of the
waiting list assessment tool: (i) The county board
determines the individual has an immediate need, in which case the individual
shall receive services in accordance with paragraph (D)(3)(b) of this
rule; (ii) The county board
determines the individual has a current need, in which case the county board
shall use community-based alternative services in the county to meet the
individual's needs or if the individual's needs cannot be met by
community-based alternative services in the county, the county board shall add
the individual's name to the waiting list for home and community-based
services; or (iii) The county board
determines the individual has neither an immediate need nor a current
need. (d) Once the waiting list assessment tool has been administered
to an individual whose name is included on the transitional list of individuals
waiting for home and community-based services and a determination made, the
county board shall notify the department and the department shall remove the
individual's name from the transitional list of individuals waiting for
home and community-based services. (3) The county board or
the department shall attempt to contact each individual whose name is included
on the transitional list of individuals waiting for home and community-based
services or the individual's guardian, as applicable, by at least two
different methods, one of which shall be certified mail to the last known
address of the individual or the individual's guardian, as applicable. The
department shall remove an individual's name from the transitional list of
individuals waiting for home and community-based services when the individual
or the individual's guardian, as applicable: (a) Fails to respond to attempts by the county board or the
department to establish contact; or (b) Declines an assessment of the individual using the waiting
list assessment tool. (J) Due process (1) Due process shall be
afforded to an individual aggrieved by an action of a county board related
to: (a) The approval, denial, withholding, reduction, suspension, or
termination of a service funded by the state medicaid program; (b) Placement on, denial of placement on, or removal from the
waiting list for home and community-based services or the transitional list of
individuals waiting for home and community-based services; or (c) A dispute regarding an individual's date of request or
status date. (2) Due process shall be
provided in accordance with section 5160.31 of the Revised Code and Chapters
5101:6-1 to 5101:6-9 of the Administrative Code.
View Appendix
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Rule 5123-9-05 | Home and community-based services waivers - retention payments for direct support professionals.
Effective:
March 23, 2023
(A) Purpose This rule establishes requirements and processes
for retention payments to benefit direct support professionals providing
specific home and community-based services to individuals enrolled in home and
community-based services waivers administered by the Ohio department of
developmental disabilities. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (4) "Department" means the Ohio
department of developmental disabilities. (5) "Direct support
professional" means: (a) An independent provider; (b) A person who is employed by an agency provider or a
residential facility in a "direct services position," as that term is
defined in section 5123.081 of the Revised Code, regardless of the
person's job title, and who is engaged in provision or supervision of
direct support for at least fifty per cent of the hours the person worked for
the employing agency provider or residential facility during the quarter used
by the department for determination of the amount of a retention payment;
or (c) A person who is under contract with an agency provider
to provide shared living. (6) "Good
standing" means a provider is not the subject of an action initiated by
the department to deny, suspend, or revoke the provider's certification or
license. (7) "Group
employment support" has the same meaning as in rule 5123-9-16 of the
Administrative Code. (8) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (9) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative Code and
includes on-site/on-call homemaker/personal care provided in accordance with
that rule. (10) "Homemaker/personal care daily
billing unit" has the same meaning as in rule 5123-9-31 of the
Administrative Code. (11) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (13) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (14) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (15) "Participant-directed
homemaker/personal care" has the same meaning as in rule 5123-9-32 of the
Administrative Code. (16) "Provider" means an
independent provider, an agency provider, or a residential facility that
provides one or more of the home and community-based services listed in
paragraphs (B)(19)(a) to (B)(19)(k) of this rule. (17) "Quarter" means one of four
three-month spans of each calendar year, that is: (a) January first through March thirty-first; (b) April first through June thirtieth; (c) July first through September thirtieth; or (d) October first through December
thirty-first. (18) "Residential facility"
means a residential facility licensed by the department pursuant to section
5123.19 of the Revised Code, other than an intermediate care facility for
individuals with intellectual disabilities. (19) "Retention
payment" means a payment intended to directly benefit direct support
professionals which the department may issue on a quarterly basis to an
eligible provider in an amount determined by the department based on a
percentage of the provider's reimbursed claims during the preceding
quarter for provision of: (a) Adult day support; (b) Career planning; (c) Group employment support; (d) Homemaker/personal care; (e) Homemaker/personal care daily billing
unit; (f) Individual employment support; (g) Non-medical transportation; (h) Participant-directed homemaker/personal
care; (i) Shared living; (j) Transportation; and (k) Vocational habilitation. (20) "Shared
living" has the same meaning as in rule 5123-9-33 of the Administrative
Code. (21) "Transportation" has the
same meaning as in rule 5123-9-24 of the Administrative Code. (22) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (C) Eligibility for retention payment -
providers (1) An independent
provider that has been reimbursed for provision of one or more of the home and
community-based services listed in paragraphs (B)(19)(a) to (B)(19)(k) of this
rule during the quarter used by the department for determination of the amount
of the retention payment and that is in good standing at the time the
department issues the retention payment, is eligible and will receive a
retention payment. The independent provider need not take any action to
participate in the retention payment program; the department will issue
retention payments to eligible independent providers in accordance with
paragraph (F)(1) of this rule. (2) An agency provider or
residential facility that has been reimbursed for provision of one or more of
the home and community-based services listed in paragraphs (B)(19)(a) to
(B)(19)(k) of this rule during the quarter used by the department for
determination of the amount of the retention payment and that is in good
standing at the time the department issues the retention payment, is eligible
to receive a retention payment when the agency provider or residential
facility: (a) Opts to participate in the retention payment program by
affirming, via the department's web-based portal for the retention payment
program, on or before the fifteenth day of the first month of the quarter
following the quarter used by the department for determination of the amount of
the retention payment, its intent to participate and assurance that it will
comply with this rule; (b) Disburses to each of its eligible direct support
professionals, the direct support professional's share of the retention
payment issued by the department in accordance with paragraph (F) of this rule;
and (c) Submits, via the department's web-based portal for
the retention payment program, on or before the fifteenth day of the first
month of the quarter following the quarter in which the department issued the
retention payment: (i) Information requested
by the department regarding the retention payment program including, but not
limited to: (a) Disbursement of the retention payment to its direct
support professionals; and (b) Any portion of a retention payment used to cover costs
associated with implementation or administration of the retention payment
program and therefore not disbursed directly to its direct support
professionals. (ii) An attestation that the retention payment was used and
disbursed to direct support professionals in accordance with this
rule. (D) Eligibility for retention payment - direct support
professionals engaged by agency providers and residential
facilities (1) A direct support
professional engaged by an agency provider or a residential facility is
eligible to receive a retention payment when the direct support
professional: (a) Provided or supervised provision of direct support
while employed by the agency provider or residential facility or was under
contract to provide shared living during the quarter used by the department for
determination of the amount of the retention payment; and (b) Is employed by the agency provider or residential
facility or under contract to provide shared living on the day the agency
provider or residential facility disburses the retention payment to its direct
support professionals. (2) Owners and management
staff of agency providers and residential facilities (e.g., directors of
operations, administrators, or operators) are not eligible to receive a
retention payment unless they meet the definition of "direct support
professional" in paragraph (B)(5) of this rule and the criteria set forth
in paragraph (D)(1) of this rule. (3) A direct support
professional who has separated from employment with the agency provider or
residential facility or is no longer under contract to provide shared living is
not eligible to receive a retention payment. (E) Use of retention
payments (1) An agency provider or
residential facility is to disburse a retention payment to its eligible direct
support professionals in accordance with one of the methods described in
paragraph (F)(3) of this rule. At least eighty-two per cent of the retention
payment is to be disbursed to direct support professionals or used to cover the
employer's share of the associated payroll taxes. (2) An agency provider or
residential facility may use up to eighteen per cent of a retention payment for
costs associated with implementation or administration of the retention payment
program, additional employee compensation, or other activities that benefit its
direct support professionals and/or improve service delivery. (3) An agency provider or
residential facility will not use a retention payment to fund a program or
incentive the agency provider or residential facility had in place prior to the
effective date of this rule unless the funding available for the program or
incentive prior to the effective date of this rule ceases to be
available. (4) An agency provider or
residential facility is to maintain records sufficient to demonstrate
compliance with this rule for a period of six years from the date of receipt of
a retention payment or until an initiated audit is resolved, whichever is
longer. (F) Disbursement of retention payments to
direct support professionals (1) The department will
issue retention payments to eligible providers via electronic funds transfer on
or before the fifteenth day of the second month of the quarter following the
quarter used by the department for determination of the amount of the retention
payment. (2) An agency provider or
residential facility will disburse to each eligible direct support
professional, on or before the fifteenth day of the third month of the quarter
following the quarter used by the department for determination of the amount of
the retention payment, the direct support professional's share of the
retention payment. (3) An agency provider or residential
facility is to choose from two methods for determining each direct support
professional's share of the retention payment: (a) Each eligible direct support professional receives the
same percentage adjustment of total wages, including standard pay and overtime
pay, or compensation for the quarter (total amount of retention payment / total
wages or compensation = percentage adjustment disbursed to each eligible direct
support professional); or (b) Each eligible direct support professional receives the
same dollar amount (total amount of retention payment / number of eligible
direct support professionals = amount disbursed to each eligible direct support
professional). (G) Recoupment of a retention payment (1) If the department
determines that a provider received a retention payment for which it was not
eligible or otherwise failed to comply with this rule, the department may
initiate recoupment. When such a determination is made, the department will
notify the provider by certified mail, return receipt requested. The notice
will explain the amount due and the basis for the recoupment and inform the
provider of the provider's right to request a hearing on the proposed
recoupment pursuant to Chapter 119. of the Revised Code. The provider will have
thirty days from the date the notice is mailed to request a hearing which, if
timely requested, will be held in accordance with Chapter 119. of the Revised
Code. (2) When a provider does not request a
hearing in accordance with paragraph (G)(1) of this rule, the amount of the
recoupment is due and payable within thirty days of the provider's receipt
of the notice. (3) At the department's discretion,
a provider may make repayment: (a) In a lump sum payment to the department;
or (b) In a single deduction from the provider's next
scheduled medicaid payment as long as the deduction will equal the total amount
due to the department. (4) The department may
charge interest on the amount of the recoupment beginning on, as
applicable: (a) The date the recoupment is due and payable in
accordance with paragraph (G)(2) of this rule; or (b) The thirtieth day following an adjudication issued by
the director of the department ordering recoupment of the retention
payment. (5) A provider that has
been subject to recoupment may be ineligible to receive future retention
payments. (H) Waiving provisions of this
rule For good cause, the director of the department
may waive a condition or specific requirement of this rule. The director's
decision to waive a condition or specific requirement is not subject to
appeal.
Last updated March 23, 2023 at 8:31 AM
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Rule 5123-9-06 | Home and community-based services waivers - administration of the individual options and level one waivers.
(A) Purpose This rule establishes standards governing administration of the individual options and level one waivers, components of the medicaid home and community-based services program the Ohio department of developmental disabilities administers pursuant to section 5166.21 of the Revised Code. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Adult" means an individual who is at least twenty-two years old or an individual who is under twenty-two years old and no longer eligible for educational services based on graduation, receipt of a diploma or equivalency certificate, or permanent discontinuation of educational services within parameters established by the Ohio department of education. (2) "Budget authority" means an individual has the authority and responsibility to manage the individual's budget for participant-directed services. This authority supports the individual in determining the budgeted dollar amount for each participant-directed waiver service that will be provided to the individual and making decisions about the acquisition of participant-directed waiver services that are authorized in the individual service plan (e.g., negotiating payment rates to providers within the applicable range as specified in rules adopted by the department). (3) "Child" means an individual who is under twenty-two years old and eligible for educational services. (4) "Cost projection and payment authorization" means the process followed and the form used by county boards (including the payment authorization for waiver services) to communicate the frequency, duration, scope, and amount of payment requested for each home and community-based service that is identified in the individual service plan. (5) "Cost projection tool" means the web-based analytical tool that is a component of the medicaid services system, developed and administered by the department, used to project the cost of home and community-based services identified in an individual service plan. (6) "County board" means a county board of developmental disabilities. (7) "Department" means the Ohio department of developmental disabilities. (8) "Employer authority" means an individual has the authority to recruit, hire, supervise, and direct the staff who furnish supports. The individual functions as the common law employer or the co-employer of these staff. (9) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time. Minutes of service delivery time accrued throughout a day shall be added together for the purpose of calculating the number of fifteen-minute billing units for the day. (10) "Financial management services entity" means a governmental entity and/or another third-party entity designated by the department to perform necessary financial transactions on behalf of individuals who receive participant-directed services. (11) "Funding range" means one of the dollar ranges contained in appendix A to this rule to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, career planning, group employment support, individual employment support, non-medical transportation, vocational habilitation, waiver nursing delegation, and waiver nursing services. The funding range applicable to an individual is determined by the score derived from the Ohio developmental disabilities profile that has been completed by a county board employee qualified to administer the tool. (12) "Guardian" means a guardian appointed by the probate court under Chapter 2111. of the Revised Code. If the individual is a minor, "guardian" means the individual's parents. If no guardian has been appointed for a minor under Chapter 2111. of the Revised Code and the minor is in the legal or permanent custody of a government agency or person other than the minor's natural or adoptive parents, "guardian" means that government agency or person. "Guardian" includes an agency under contract with the department for the provision of protective service in accordance with sections 5123.55 to 5123.59 of the Revised Code. (13) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised Code. (14) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (15) "Individual funding level," as established for each individual enrolled in the individual options waiver, means the total funds, calculated on a twelve-month basis, that result from applying the payment rates in service-specific rules in Chapter 5123-9 of the Administrative Code to the units of all waiver services other than adult day support, career planning, group employment support, individual employment support, non-medical transportation, vocational habilitation, waiver nursing delegation, and waiver nursing services established by the individual service plan development process to be sufficient in frequency, duration, and scope to meet the individual's health and welfare needs. Unless prior authorization has been obtained in accordance with rule 5123-9-07 of the Administrative Code, the individual funding level for services paid in accordance with this rule shall be within or below the funding range assigned to the individual as the result of administration of the Ohio developmental disabilities profile. (16) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual developed in accordance with rule 5123-4-02 of the Administrative Code. (17) "Natural supports" means the personal associations and relationships typically developed in the community that enhance the quality of life for individuals. Natural supports may include family members, friends, neighbors, and others in the community or organizations that serve the general public who provide voluntary support to help an individual achieve agreed upon outcomes through the individual service plan development process. (18) "Ohio developmental disabilities profile" means the standardized instrument used by the department to assess the relative needs and circumstances of an individual compared to others. The individual's responses are scored and the individual is linked to a funding range, which enables similarly situated individuals to access comparable waiver services paid in accordance with rules adopted by the department. (19) "Participant direction" means an individual has authority to make decisions about the individual's waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and/or employer authority as set forth in paragraph (E) of this rule. (20) "Prior authorization" means the process to be followed in accordance with rule 5123-9-07 of the Administrative Code to authorize an individual funding level for an individual enrolled in the individual options waiver that exceeds the maximum value of the funding range. (21) "Provider" means a person or entity certified or licensed by the department that has met the provider qualification requirements to provide specific home and community-based services and holds a valid medicaid provider agreement with the Ohio department of medicaid or a person or entity that has been determined by the financial management services entity to be qualified to provide participant-directed goods and services or self-directed transportation. (22) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (23) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in service-specific rules in Chapter 5123-9 of the Administrative Code to validate payment for medicaid services. (24) "Team" has the same meaning as in rule 5123-4-02 of the Administrative Code. (25) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (C) Funding ranges and individual funding levels for individuals enrolled in the individual options waiver (1) Individuals enrolled in the individual options waiver shall be assigned to a funding range based on completion and scoring of the Ohio developmental disabilities profile and the cost-of-doing-business category that applies to the county in which the individual receives the preponderance of services. The funding ranges are contained in appendix A to this rule. The cost-of-doing-business categories are contained in appendix B to this rule. (2) The funding ranges shall consider: (a) The natural supports available to the individual; (b) The individual's living arrangement; (c) The individual's behavioral support and medical assistance needs; (d) The individual's mobility; (e) The individual's ability for self care; and (f) Any other variable that significantly impacts the individual's needs as determined by the department through statistical analysis. (3) The service and support administrator shall ensure that an Ohio developmental disabilities profile is completed with input from the individual and the team. The service and support administrator shall inform the individual, and the team with consent of the individual, of the assigned funding range at the time of enrollment and any time the Ohio developmental disabilities profile is reviewed or updated. The service and support administrator shall ensure the individual, and the team with consent of the individual, have access to review the Ohio developmental disabilities profile and other assessments used in relation to completion of the Ohio developmental disabilities profile. (4) Following assignment of a funding range, an individual service plan that assures the individual's health and welfare shall be reviewed, revised, or developed with the individual. The service and support administrator shall ensure that individuals share services to whatever extent practical and with the agreement of the team. Paid services should be used in conjunction with available natural supports. The service and support administrator shall ensure that development or revision of the individual service plan addresses the availability of natural supports that currently exist or could be developed to meet assessed needs, including: (a) Supports that family members provide including, but not limited to, basic personal care, performing health care activities, transportation, attending family/social/recreational activities, laundry, meal preparation, and grocery shopping; and (b) Supports that friends, neighbors, and others in the community provide. (5) The county board shall apply rates for the units of each waiver service, other than adult day support, career planning, group employment support, individual employment support, non-medical transportation, vocational habilitation, waiver nursing delegation, and waiver nursing services, resulting from completion of the individual service plan development process to calculate the individual funding level. (6) The county board shall determine whether the individual funding level is within, exceeds, or is below the assigned funding range for the individual. The service and support administrator shall inform the individual of this determination in accordance with procedures developed by the department. (7) When an individual service plan is revised and a new funding level is determined, the providers of waiver services to the individual shall verify to the county board the number of units of each waiver service delivered during the individual's current waiver eligibility span so that the county board may accurately calculate the number of units of services available for the individual's use during the remainder of the waiver eligibility span. (8) The county board shall complete the cost projection and payment authorization and the service and support administrator shall ensure waiver services are initiated for an individual whose funding level is within the funding range determined by the Ohio developmental disabilities profile. The service and support administrator shall inform the individual in writing and in a form and manner the individual can understand of the individual's due process rights and responsibilities as set forth in section 5160.31 of the Revised Code. (9) When the individual funding level exceeds the assigned funding range: (a) The county board shall inform the individual of the individual's right to request prior authorization to obtain services that result in an individual funding level that exceeds the funding range using the process described in rule 5123-9-07 of the Administrative Code. (b) If, through the prior authorization process, the request for the funding level is approved, the county board shall ensure the cost projection and payment authorization is completed and waiver services are initiated. (c) If, through the prior authorization process, the request for the funding level is denied, the service and support administrator shall continue the individual service plan development process to determine if an individual service plan that assures the individual's health and welfare can be developed within the individual's funding range. (i) If an individual service plan that meets these conditions is developed, the county board shall ensure the cost projection and payment authorization is completed and waiver services are initiated. (ii) If an individual service plan that meets these conditions cannot be developed, the county board shall propose to deny the individual's initial or continuing enrollment in the waiver and inform the individual of the individual's due process rights and responsibilities as set forth in section 5160.31 of the Revised Code. (10) The department shall use the twelve-month period following either an individual's initial waiver enrollment date or a subsequent waiver eligibility re-determination date to verify that cumulative payments made for waiver services remain within the approved funding range for each individual or that cumulative payments made for waiver services remain within the approved funding range when prior authorization has been granted. (11) The department shall periodically re-examine the scoring of the Ohio developmental disabilities profile and the linkage of the scores to the funding ranges. (D) Changes to individual funding levels and funding ranges (1) The individual funding level may increase or decrease based on the outcome of the individual service plan development process. In no instance shall the individual funding level exceed the cost cap approved for the waiver in which the individual is enrolled. The county board has the authority and responsibility to make changes to individual funding levels which result from the individual service plan development process in accordance with paragraph (C) of this rule. Changes to individual funding levels are subject to review by the department. (2) A funding range established for an individual shall change only when changes in assessment variable scores on the Ohio developmental disabilities profile justify assignment of a new funding range. Any or all Ohio developmental disabilities profile variables may be revised at any time at the request of the individual or at the discretion of the service and support administrator, with the individual's knowledge. (3) Neither the department nor the county board shall recommend a change in individual funding level within the funding range or assign a new funding range after notification that the individual has requested a hearing pursuant to section 5160.31 of the Revised Code concerning the approval, denial, reduction, or termination of services. (E) Participant direction (1) The individual options and level one waivers support individuals who want to direct some of their services through participant direction. The individual or the individual's guardian or the individual's designee must be willing and able to perform the duties associated with participant direction. (2) An individual enrolled in the individual options waiver may exercise: (a) Budget authority for: (i) Participant-directed homemaker/personal care; and (ii) Self-directed transportation. (b) Employer authority for: (i) Participant-directed homemaker/personal care; and (ii) Self-directed transportation. (3) An individual enrolled in the level one waiver may exercise: (a) Budget authority for: (i) ) Clinical/therapeutic intervention; (ii) Participant-directed goods and services; (iii) Participant-directed homemaker/personal care; and (iv) Self-directed transportation. (b) Employer authority for: (i) Participant-directed homemaker/personal care; and (ii) Self-directed transportation. (F) Level one waiver benefit limitation The cost of services available under the level one waiver shall not exceed: (1) Forty-five thousand dollars per waiver eligibility span for an adult; or (2) Thirty thousand dollars per waiver eligibility span for a child. (G) Staffing ratios (1) In situations where more than one staff member serves more than one individual simultaneously, the individuals' needs and circumstances shall determine staffing ratios, based on a unit of one staff to the portion of the total group that includes the individual. Only when it is impractical to determine staff ratios based on a unit of one staff, the provider shall, as authorized in the individual service plan, use the applicable service codes and payment rates established in service-specific rules in Chapter 5123-9 of the Administrative Code to indicate both staff size and group size. (2) Staffing ratios do not change at times when one or more individuals, for whom the staff is responsible, are not physically present, but are within verbal, visual, or technological supervision of the staff providing the service. Technological supervision includes staff contact with individuals through telecommunication and/or electronic signaling devices. (H) Projection of the cost of an individual's services (1) Prior to the beginning of an individual's waiver eligibility span, the individual's service and support administrator or other county board designee shall prepare a projection of the annual cost of every individual options or level one waiver service that is authorized in the individual service plan for the waiver eligibility span using the cost projection tool. (2) The cost projection shall be based on staffing ratios and the total estimated number of service units the individual is expected to receive in accordance with the individual service plan during the waiver eligibility span. Staffing ratios contained in the cost projection tool shall be considered a part of the individual service plan. (3) The total number of service units shall be determined with input from the individual and the individual's team as part of the individual service plan development process. (4) The cost projection tool shall project the cost of services based on the payment rates established in service-specific rules in Chapter 5123-9 of the Administrative Code. (5) Rule 5123-9-31 of the Administrative Code shall govern the circumstances when an individual receives the homemaker/personal care daily billing unit. (6) The cost projection tool shall be used to project costs based on medicaid payment rates for individuals, regardless of funding source, who share services with individuals enrolled in home and community-based services waivers. (7) The individual's provider shall have access to the cost projection tool including, but not limited to, the detail and summary information. At the request of the individual, other persons shall have access to the detail and summary information in the cost projection tool. (8) When changes occur that the team determines affect the service authorization, the county board shall enter changes to the cost projection tool within ten calendar days of a recommendation from the team to change the service authorization. These changes shall be made along with any necessary revisions to the individual service plan and prior authorization request (as applicable) for the individual or individuals affected by the changes. (9) County boards shall complete a cost projection using the cost projection tool when an individual is initially enrolled in an individual options or level one waiver and when an individual is annually re-determined eligible for continued enrollment in an individual options or level one waiver. The cost projection tool shall be the only authorized cost projection instrument. (I) Service documentation (1) Providers shall maintain service documentation in accordance with this rule and service-specific rules in Chapter 5123-9 of the Administrative Code. (2) Claims for payment a provider submits to the department for services delivered shall not be considered service documentation. Any information contained in the submitted claim for payment may not and shall not be substituted for any required service documentation information that a provider is required to maintain to validate payment for medicaid services. (3) Each provider shall maintain all service documentation in an accessible location. The service documentation shall be made available upon request for review by the department, the Ohio department of medicaid, the centers for medicare and medicaid services, a county board or regional council of governments that submits to the department payment authorization for the service, and those designated or assigned authority by the department or the Ohio department of medicaid to review service documentation. (4) When a provider discontinues operations, the provider shall, within seven calendar days, notify the county boards for the counties in which individuals for whom the provider has provided services reside, of the location where the service documentation will be stored, and provide the county board with the name and telephone number of the person responsible for maintaining the service documentation. (J) Payment for waiver services (1) Providers shall be paid the lesser of their usual and customary rate or the payment rate for each waiver service that is delivered. The department will maintain a mechanism through which providers shall communicate their usual and customary rates to the department. A single provider may charge different usual and customary rates for the same service when the service is provided in different geographic areas of the state. In this instance, the usual and customary rates charged shall be declared for each cost-of-doing-business category contained in appendix B to this rule that identifies the counties in which the provider intends to provide specific services. Upon notification of a provider's usual and customary rate or change in usual and customary rate, the department shall provide notice to the appropriate county board. (2) The billing units, service codes, and payment rates for waiver services are contained in service-specific rules in Chapter 5123-9 of the Administrative Code including, but not limited to: (a) 5123-9-12 (assistive technology under the individual options and level one waivers); (b) 5123-9-13 (career planning under the individual options and level one waivers); (c) 5123-9-14 (vocational habilitation under the individual options and level one waivers); (d) 5123-9-15 (individual employment support under the individual options and level one waivers); (e) 5123-9-16 (group employment support under the individual options and level one waivers); (f) 5123-9-17 (adult day support under the individual options and level one waivers); (g) 5123-9-18 (non-medical transportation under the individual options and level one waivers); (h) 5123-9-20 (money management under the individual options and level one waivers); (i) 5123-9-21 (informal respite under the level one waiver); (j) 5123-9-22 (community respite under the individual options and level one waivers); (k) 5123-9-23 (environmental accessibility adaptations under the individual options and level one waivers); (l) 5123-9-24 (transportation under the individual options and level one waivers); (m) 5123-9-25 (specialized medical equipment and supplies under the individual options and level one waivers); (n) 5123-9-26 (self-directed transportation under the individual options and level one waivers); (o) 5123-9-28 (nutrition services under the individual options waiver); (p) 5123-9-29 (home-delivered meals under the individual options and level one waivers); (q) 5123-9-30 (homemaker/personal care under the individual options and level one waivers); (r) 5123-9-31 (homemaker/personal care daily billing unit under the individual options waiver); (s) 5123-9-32 (participant-directed homemaker/personal care under the individual options and level one waivers); (t) 5123-9-33 (shared living under the individual options waiver); (u) 5123-9-34 (residential respite under the individual options and level one waivers); (v) 5123-9-35 (remote support under the individual options and level one waivers); (w) 5123-9-36 (interpreter services under the individual options waiver); (x) 5123-9-37 (waiver nursing delegation under the individual options and level one waivers); (y) 5123-9-38 (social work under the individual options waiver); (z) 5123-9-39 (waiver nursing services under the individual options waiver); (aa) 5123-9-41 (clinical/therapeutic intervention under the level one waiver); (bb) 5123-9-43 (functional behavioral assessment under the level one waiver); (cc) 5123-9-45 (participant-directed goods and services under the level one waiver); (dd) 5123-9-46 (participant/family stability assistance under the level one waiver); and (ee) 5123-9-48 (community transition under the individual options waiver). (3) The department shall periodically collect payment information for a comprehensive, statistically valid sample of individuals from providers of home and community-based services at the time the information is collected. Based upon the department's review of the information, the department shall recommend to the Ohio department of medicaid any changes necessary to assure that the payment rates are sufficient to enlist enough waiver providers so that waiver services are readily available to individuals, to the extent that these types of services are available to the general population, and that provider payment is consistent with efficiency, economy, and quality of care. (4) Payment for home and community-based services constitutes payment in full. Payment shall be made for home and community-based services when: (a) The service is identified in an approved individual service plan; (b) The service is recommended for payment through the cost projection and payment authorization process; and (c) The service is provided by a provider selected by an individual enrolled in the waiver. (5) Payment for waiver services shall not exceed amounts authorized through the cost projection and payment authorization for the individual's corresponding waiver eligibility span. (K) Claims for payment for home and community-based services (1) When home and community-based services are also available on the medicaid state plan, state plan services shall be billed first. Only home and community-based services in excess of those covered under the medicaid state plan shall be authorized. (2) Claims for payment for home and community-based services shall be submitted to the department in the format prescribed by the department. The department shall inform county boards of the billing information submitted by providers in a manner and at a frequency necessary to assist county boards to manage the waiver expenditures being authorized. (3) Claims for payment for home and community-based services shall be submitted within three hundred fifty calendar days after the home and community-based services are provided. Payment shall be made in accordance with the requirements of rule 5160-1-19 of the Administrative Code. Claims for payment shall include the number of units of service. (4) All providers of home and community-based services shall take reasonable measures to identify any third-party health care coverage available to the individual and file a claim with that third party in accordance with the requirements of rule 5160-1-08 of the Administrative Code. (5) For individuals with a monthly patient liability for the cost of home and community-based services, as described in rule 5160:1-6-07.1 of the Administrative Code, and determined by the county department of job and family services for the county in which the individual resides, payment is available only for the home and community-based services delivered to the individual that exceed the amount of the individual's monthly patient liability. Verification that patient liability has been satisfied shall be accomplished as follows: (a) The department shall provide notification to the appropriate county board identifying each individual who has a patient liability for home and community-based services and the monthly amount of the patient liability. (b) The county board shall assign the home and community-based services to which each individual's patient liability shall be applied and assign the corresponding monthly patient liability amount to the provider that provides the preponderance of home and community-based services. The county board shall notify each individual and provider, in writing, of this assignment. (c) Upon submission of a claim for payment, the designated provider shall report the home and community-based services to which the patient liability was assigned and the applicable patient liability amount on the claim for payment using the format prescribed by the department. (6) The department, the Ohio department of medicaid, the centers for medicare and medicaid services, and/or the auditor of state may audit any funds a provider of home and community-based services receives pursuant to this rule, including any source documentation supporting the claiming and/or receipt of such funds. (7) Overpayments, duplicate payments, payments for services not rendered, payments for which there is no documentation of services delivered or for which the documentation does not include all of the items required in service-specific rules in Chapter 5123-9 of the Administrative Code, or payments for services not in accordance with an approved individual service plan are recoverable by the department, the Ohio department of medicaid, the auditor of state, or the office of the attorney general. All recoverable amounts are subject to the application of interest in accordance with rule 5160-1-25 of the Administrative Code. (8) Providers of home and community-based services shall maintain the records necessary and in such form to disclose fully the extent of home and community-based services provided, for a period of six years from the date of receipt of payment or until an initiated audit is resolved, whichever is longer. The records shall be made available upon request to the department, the Ohio department of medicaid, the centers for medicare and medicaid services, and/or the auditor of state. Providers who fail to produce the records requested within thirty calendar days following the request shall be subject to denial, suspension, or revocation of certification and/or loss of their medicaid provider agreement. (L) Due process rights and responsibilities (1) Applicants for and recipients of waiver services administered by the department may use the process set forth in section 5160.31 of the Revised Code and rules implementing that statute for any purpose authorized by that statute. The process set forth in section 5160.31 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives. Providers shall have no standing in an appeal under that section. (2) Applicants for and recipients of waiver services administered by the department shall use the process set forth in section 5160.31 of the Revised Code and rules implementing that statute for any challenge related to the administration and/or scoring of the Ohio developmental disabilities profile or to the type, amount, level, scope, or duration of services included in or excluded from an individual service plan. A change in staff to waiver recipient service ratios does not necessarily result in a change in the level of services received by an individual. (M) Ohio department of medicaid authority The Ohio department of medicaid retains final authority to establish funding ranges for home and community-based services; to establish payment rates for home and community-based services; to review and approve each service identified in an individual service plan that is funded through a home and community-based services waiver; and to authorize the provision of and payment for home and community-based services through the cost projection and payment authorization.
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Last updated July 1, 2022 at 1:20 PM
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Rule 5123-9-07 | Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver.
Effective:
November 19, 2020
(A) Purpose This rule establishes standards and procedures
for prior authorization of waiver services when an individual funding level
exceeds the funding range determined by the Ohio developmental disabilities
profile for an individual enrolled in the individual options waiver. (B) Definitions (1) "Cost projection tool"
means the web-based analytical tool, developed and administered by the
department, used to project the cost of waiver services identified in the
individual service plans of individuals enrolled in individual options and
level one waivers. (2) "County board" means a
county board of developmental disabilities. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Funding range" means one
of the dollar ranges contained in appendix A to rule 5123-9-06 of the
Administrative Code to which individuals enrolled in the individual options
waiver have been assigned for the purpose of funding services other than adult
day support, career planning, group employment support, individual employment
support, non-medical transportation, vocational habilitation, waiver nursing
delegation, and waiver nursing services. The funding range applicable to an
individual is determined by the score derived from the Ohio developmental
disabilities profile that has been completed by a county board employee
qualified to administer the tool. (5) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (6) "Individual funding level"
means the total funds, calculated on a twelve-month basis, that result from
applying the payment rates in service-specific rules in Chapters 5123-9 and
5123:2-9 of the Administrative Code to the units of all waiver services other
than adult day support, career planning, group employment support, individual
employment support, non-medical transportation, vocational habilitation, waiver
nursing delegation, and waiver nursing services established by the individual
service plan development process to be sufficient in frequency, duration, and
scope to meet the health and welfare needs of an individual enrolled in the
individual options waiver. (7) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (8) "Medicaid
services system" means the comprehensive information system that
integrates cost projection, prior authorization, daily rate calculation, and
payment authorization of waiver services. (9) "Ohio
developmental disabilities profile" means the standardized instrument
utilized by the department to assess the relative needs and circumstances of an
individual compared to others. The individual's responses are scored and
the individual is linked to a funding range, which enables similarly situated
individuals to access comparable waiver services paid in accordance with rules
adopted by the department. (10) "Prior authorization" means
the process to be followed in accordance with this rule to authorize an
individual funding level for an individual enrolled in the individual options
waiver that exceeds the maximum value of the funding range. (11) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (12) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility redetermination
date. (C) Standards (1) The county board shall inform an
individual, in writing, of the individual's right to request prior
authorization whenever development or proposed revision of the individual
service plan results in an individual funding level that exceeds the funding
range assigned to the individual. (2) Unless a request for
prior authorization has been approved in accordance with this rule, the
individual funding level for services shall be within or below the funding
range assigned to the individual. (3) Approval of a request
for prior authorization is valid only for the duration of the individual's
waiver eligibility span for which the request was made. (4) The department shall
not consider a request for prior authorization submitted after the end date of
the waiver eligibility span for which the request is made. (D) Procedures (1) A request for prior
authorization shall be submitted to the department during the waiver
eligibility span for which the request is made and as soon as possible after
development or proposed revision of the individual service plan results in an
individual funding level that exceeds the funding range assigned to the
individual. (2) An individual shall
initiate the prior authorization process by submitting a signed and dated
request to the county board. A county board shall assist in the preparation of
the request when the individual requests assistance. (3) The county board shall submit the
request for prior authorization with the current or proposed individual service
plan and supporting documentation to the department through the medicaid
services system within ten business days of receiving the individual's
request. Supporting documentation shall provide evidence that the requested
services are medically necessary in accordance with the criteria set forth in
paragraph (D)(7) of this rule. (4) When the county board
is unable to support the request based on the county board's documentation
that the requested services do not meet the criteria set forth in paragraph
(D)(7) of this rule, the county board shall provide to the
department: (a) A detailed description of the county board's efforts to
develop an individual service plan that results in an individual funding level
within the funding range assigned to the individual; and (b) An alternative cost projection that ensures the health and
safety of the individual, including the date the alternative cost projection
was reviewed and declined by the individual; and (c) Supporting documentation evidencing that the requested
services are not medically necessary in accordance with the criteria set forth
in paragraph (D)(7) of this rule. (5) Within ten business days of receiving
the request, the department shall notify the county board if additional
information is needed to make a determination. The county board shall submit
the additional information to the department within five business days of
receiving notification from the department. (6) The department shall
review the request and make a determination within ten business days of
receiving all necessary information. (7) When reviewing a
request, the department shall determine whether the waiver services for which
prior authorization is requested meet the waiver service definition and are
medically necessary. The department shall determine the services to be
medically necessary if the services: (a) Are appropriate for the individual's health and welfare
needs, living arrangement, circumstances, and expected outcomes;
and (b) Are of an appropriate type, amount, duration, scope, and
intensity; and (c) Are the most efficient, effective, and lowest cost
alternative that, when combined with non-waiver services, ensure the health and
welfare of the individual receiving the services; and (d) Protect the individual from substantial harm expected to
occur if the requested services are not authorized. (8) The department may limit its review
to the individual's request in the medicaid services system and the cost
projection tool that produced an individual funding level that exceeds the
funding range assigned to the individual when the county board supports the
request and: (a) The costs exceed the funding range solely as a result of a
payment rate increase taking effect during the individual's waiver
eligibility span and not as a result of a change in the type, amount, duration,
scope, or intensity of services authorized; or (b) The projected individual funding level exceeds the funding
range assigned to the individual by no more than ten per cent; or (c) The request is for an individual for whom prior authorization
has been approved for a previous waiver eligibility span and the request
includes an attestation by the service and support administrator that the
individual's needs, waiver services, and cost of waiver services have not
changed since the preceding request. (9) Based on its review,
the department shall: (a) Approve the request if it finds that the services for which
prior authorization is requested meet the criteria set forth in paragraph
(D)(7) of this rule; or (b) Deny the request; or (c) Approve the request for a partial or full waiver eligibility
span for all or some of the services provided the criteria set forth in
paragraph (D)(7) of this rule are met. (10) When the department makes a
determination regarding a request for prior authorization, the department
shall: (a) Issue written notification to the individual which sets forth
the reason for denial or reflects the total amount authorized for the current
waiver eligibility span and includes the individual's right to request a
hearing in accordance with section 5101.35 of the Revised Code and division
5101:6 of the Administrative Code; and (b) Update the prior authorization status to reflect its
determination in the medicaid services system. (11) When the request for prior
authorization is denied, the individual and the service and support
administrator shall meet to revise the individual service plan. (E) If the individual requests a hearing
in accordance with paragraph (D)(10)(a) of this rule, the county board shall
offer a county conference in accordance with rule 5101:6-5-01 of the
Administrative Code and comply with applicable requirements of division 5101:6
of the Administrative Code. (F) Failure by a county board or the
department to comply with the timelines established in this rule shall not
constitute approval of a request for prior authorization. (G) The Ohio department of medicaid reserves the right to review
all requests for prior authorization submitted through the medicaid services
system to ensure compliance with this rule. (H) During the COVID-19 state of
emergency declared by the governor, the director of the department may waive or
suspend the standards and procedures set forth in this rule.
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Rule 5123-9-11 | Home and community-based services waivers - free choice of providers.
Effective:
November 19, 2020
(A) Purpose This rule establishes the responsibilities of a
county board of developmental disabilities for assuring an individual's
right to obtain home and community-based services from any qualified and
willing provider in accordance with 42 C.F.R. 431.51 as in effect on the
effective date of this rule and sections 5123.044 and 5126.046 of the Revised
Code. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency provider" means an
entity that employs persons for the purpose of providing services for which the
entity must be certified under rules adopted by the department. (3) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (4) "County board" means a
county board of developmental disabilities. (5) "Department" means the Ohio
department of developmental disabilities. (6) "Group
employment support" has the same meaning as in rule 5123:2-9-16 of the
Administrative Code. (7) "Home and community-based
services" has the same meaning as in section 5123.01 of the Revised
Code. (8) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (9) "Independent provider"
means a self-employed person who provides services for which he or she must be
certified under rules adopted by the department and who does not employ, either
directly or through contract, anyone else to provide the services. (10) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (11) "Individual
employment support" has the same meaning as in rule 5123:2-9-15 of the
Administrative Code. (12) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (13) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (14) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (C) Notification of free choice of
providers, assistance with the provider selection process, and procedural
safeguards (1) The county board
shall notify each individual at the time of enrollment in a home and
community-based services waiver and at least annually thereafter, of the
individual's right to choose any qualified and willing provider of home
and community-based services. The notification shall specify that: (a) The individual may choose agency providers, independent
providers, or a combination of agency providers and independent
providers; (b) The individual may choose providers from all qualified
and willing providers available statewide and is not limited to those currently
providing services in a given county; (c) When a provider offers more than one service, the
individual may choose to receive only one of the offered services from that
provider. (d) The individual may choose to receive services from a
different provider at any time; (e) An individual choosing to receive homemaker/personal
care in a licensed residential facility is choosing both the place of residence
and the homemaker/personal care provider, but maintains free choice of
providers for all other home and community-based services and the right to move
to another setting at any time if a new homemaker/personal care provider is
desired; and (f) The service and support administrator will assist the
individual with the provider selection process if the individual requests
assistance. (2) A service and support
administrator shall assist an individual enrolled in a home and community-based
services waiver with one or more of the following, as requested by the
individual: (a) Accessing the department's website to conduct a
search for qualified and willing providers; (b) Providing the individual with the department's
guide to interviewing prospective providers; (c) Sharing objective information with the individual about
providers that includes reports of provider compliance reviews conducted in
accordance with section 5123.162 or 5123.19 of the Revised Code, approved plans
of correction submitted by providers in response to compliance reviews, number
of individuals currently served, and any information about services offered by
the provider to meet the unique needs of a specific group of individuals such
as aging adults, children with autism, or individuals with intense medical or
behavioral needs; (d) Utilizing the statewide, uniform format to create a
profile that shall include the type of services and supports the individual
requires, hours of services and supports required, the individual's
essential service preferences, the funding source of services, and any other
information the individual chooses to share with prospective
providers; (e) Making available to all qualified providers in the
county that have expressed an interest in serving additional individuals, the
individual-specific profile created in accordance with paragraph (C)(2)(d) of
this rule to identify willing providers of the service; (f) Contacting providers on the individual's
behalf; (g) Developing provider interview questions that reflect
the characteristics of the individual's preferred provider;
and (h) Scheduling and participating as needed in interviews of
prospective providers. If the individual chooses to interview the county board
as a prospective provider, the service and support administrator shall disclose
to the individual that the service and support administrator is employed by the
same agency. The service and support administrator may participate in this
interview as directed by the individual. (3) The county board
shall document the alternative home and community-based services settings that
were considered by each individual and ensure that each individual service plan
reflects the setting options chosen by the individual. (4) The county board
shall document that each individual has been offered free choice among all
qualified and willing providers of home and community-based
services. (5) If a county board
receives a complaint from an individual regarding the free choice of provider
process, the county board shall respond to the individual within thirty
calendar days and provide the department with a copy of the individual's
complaint and the county board's response. The department shall review the
complaint and the county board's response and take actions it determines
necessary to ensure that each individual has been afforded free choice among
all qualified and willing providers of home and community-based
services. (6) The county board
shall notify the department if the county board becomes aware of a provider
conditioning willingness to provide a home and community-based service to an
individual on being selected by that individual to provide another
service. (D) Additional requirements that apply
when a county board provides home and community-based services (1) So long as a county
board is a provider of home and community-based services, the county board
shall: (a) Ensure administrative separation between county board
staff doing assessments and service planning and county board staff delivering
direct services. (b) Establish and implement annual benchmarks for
recruitment of sufficient providers of adult day support, career planning,
group employment support, individual employment support, non-medical
transportation, and vocational habilitation. Benchmarks are subject to approval
by the department. The county board shall report progress on achieving
benchmarks to the department twice per year in accordance with the schedule and
format established by the department. (c) Implement annual benchmarks for reducing by one-third
in calendar years 2021, 2022, and 2023, the number of individuals for whom the
county board provides adult day support, career planning, group employment
support, individual employment support, non-medical transportation, and
vocational habilitation as of the effective date of this rule. The county board
shall report in writing to the department on April first and October first of
calendar years 2021, 2022, and 2023, progress made, including a detailed
explanation of actions the county board is taking to ensure achievement of the
established benchmarks. (d) Refrain from providing adult day support, career
planning, group employment support, individual employment support, non-medical
transportation, or vocational habilitation to an individual for whom the county
board was not already providing the service prior to the effective date of this
rule. (2) In accordance with
Ohio's home and community-based services waiver amendments approved by the
federal centers for medicare and medicaid services on May 22, 2020 and 42
C.F.R. 441.301(c)(1)(vi) in effect on the effective date of this rule, a county
board shall cease providing home and community-based services on or before
February 28, 2024. (E) Commencement of services The county board shall adopt written procedures
to ensure that home and community-based services begin in accordance with the
date established in the individual service plan. The procedures shall include a
requirement for the county board to monitor the service commencement process
and implement corrective measures if services do not begin as indicated. (F) Department training and
oversight (1) The department shall
periodically provide training and assistance to familiarize county boards and
individuals with the rights and responsibilities set forth in this
rule. (2) The department shall investigate or
cause an investigation when an individual alleges that he or she is being
denied free choice of providers for home and community-based
services. (3) The department shall utilize the
accreditation process in accordance with rule 5123-4-01 of the Administrative
Code to monitor county board compliance with requirements of this
rule. (G) Due process and appeal
rights (1) Any recipient of or
applicant for home and community-based services may utilize the process set
forth in section 5101.35 of the Revised Code, in accordance with division
5101:6 of the Administrative Code, for any purpose authorized by that statute
and the rules implementing the statute, including being denied the choice of a
provider who is qualified and willing to provide home and community-based
services. The process set forth in section 5101.35 of the Revised Code is
available only to applicants, recipients, and their lawfully authorized
representatives. (2) Providers shall not
utilize or attempt to utilize the process set forth in section 5101.35 of the
Revised Code. Providers shall not appeal or pursue any other legal challenge to
a decision resulting from the process set forth in section 5101.35 of the
Revised Code. (3) The county board
shall inform the individual, in writing and in a manner the individual can
understand, of the individual's right to request a hearing in accordance
with division 5101:6 of the Administrative Code. (4) The county board
shall immediately implement any final state hearing decision or administrative
appeal decision relative to free choice of providers for home and
community-based services issued by the Ohio department of medicaid, unless a
court of competent jurisdiction modifies such a decision as the result of an
appeal by the medicaid applicant or recipient. (H) Authority of director to modify
provisions of this rule During the COVID-19 state of emergency declared
by the governor, the director of the department may modify the requirements in
paragraph (C)(2) of this rule to allow a service and support administrator to
assist an individual as described in paragraphs (C)(2)(a) to (C)(2)(h) of this
rule, to the extent possible during the emergency, by using telephone, video
conference, electronic communication, or other means.
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Rule 5123-9-12 | Home and community-based services waivers - assistive technology under the individual options, level one, and self-empowered life funding waivers.
Effective:
October 15, 2021
(A) Purpose This rule defines assistive technology and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Accredited
college or university" means a college or university accredited by a
national or regional association recognized by the secretary of the United
States department of education or a foreign college or university of comparable
standing. (2) "Acquisition costs" means
the cost of any attachments, accessories, or auxiliary apparatus necessary to
make assistive technology equipment usable; taxes; duty; protective in-transit
insurance; and freight charges. (3) "Actual price" means the
actual price that a provider of assistive technology equipment is charged to
purchase an item of equipment by the seller and that fully and accurately
reflects any discount or rebate the provider receives. The provider shall
maintain documentation of the actual price in the form of an invoice from the
seller that gives details of date, price, quantity, and type of the assistive
technology equipment or other documentation approved by the
department. (4) "Agency provider" has the
same meaning as in rule 5123-2-08 of the Administrative Code. (5) "Assistive technology"
means an interactive electronic item, device, product system, or engineered
solution, whether acquired commercially, modified, or customized, that
addresses an individual's needs and outcomes identified in the individual
service plan and that is for the direct benefit of the individual in
maintaining or improving independence, functional capabilities, vocational
skills, community involvement, or physical skills. Assistive technology has
three distinct components: (a) "Assistive technology consultation" means an
evaluation of the assistive technology needs of an individual, including a
functional evaluation of technologies available to address the
individual's assessed needs and support the individual to achieve outcomes
identified in his or her individual service plan. (b) "Assistive technology equipment" means the cost of
equipment comprising the assistive technology and may include engineering,
designing, fitting, customizing, or otherwise adapting the equipment to meet an
individual's specific needs. Assistive technology equipment may include
equipment used for remote support such as motion sensing system, radio
frequency identification, live video feed, live audio feed, web-based
monitoring, or other device that meets the requirements set forth in this rule
and rule 5123-9-35 of the Administrative Code. Assistive technology equipment
does not include non-technical, non-electronic equipment (e.g., grab bars or
wheelchair ramps) or items otherwise available as environmental accessibility
adaptations or specialized medical equipment and supplies. (c) "Assistive technology support" means education and
training that aids an individual in the use of assistive technology equipment
as well as training for the individual's family members, guardian, staff,
or other persons who provide natural supports or paid services, employ the
individual, or who are otherwise substantially involved in activities being
supported by the assistive technology equipment. Assistive technology support
may include, when necessary, coordination with complementary therapies or
interventions and adjustments to existing assistive technology to ensure its
ongoing effectiveness. (6) "County board" means a
county board of developmental disabilities. (7) "Department" means the Ohio
department of developmental disabilities. (8) "Environmental accessibility
adaptations" has the same meaning as in rule 5123-9-23 of the
Administrative Code. (9) "Fifteen-minute billing
unit" means a billing unit that equals fifteen minutes of service delivery
time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day shall be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (10) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (11) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (14) "Manufacturer's suggested
retail price" means the current retail price of an item of assistive
technology equipment that is recommended by the item's manufacturer. If a
provider of assistive technology equipment is also the manufacturer, the
provider may establish a suggested retail price if the price is equal to or
less than the suggested retail price for the same or a comparable item of
equipment recommended by one or more other manufacturers. (15) "Remote support" has the
same meaning as in rule 5123-9-35 of the Administrative Code. (16) "Remote support vendor" has
the same meaning as in rule 5123-9-35 of the Administrative Code. (17) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (18) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (19) "Specialized medical equipment
and supplies" has the same meaning as in rule 5123-9-25 of the
Administrative Code. (20) "Team" has the same meaning
as in rule 5123-4-02 of the Administrative Code. (21) "Useful life" means two
years. (22) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Assistive technology
shall be provided by an agency provider that meets the requirements of this
rule and that has a medicaid provider agreement with the Ohio department of
medicaid. (2) Assistive technology
shall not be provided by an independent provider, a county board, or a regional
council of governments formed under section 5126.13 of the Revised Code by two
or more county boards. (3) An applicant seeking
approval to provide assistive technology shall complete and submit an
application through the department's website
(http://dodd.ohio.gov). (4) An applicant seeking
approval to provide assistive technology consultation shall submit
documentation to the department demonstrating that persons who deliver the
service: (a) Hold a license in occupational therapy or physical therapy
issued in accordance with Chapter 4755. of the Revised Code; or (b) Hold a license in speech-language pathology issued in
accordance with Chapter 4753. of the Revised Code; or (c) Hold assistive technology professional certification issued
by the "Rehabilitation Engineering and Assistive Technology Society of
North America;" or (d) Have at least two years of full-time (or part-time
equivalent), paid work experience in the developmental disabilities services
delivery system and hold a bachelor's degree from an accredited college or
university in: (i) Biomedical, computer,
electrical, or mechanical engineering; (ii) Health and
rehabilitation sciences including, but not limited to, occupational therapy,
physical therapy, speech-language pathology, or rehabilitation counseling;
or (iii) Engineering
technology, special education, or a related program. (5) An applicant seeking
approval to provide assistive technology equipment shall provide written
assurance that the applicant has experience related to interactive electronic
items, devices, product systems, or engineered solutions that directly benefit
individuals in maintaining or improving independence, functional capabilities,
vocational skills, community involvement, or physical skills. (6) An applicant seeking
approval to provide assistive technology support shall either: (a) Meet the requirements set forth in paragraph (C)(4) or this
rule; or (b) Meet the requirements set forth in paragraph (C)(5) of this
rule. (7) Failure to comply
with this rule and rule 5123-2-08 of the Administrative Code may result in
denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) Assistive technology
is intended to address an individual's assessed needs in a manner that
promotes autonomy and minimizes dependence on paid support staff and should be
explored prior to authorizing services that may be more intrusive, including
homemaker/personal care. (2) Assistive technology
shall be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (3) Prior to selecting
assistive technology equipment, the team may access assistive technology
consultation by a qualified provider to assess the fit between an individual
and a device or system being considered for purchase or lease. (4) In accordance with
rule 5123:2-9-02 of the Administrative Code, waiver funds may be used for
assistive technology only when no other funds or resources are
available. (5) Purchase or lease of
assistive technology equipment shall be the least costly alternative that
reasonably meets an individual's assessed needs. (6) Assistive technology
equipment shall not include: (a) Internet
service; (b) Items or equipment that are illegal or otherwise
prohibited by federal or state statutes or regulations; (c) Items or equipment used solely for entertainment or
recreational purposes; (d) Items or equipment used solely for the purpose of
general utility; (e) New equipment or repair of previously approved
equipment that has been damaged as a result of confirmed misuse, abuse, or
negligence; or (f) Purchase or lease of a personal computing device such
as a desktop, laptop, or tablet that duplicates any similar equipment in the
possession of, or service currently used by, the individual. (7) A provider of
assistive technology equipment shall be responsible for: (a) Delivery of the assistive technology equipment to the
individual; (b) Assembly and set-up of the assistive technology
equipment; (c) Coordinating as necessary with a provider of assistive
technology support to ensure the individual and others identified by the
individual receive instruction in effective use of the assistive technology
equipment; and (d) Maintenance, necessary repairs, and replacement of the
assistive technology equipment prior to expiration of its useful life for any
reason other than misuse or damage by the individual. (8) Assistive technology
equipment to be used for remote support shall be designed so that it may be
turned off by the remote support vendor when requested by a person designated
in the individual service plan. (9) Assistive technology support shall
not exceed forty hours per waiver eligibility span. (10) A provider of assistive technology
support shall coordinate as necessary with the provider of assistive technology
equipment to ensure that the individual and others identified by the individual
receive instruction in effective use of the assistive technology
equipment. (E) Documentation of
services (1) Service documentation
for assistive technology shall include each of the following to validate
payment for medicaid services. (a) Type of service (i.e., assistive technology consultation,
assistive technology equipment, or assistive technology support). (b) Name of individual receiving service. (c) Medicaid identification number of individual receiving
service. (d) Name of provider. (e) Provider identifier/contract number. (2) In addition to the
requirements set forth in paragraph (E)(1) of this rule, service documentation
for assistive technology consultation shall include: (a) A description of the functional evaluation process and
technologies considered to address the individual's needs and support
desired outcomes. (b) A written recommendation that identifies the specific items
and estimated cost of assistive technology equipment necessary to advance
achievement of outcomes defined in the individual service plan. (c) The date the written recommendation was completed and
submitted to the individual's service and support
administrator. (3) In addition to the
requirements set forth in paragraph (E)(1) of this rule, service documentation
for assistive technology equipment shall include: (a) The address where assistive technology equipment is
installed. (b) A list of installed assistive technology equipment including
the date each item of assistive technology equipment is installed, modified,
repaired, or removed and the reasons therefore, and associated adjustments in
cost. (4) In addition to the
requirements set forth in paragraph (E)(1) of this rule, service documentation
for assistive technology support shall include, as applicable: (a) The date, time, duration, location, and description of
education and training provided and the names of persons receiving the
education and training. (b) The date, time, duration, location, and description of
activities necessary to coordinate assistive technology with complementary
therapies or interventions. (F) Payment standards (1) The billing units,
service codes, and payment rates for assistive technology are contained in the
appendix to this rule. (2) A county board shall
authorize payment for assistive technology consultation within ten calendar
days of receiving the written recommendation described in paragraph (E)(2)(b)
of this rule. (3) The cost of all
components of assistive technology equipment shall not exceed five thousand
dollars per waiver eligibility span. (4) Purchase or lease of assistive
technology equipment shall include, as appropriate, monthly fees and the
manufacturer's and seller's warranties. (5) When a provider of assistive
technology equipment leases or manufactures assistive technology equipment, the
cost billed to the department shall be the lesser of the provider's usual
and customary charge or the manufacturer's suggested retail price (which
shall be prorated over the useful life of the assistive technology equipment)
plus a reasonable percentage adequate to cover the cost of the provider's
responsibilities as set forth in paragraph (D)(7) of this rule. (6) When a provider of assistive
technology equipment purchases assistive technology equipment, the cost billed
to the department shall be the lesser of the provider's usual and
customary charge or the actual price plus acquisition costs of the item plus a
reasonable percentage adequate to cover the cost of the provider's
responsibilities as set forth in paragraph (D)(7) of this rule. (7) Claims for payment for assistive
technology shall be submitted to the department upon the provider's
receipt of verification from the county board that the delivered services meet
the requirements specified in the individual service plan. (8) When two or more individuals share
assistive technology equipment, the payment rate shall be divided equally among
those individuals, without regard to funding source for the
service.
Last updated October 15, 2021 at 8:30 AM
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Rule 5123-9-13 | Home and community-based services waivers - career planning under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines career planning and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. The expected outcome of career
planning is the individual's achievement of competitive integrated
employment and/or career advancement in competitive integrated
employment. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency provider" has the
same meaning as in rule 5123-2-08 of the Administrative Code. (3) "Budget
limitation" has the same meaning as in rule 5123-9-19 of the
Administrative Code. (4) "Career planning" means
individualized, person-centered, comprehensive employment planning and support
that provides assistance for individuals to achieve or advance in competitive
integrated employment. Career planning is a focused and time-limited engagement
of an individual in identification of a career direction and development of a
plan for achieving competitive integrated employment and the supports needed to
achieve that employment. Components of career planning include: (a) Benefits education and analysis. Benefits education and
analysis, also known as "work incentives planning," provides
information to individuals, families, guardians, advocates, service and support
administrators, and educators about the impact of paid employment on a range of
public assistance and benefits programs, including but not limited to
supplemental security income, social security disability insurance, medicaid
buy-in for workers with disabilities, medicare continuation benefits,
veteran's benefits, supplemental nutrition assistance program, and housing
assistance. A maximum of four benefits education and analyses may be funded
through the individual's waiver in a waiver eligibility span. (b) Career discovery. Career discovery is an individualized,
comprehensive process to help an individual, who is pursuing individualized
integrated employment or self-employment, reveal how interests and activities
of daily life may be translated into possibilities for integrated employment.
Career discovery results in identification of the individual's interests
in one or more specific aspects of the job market; the individual's
skills, strengths, and other contributions likely to be valuable to employers
or valuable to the community if offered through self-employment; and conditions
necessary for the individual's successful employment or self-employment.
This service culminates in development of a written career discovery profile
summarizing the process, revelations, and recommendations for next steps which
shall be used to develop the individual's vocational portfolio. A maximum
of four career discovery processes may be funded through the individual's
waiver in a waiver eligibility span. (c) Career exploration. Career exploration assists an individual
to interact with job holders and observe jobs and job tasks. Career exploration
may include informational interviews with and/or shadowing persons who are
actually performing the job duties of the identified occupation. When possible,
the individual shall be given an opportunity to perform actual job duties as
well. (d) Employment/self-employment plan. Employment/self-employment
plan is an individualized service to create a clear plan for employment or the
start-up phase of self-employment and includes a planning meeting involving the
job seeker and other key people who will be instrumental in supporting the job
seeker to become employed in competitive integrated employment. The service may
include career advancement planning for individuals who are already employed.
This service culminates in development of a written employment plan directly
tied to the results of career exploration, if previously authorized,
situational observation and assessment, and/or career discovery. For
individuals seeking self-employment, this service culminates in development of
a self-employment business plan that identifies training and technical
assistance needs and potential supports and resources for those services as
well as potential sources of business financing given that medicaid funds may
not be used to defray the capital expenses associated with starting a business.
A maximum of four employment/self-employment plans may be funded through the
individual's waiver in a waiver eligibility span. (e) Job development. Job development is an individualized service
to develop a strategy to achieve competitive integrated employment. The job
development strategy shall reflect best practices. The service may include
analyzing a job site, identifying necessary accommodations, and negotiating
with an employer for customized employment. This service is intended to result
in achievement of competitive integrated employment consistent with the job
seeker's or job holder's personal and career goals as identified in
the individual service plan, as determined through career exploration,
situational observation and assessment, career discovery, and/or the employment
planning process. This service shall not be provided to an individual on place
four of the path to community employment as described in paragraph
(D)(2)(a)(iv) of rule 5123:2-2-05 of the Administrative Code. (f) Self-employment launch. Self-employment launch is support to
implement a self-employment business plan and launch a business. This service
is intended to result in the achievement of an integrated employment outcome
consistent with the job seeker's or job holder's personal and career
goals as identified in the individual service plan, as determined through
career exploration, situational observation and assessment, career discovery,
and/or the employment planning process. This service shall not be provided to
an individual on place four of the path to community employment as described in
paragraph (D)(2)(a)(iv) of rule 5123:2-2-05 of the Administrative
Code. (g) Situational observation and assessment. Situational
observation and assessment is observation and assessment, not to exceed thirty
days, of the individual's interpersonal skills, work behaviors, and
vocational skills through practical, experiential, community integrated, paid
work experiences related to the individual's preferences as established in
the individual service plan. Information gathered through situational
observation and assessment provides a context to further determine the skills
or behaviors to be developed by the individual to ensure his or her success in
the individual's preferred work environment. A maximum of four situational
observations and assessments may be funded through the individual's waiver
in a waiver eligibility span. (h) Worksite accessibility. Worksite accessibility
includes: (i) Time spent
identifying the need for and ensuring the provision of reasonable worksite
accommodations that allow the job seeker or job holder to gain, retain, and
enhance employment or self-employment; and (ii) Time spent ensuring
the provision of reasonable worksite accommodations through partnership efforts
with the employer and, when appropriate, the opportunities for Ohioans with
disabilities agency. (5) "Competitive
integrated employment" means work (including self-employment) that is
performed on a full-time or part-time basis: (a) For which an individual is: (i) Compensated: (a) At a rate that shall be not less than the higher of the rate
specified in the Fair Labor Standards Act of 1938, 29 U.S.C. 206(a)(1), as in
effect on the effective date of this rule, or the rate specified in the
applicable state or local minimum wage law and is not less than the customary
rate paid by the employer for the same or similar work performed by other
employees who do not have disabilities, and who are in similar occupations by
the same employer and who have similar training, experience, and skills;
or (b) In the case of an individual who is self-employed, yields an
income that is comparable to the income received by persons without
disabilities, who are self-employed in similar occupations or on similar tasks
and who have similar training, experience, and skills; and (ii) Eligible for the
level of benefits provided to other full-time and part-time
employees; (b) At a location where the individual interacts with persons
without disabilities to the same extent as employees who are not receiving home
and community-based services; (c) That is not performed in: (i) Dispersed enclaves in
which individuals work in a self-contained unit within a company or service
site in the community or perform multiple jobs in the company, but are not
integrated with non-disabled employees of the company; or (ii) Mobile work crews
comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the community;
and (d) That, as appropriate, presents opportunities for advancement
that are similar to those for persons without disabilities who have similar
positions. (6) "County board" means a
county board of developmental disabilities. (7) "Customized
employment" means competitive integrated employment designed to meet the
specific abilities of an individual with a significant disability and the
business needs of an employer that is carried out through flexible strategies
such as job exploration by the individual and working with an employer to
facilitate placement including: (a) Customizing a job description based on current employer needs
or on previously unidentified and unmet employer needs; (b) Developing a set of job duties, a work schedule and job
arrangement, and specifics of supervision (including performance evaluation and
review), and determining a job location; and (c) Providing services and supports at the job
location. (8) "Department" means the Ohio
department of developmental disabilities. (9) "Fifteen-minute billing
unit" means a billing unit that equals fifteen minutes of service delivery
time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day may be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (10) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (11) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (14) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (15) "Mentor"
means a person employed by or under contract with the agency provider who has
experience providing direct services to persons with developmental disabilities
and who is available on a regular basis to provide guidance to new direct
support professionals regarding techniques and practices that enhance the
effectiveness of the provision of career planning. (16) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (17) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (18) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (19) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
re-determination date. (C) Provider qualifications (1) Career planning shall
be provided by an agency provider or an independent provider that meets the
requirements of this rule and that has a medicaid provider agreement with the
Ohio department of medicaid. (2) An applicant seeking
approval to provide career planning shall complete and submit an application
through the department's website (http://dodd.ohio.gov). (3) An applicant seeking
independent provider certification to provide career planning shall
have: (a) At least one year of full-time (or part-time equivalent),
paid work experience related to employment planning and support that assists
individuals to achieve competitive integrated employment; or (b) Thirty hours of formal training related to employment
planning and support that assists individuals to achieve competitive integrated
employment. (4) In addition to
meeting the requirements set forth in paragraph (C)(3) of this rule, an
applicant seeking independent provider certification to provide some components
of career planning shall meet additional requirements: (a) An independent provider of the benefits education and
analysis component of career planning shall demonstrate that he or she has
successfully completed nationally approved or accredited training in benefits
education and analysis. (b) An independent provider of the worksite accessibility
component of career planning shall demonstrate that he or she holds an
appropriate license (e.g., occupational therapist) or certification (e.g.,
certified professional ergonomist issued by the "Board of Certification in
Professional Ergonomics"), or has successfully completed appropriate
training by an accredited college or university. (5) An agency provider
shall ensure that direct support professionals who provide career planning
successfully complete, no later than thirty calendar days after hire, training
in: (a) Services that comprise career planning including the
expectation that career planning will eventually lead to competitive integrated
employment; (b) Signs and symptoms of illness or injury and procedure
for response; (c) Building/site-specific emergency response plans;
and (d) Program-specific transportation safely. (6) An agency provider shall ensure
that: (a) Direct support professionals who perform the benefits
education and analysis component of career planning have successfully completed
nationally approved or accredited training in benefits education and
analysis. (b) Direct support professionals who perform the worksite
accessibility component of career planning hold an appropriate license (e.g.,
occupational therapist) or certification (e.g., certified professional
ergonomist issued by the "Board of Certification in Professional
Ergonomics"), or have successfully completed appropriate training by an
accredited college or university. (7) An agency provider shall ensure that
direct support professionals who provide career planning (other than those who
have at least one year of experience providing career planning at the point of
hire), during the first year after hire, are assigned and have access to a
mentor. (8) An agency provider shall ensure that
direct support professionals who provide career planning (other than those who
have at least one year of experience providing career planning at the point of
hire), no later than one year after hire, successfully complete at least eight
hours of training specific to the provision of career planning that includes,
but is not limited to: (a) Skill building in advancement of individuals on the path to
community employment as described in rule 5123:2-2-05 of the Administrative
Code and development of individuals' strengths and skills necessary for
competitive integrated employment; and (b) Self-determination which includes assisting the individual to
develop self-advocacy skills, to exercise his or her civil rights, to exercise
control and responsibility over the services he or she receives, and to acquire
skills that enable him or her to become more independent, productive, and
integrated within the community. (9) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) The expected outcome
of career planning is the individual's achievement of competitive
integrated employment and/or career advancement in competitive integrated
employment. (2) The service and
support administrator shall ensure that documentation is maintained to
demonstrate that the service provided as career planning to an individual
enrolled in a waiver is not otherwise available as vocational rehabilitation
services funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C.
730, as in effect on the effective date of this rule, or as special education
or related services as those terms are defined in section 602 of the
Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C.
1401, as in effect on the effective date of this rule. (3) Career planning shall be provided
pursuant to a person-centered individual service plan that conforms to the
requirements of rules 5123-4-02 and 5123:2-2-05 of the Administrative Code and
shall be coordinated with other services and supports set forth in the
individual service plan. (4) Career planning may be provided in a
variety of settings but shall not be furnished in the individual's home
except when a home visit is conducted as part of the career discovery component
of career planning or when the individual is self-employed and the home is the
site of self-employment. (5) Career planning shall be provided at
a ratio of one direct support professional to one individual. (6) Career planning services may extend
to those times when the individual is not physically present while the provider
is performing career planning activities on behalf of the
individual. (7) A provider of career planning shall
complete reports and collect and submit data via the department's
employment tracking system in accordance with rule 5123:2-2-05 of the
Administrative Code. (8) A provider of career planning shall
recognize changes in the individual's condition and behavior as well as
safety and sanitation hazards, report to the service and support administrator,
and record the changes in the individual's written record. (E) Documentation of
services (1) Service documentation
for the career exploration, job development, self-employment launch, and
worksite accessibility components of career planning shall include each of the
following to validate payment for medicaid services: (a) Type of service. (b) Date of service. (c) Place of service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving
service. (f) Name of provider. (g) Provider identifier/contract number. (h) Written or electronic signature of the person delivering the
service, or initials of the person delivering the service if a signature and
corresponding initials are on file with the provider. (i) Description and details of the services delivered that
directly relate to the services specified in the approved individual service
plan as the services to be provided. (j) Times the delivered service started and stopped. (k) Number of units of the delivered service. (2) Service documentation
for the benefits education and analysis, career discovery,
employment/self-employment plan, and situational observation and assessment
components of career planning shall include each of the following to validate
payment for medicaid services: (a) Type of service. (b) Date of service. (c) Place of service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving
service. (f) Name of provider. (g) Provider identifier/contract number. (h) Written or electronic signature of the person delivering the
service, or initials of the person delivering the service if a signature and
corresponding initials are on file with the provider. (i) Description and details of the services delivered that
directly relate to the services specified in the approved individual service
plan as the services to be provided. The description and details of the
services delivered shall be sufficient to demonstrate achievement of the
desired outcomes in order to serve as the report required for payment for
delivery of the services. (F) Payment standards (1) The billing units,
service codes, and payment rates for career planning are contained in the
appendix to this rule. (2) Payment for adult day
support, career planning, group employment support, individual employment
support, and vocational habilitation, alone or in combination, shall not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (3) The county board
shall authorize payment for the benefits education and analysis, career
discovery, employment/self-employment plan, and situational observation and
assessment components of career planning within ten calendar days of acceptance
of a report required for payment for delivery of services pursuant to paragraph
(E)(2)(i) of this rule. (4) Payment rates for the career
exploration, job development, self-employment launch, and worksite
accessibility components of career planning shall be modified to reflect the
needs of an individual requiring behavioral support upon determination by the
department that the individual meets the criteria set forth in paragraph
(F)(4)(a) of this rule. The amount of the behavioral support rate modification
applied to each fifteen-minute billing unit of service is contained in the
appendix to this rule. (a) The department shall determine that an individual meets the
criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual either: (a) Has a response of "yes" to at least four items in
question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed, will
result in the individual's engagement in behavior destructive to self or
others. (b) The duration of the behavioral support rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (5) Payment rates for the career
exploration, job development, self-employment launch, and worksite
accessibility components of career planning shall be modified to reflect the
needs of an individual requiring medical assistance upon determination by the
county board that the individual meets the criteria set forth in paragraph
(F)(5)(a) of this rule. The amount of the medical assistance rate modification
applied to each fifteen-minute billing unit of service is contained in the
appendix to this rule. (a) The county board shall determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy and/or jejunostomy tube, and/or requires the administration
of routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually.
Last updated January 3, 2022 at 9:56 AM
|
Rule 5123-9-14 | Home and community-based services waivers - vocational habilitation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines vocational habilitation and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of vocational habilitation is the advancement of an individual on his
or her path to community employment in accordance with rule 5123:2-2-05 of the
Administrative Code and the individual's achievement of competitive
integrated employment in a job well-matched to the individual's interests,
strengths, priorities, and abilities. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Budget
limitation" has the same meaning as in rule 5123-9-19 of the
Administrative Code. (4) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (5) "Competitive
integrated employment" means work (including self-employment) that is
performed on a full-time or part-time basis: (a) For which an individual is: (i) Compensated: (a) At a rate that shall be not less than the higher of the rate
specified in the Fair Labor Standards Act of 1938, 29 U.S.C. 206(a)(1), as in
effect on the effective date of this rule, or the rate specified in the
applicable state or local minimum wage law and is not less than the customary
rate paid by the employer for the same or similar work performed by other
employees who do not have disabilities, and who are in similar occupations by
the same employer and who have similar training, experience, and skills;
or (b) In the case of an individual who is self-employed, yields an
income that is comparable to the income received by persons without
disabilities, who are self-employed in similar occupations or on similar tasks
and who have similar training, experience, and skills; and (ii) Eligible for the
level of benefits provided to other full-time and part-time
employees; (b) At a location where the individual interacts with persons
without disabilities to the same extent as employees who are not receiving home
and community-based services; (c) That is not performed in: (i) Dispersed enclaves in
which individuals work in a self-contained unit within a company or service
site in the community or perform multiple jobs in the company, but are not
integrated with non-disabled employees of the company; or (ii) Mobile work crews
comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the community;
and (d) That, as appropriate, presents opportunities for advancement
that are similar to those for persons without disabilities who have similar
positions. (6) "County board" means a
county board of developmental disabilities. (7) "Daily billing
unit" means a billing unit that may be used when between five and seven
hours of vocational habilitation are delivered by the same provider to the same
individual during one calendar day in accordance with the conditions specified
in paragraph (F)(2) of this rule. (8) "Department" means the Ohio
department of developmental disabilities. (9) "Fifteen-minute billing
unit" means a billing unit that equals fifteen minutes of service delivery
time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. (10) "Group
employment support" has the same meaning as in rule 5123-9-16 of the
Administrative Code. (11) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (12) "Individual" means a person with a developmental
disability or for purposes of giving, refusing to give, or withdrawing consent
for services, his or her guardian in accordance with section 5126.043 of the
Revised Code or other person authorized to give consent. (13) "Individual
employment support" has the same meaning as in rule 5123-9-15 of the
Administrative Code. (14) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (15) "Integrated
community setting" means a setting that is integrated in and supports full
access of individuals to the greater community to the same degree of access as
persons not receiving home and community-based services. (16) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of vocational habilitation. (17) "Natural supports" means
the personal associations and relationships typically developed in the
community that enhance the quality of life for individuals. Natural supports
may include family members, friends, neighbors, and others in the community or
organizations that serve the general public who provide voluntary support to
help an individual achieve agreed upon outcomes through the individual service
plan development process. (18) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (19) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (20) "Virtual
support" means the provision of services by direct support professionals
at a distant site who engage with an individual using interactive technology
that has the capability for two-way, real time audio and video
communication. (21) "Vocational habilitation"
means services that provide learning and work experiences, including volunteer
work, where the individual develops general skills that lead to competitive
integrated employment such as ability to communicate effectively with
supervisors, coworkers, and customers; generally-accepted community workplace
conduct and dress; ability to follow directions; ability to attend to tasks;
workplace problem-solving skills and strategies; and workplace safety and
mobility training. Services are expected to occur over a defined period of time
with specific outcomes to be achieved determined by the individual and his or
her team. Activities that constitute vocational habilitation include, but are
not limited to: (a) Ongoing support, that may be provided in-person or through
virtual support, which includes direct supervision, monitoring and/or
counseling, and the provision of some or all of the following supports to
promote the development of general work skills: (i) Developing a
systematic plan of instruction and support, including task analyses to prepare
the individual for competitive integrated employment; (ii) Assisting the
individual to perform activities that result in increasing his or her social
integration with other persons employed at the worksite; (iii) Supporting and
training the individual in the use of individualized or community-based
transportation services; (iv) Providing services
and training that assist the individual with problem-solving and meeting
job-related expectations; (v) Assisting the
individual to use natural supports and community resources; (vi) Providing training
to the individual to maintain current skills, enhance personal hygiene, learn
new work skills, attain self-determination goals, and improve social skills;
(vii) Developing and
implementing a plan to assist the individual to transition from his or her
vocational habilitation setting to competitive integrated employment
emphasizing the use of natural supports; and (viii) Providing information about or referral to career planning
services, disability benefits services, or other appropriate consultative
services. (b) Ongoing support, that may only be provided in-person,
assisting the individual with self-medication or health-related activities or
performing medication administration or health-related activities in accordance
with Chapters 5123-6 and 5123:2-6 of the Administrative Code. (22) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Vocational
habilitation shall be provided by an agency provider that meets the
requirements of this rule and that has a medicaid provider agreement with the
Ohio department of medicaid. (2) Vocational
habilitation shall not be provided by an independent provider. (3) An applicant seeking
approval to provide vocational habilitation shall complete and submit an
application through the department's website (http://dodd.ohio.gov/) and
adhere to the requirements of rule 5123-2-08 of the Administrative
Code. (4) An agency provider
shall ensure that direct support professionals who provide vocational
habilitation successfully complete, no later than thirty calendar days after
hire, training in: (a) Services that comprise vocational habilitation including the
expectation that vocational habilitation will eventually lead to competitive
integrated employment; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Site-specific emergency response plans; and (d) Program-specific transportation safety. (5) An agency provider
shall ensure that direct support professionals who provide vocational
habilitation (other than those who have at least one year of experience
providing vocational habilitation at the point of hire), during the first year
after hire, are assigned and have access to a mentor. (6) An agency provider
shall ensure that direct support professionals who provide vocational
habilitation (other than those who have at least one year of experience
providing vocational habilitation at the point of hire), no later than one year
after hire, successfully complete at least eight hours of training specific to
the provision of vocational habilitation that includes, but is not limited
to: (a) Skill building in advancement of individuals on the path to
community employment as described in rule 5123:2-2-05 of the Administrative
Code and development of individuals' strengths and skills necessary for
competitive integrated employment; and (b) Self-determination which includes assisting the individual to
develop self-advocacy skills, to exercise his or her civil rights, to exercise
control and responsibility over the services he or she receives, and to acquire
skills that enable him or her to become more independent, productive, and
integrated within the community. (7) Failure to comply with this rule and
rule 5123-2-08 of the Administrative Code may result in denial, suspension, or
revocation of the agency provider's certification. (D) Requirements for service
delivery (1) The expected outcome
of vocational habilitation is the advancement of an individual on his or her
path to community employment in accordance with rule 5123:2-2-05 of the
Administrative Code and the individual's achievement of competitive
integrated employment in a job well-matched to the individual's interests,
strengths, priorities, and abilities. (2) Vocational
habilitation is available to individuals who are no longer eligible for
educational services based on their graduation and/or receipt of a diploma or
equivalency certificate and/or their permanent discontinuation of educational
services within parameters established by the Ohio department of
education. (3) The service and
support administrator shall ensure that documentation is maintained to
demonstrate that the service provided as vocational habilitation to an
individual enrolled in a waiver is not otherwise available as vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this
rule. (4) Vocational habilitation shall be
provided pursuant to a person-centered individual service plan that conforms to
the requirements of rules 5123-4-02 and 5123:2-2-05 of the Administrative Code
and shall be coordinated with other services and supports set forth in the
individual service plan. An individual receiving vocational habilitation shall
have community employment outcomes in his or her individual service plan;
vocational habilitation activities shall be designed to support the
individual's community employment outcomes. (5) Vocational habilitation provided
in-person shall take place in a non-residential setting separate from any
individual's home. An individual participating in vocational habilitation
provided through virtual support may do so from his or her home. (6) Vocational habilitation may be
provided through virtual support under the following conditions: (a) Virtual support does not have the effect of isolating an
individual from the individual's community or preventing the individual
from interacting with people with or without disabilities. (b) The use of virtual support has been agreed to by an
individual and the individual's team and is specified in the individual
service plan. (c) The use of virtual support complies with applicable laws
governing an individual's right to privacy and the individual's
protected health information. (d) Provision of vocational habilitation through virtual support
does not include assisting an individual with self-medication or health-related
activities or performing medication administration or health-related activities
in accordance with Chapters 5123-6 and 5123:2-6 of the Administrative
Code. (7) A provider of vocational habilitation
shall notify the department within fourteen calendar days when there is a
change in the physical address (i.e., adding a new location or closing an
existing location) of any facility where vocational habilitation takes
place. (8) A provider of vocational habilitation
shall complete reports and collect and submit data via the department's
employment tracking system in accordance with rule 5123:2-2-05 of the
Administrative Code. (9) Individuals receiving vocational
habilitation shall be compensated in accordance with applicable federal and
state laws and regulations. A determination that an individual receiving
vocational habilitation is eligible to be paid at special minimum wage rates in
accordance with 29 C.F.R. Part 525, "Employment of Workers with
Disabilities Under Special Certificates," as in effect on the effective
date of this rule, shall be based on documented evaluations and
assessments. (10) A provider of vocational habilitation
shall ensure that appropriate staff are knowledgeable about the Workforce
Innovation and Opportunity Act as in effect on the effective date of this rule,
wage and hour laws, benefits, work incentives, and employer tax credits for
individuals with developmental disabilities and ensure that individuals served
receive this information. (11) A provider of vocational habilitation
shall comply with applicable laws, rules, and regulations of the federal,
state, and local governments pertaining to the physical environment (building
and grounds) where vocational habilitation is provided. A provider of
vocational habilitation shall be informed of and comply with standards
applicable to the service setting. (12) A provider of vocational habilitation
shall recognize changes in the individual's condition and behavior as well
as safety and sanitation hazards, report to the service and support
administrator, and record the changes in the individual's written
record. (E) Documentation of
services Service documentation for vocational habilitation
shall include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (10) Times the delivered
service started and stopped. (11) Number of units of
the delivered service. (F) Payment standards (1) The billing units,
service codes, and payment rates for vocational habilitation are contained in
appendix A to this rule. Payment rates, except payment rates for vocational
habilitation provided in-person in an integrated community setting for a group
of four or fewer individuals, are based on individuals' group assignments
determined in accordance with rule 5123-9-19 of the Administrative Code and the
county cost-of-doing-business category. Payment rates for vocational
habilitation provided in-person in an integrated community setting for a group
of four or fewer individuals are based on the county cost-of-doing-business
category. The cost-of-doing-business category for an individual is the category
assigned to the county in which the service is actually provided for the
preponderance of time. The cost-of-doing-business categories are contained in
appendix B to this rule. (2) A provider of vocational habilitation
may use the daily billing unit when the provider delivers between five and
seven hours of vocational habilitation in-person to the same individual during
one calendar day and: (a) The individual does not qualify for or the provider elects
not to receive the behavioral support rate modification described in paragraph
(F)(6) of this rule; (b) The individual does not qualify for or the provider elects
not to receive the medical assistance rate modification described in paragraph
(F)(7) of this rule; and (c) The provider does not provide vocational habilitation to the
individual in multiple modes on the same day (i.e., in an integrated community
setting when the individual is part of a group of four or fewer individuals and
in another setting). (3) A provider of
vocational habilitation shall use the fifteen-minute billing unit
when: (a) The provider delivers less than five hours or more than seven
hours of vocational habilitation to the same individual during one calendar
day; (b) The individual being served qualifies for and the provider
elects to receive the behavioral support rate modification in accordance with
paragraph (F)(6) of this rule; (c) The individual being served qualifies for and the provider
elects to receive the medical assistance rate modification in accordance with
paragraph (F)(7) of this rule; (d) The provider provides vocational habilitation to the
individual in multiple modes on the same day (i.e., in an integrated community
setting when the individual is part of a group of four or fewer individuals and
in another setting); or (e) The provider provides
vocational habilitation to the individual through virtual support. (4) A provider of
vocational habilitation shall not bill a daily billing unit on the same day the
provider bills fifteen-minute billing units for the same
individual. (5) Payment for adult day
support, career planning, group employment support, individual employment
support, and vocational habilitation, alone or in combination, shall not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (6) Payment rates for
vocational habilitation provided in-person at the fifteen-minute billing unit
shall be eligible for adjustment by the behavioral support rate modification to
reflect the needs of an individual requiring behavioral support upon
determination by the department that the individual meets the criteria set
forth in paragraph (F)(6)(a) of this rule. The amount of the behavioral support
rate modification applied to each fifteen-minute billing unit of service is
contained in appendix A to this rule. (a) The department shall determine that an individual meets the
criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four items in
question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed, will
result in the individual's engagement in behavior destructive to self or
others. (b) The duration of the behavioral support rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (7) Payment rates for
vocational habilitation provided in-person at the fifteen-minute billing unit
shall be eligible for adjustment by the medical assistance rate modification to
reflect the needs of an individual requiring medical assistance upon
determination by the county board that the individual meets the criteria set
forth in paragraph (F)(7)(a) of this rule. The amount of the medical assistance
rate modification applied to each fifteen-minute billing unit of service is
contained in appendix A to this rule. (a) The county board shall determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy and/or jejunostomy tube, and/or requires the administration
of routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually.
View Appendix
Last updated January 3, 2022 at 9:56 AM
|
Rule 5123-9-15 | Home and community-based services waivers - individual employment support under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines individual employment support
and sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of individual employment support is competitive integrated employment
in a job well-matched to the individual's interests, strengths,
priorities, and abilities that meets the individual's personal and career
goals. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Budget
limitation" has the same meaning as in rule 5123-9-19 of the
Administrative Code. (4) "Career planning" has the
same meaning as in rule 5123-9-13 of the Administrative Code. (5) "Competitive integrated
employment" means work (including self-employment) that is performed on a
full-time or part-time basis: (a) For which an individual is: (i) Compensated: (a) At a rate that shall be not less than the higher of the
rate specified in the Fair Labor Standards Act of 1938, 29 U.S.C. 206(a)(1), as
in effect on the effective date of this rule, or the rate specified in the
applicable state or local minimum wage law and is not less than the customary
rate paid by the employer for the same or similar work performed by other
employees who do not have disabilities, and who are in similar occupations by
the same employer and who have similar training, experience, and skills;
or (b) In the case of an individual who is self-employed,
yields an income that is comparable to the income received by persons without
disabilities, who are self-employed in similar occupations or on similar tasks
and who have similar training, experience, and skills; and (ii) Eligible for the
level of benefits provided to other full-time and part-time
employees; (b) At a location where the individual interacts with
persons without disabilities to the same extent as employees who are not
receiving home and community-based services; (c) That is not performed in: (i) Dispersed enclaves in
which individuals work in a self-contained unit within a company or service
site in the community or perform multiple jobs in the company, but are not
integrated with non-disabled employees of the company; or (ii) Mobile work crews
comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the community; and
(d) That, as appropriate, presents opportunities for
advancement that are similar to those for persons without disabilities who have
similar positions. (6) "County board" means a
county board of developmental disabilities. (7) "Customized employment"
means competitive integrated employment designed to meet the specific abilities
of an individual with a significant disability and the business needs of an
employer that is carried out through flexible strategies such as job
exploration by the individual and working with an employer to facilitate
placement including: (a) Customizing a job description based on current employer
needs or on previously unidentified and unmet employer needs; (b) Developing a set of job duties, a work schedule and job
arrangement, and specifics of supervision (including performance evaluation and
review), and determining a job location; and (c) Providing services and supports at the job
location. (8) "Department" means the Ohio
department of developmental disabilities. (9) "Fifteen-minute billing
unit" means a billing unit that equals fifteen minutes of service delivery
time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. (10) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (11) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual employment
support" means individualized support for an individual to maintain
competitive integrated employment. Activities that constitute individual
employment support include but are not limited to: (a) Job coaching which is identification and provision of
services and supports, utilizing task analysis and systematic instruction that
assist the individual in maintaining employment and/or advancing his or her
career. Job coaching includes supports provided to the individual and his or
her supervisor or coworkers on behalf of the individual, either in-person or
remotely via technology. Job coaching may include the engagement of natural
supports in the workplace to provide additional supports that allow the job
coach to maximize his or her ability to fade. Examples of job coaching
strategies include job analysis, job adaptations, instructional prompts, verbal
instruction, self-management tools, physical assistance, role playing, coworker
modeling, and written instruction. Job coaching for self-employment includes
identification and provision of services and supports, including counseling and
guidance, which assist the individual in maintaining self-employment through
the operation of a business. When job coaching is provided, a plan outlining
the steps to reduce job coaching over time shall be in place within thirty
calendar days. (b) Training in assistive or other technology utilized by
the individual while on the job. (c) Other workplace support services including services not
specifically related to job skill training that enable the individual to be
successful in integrating into the job setting. (d) Personal care and assistance, which may be a component
of individual employment support but shall not comprise the entirety of the
service. (14) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (15) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of individual employment support. (16) "Natural
supports" means the personal associations and relationships typically
developed in the community that enhance the quality of life for individuals.
Natural supports may include family members, friends, neighbors, and others in
the community or organizations that serve the general public who provide
voluntary support to help an individual achieve agreed upon outcomes through
the individual service plan development process. (17) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (18) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (19) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (20) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
re-determination date. (C) Provider qualifications (1) Individual employment
support shall be provided by an agency provider or an independent provider that
meets the requirements of this rule and that has a medicaid provider agreement
with the Ohio department of medicaid. (2) An applicant seeking
approval to provide individual employment support shall complete and submit an
application through the department's website (http://dodd.ohio.gov/) and
adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (3) An applicant seeking
independent provider certification to provide individual employment support
shall have: (a) At least one year of full-time (or part-time
equivalent), paid work experience related to supporting individuals to maintain
jobs in the general workforce; or (b) Thirty hours of formal training related to supporting
individuals to maintain jobs in the general workforce. (4) An agency provider
shall ensure that direct support professionals who provide individual
employment support successfully complete, no later than thirty calendar days
after hire, training in: (a) Services that comprise individual employment
support; (b) Signs and symptoms of illness or injury and procedure
for response; (c) Building/site-specific emergency response plans;
and (d) Program-specific transportation safety. (5) An agency provider
shall ensure that direct support professionals who provide individual
employment support (other than those who have at least one year of experience
providing individual employment support at the point of hire), during the first
year after hire, are assigned and have access to a mentor. (6) An agency provider
shall ensure that direct support professionals who provide individual
employment support (other than those who have at least one year of experience
providing individual employment support at the point of hire), no later than
one year after hire, successfully complete at least eight hours of training
specific to the provision of individual employment support that includes, but
is not limited to: (a) Skill-building in job training and systematic
instruction that assists the individual in maintaining employment and or
advancing his or her career; and (b) Self-determination which includes assisting the
individual to develop self-advocacy skills, to exercise his or her civil
rights, to exercise control and responsibility over the services he or she
receives, and to acquire skills that enable him or her to become more
independent, productive, and integrated within the community. (7) Failure to comply
with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) The expected outcome
of individual employment support is competitive integrated employment in a job
well-matched to the individual's interests, strengths, priorities, and
abilities that meets the individual's personal and career
goals. (2) Individual employment
support shall be provided pursuant to a person-centered individual service plan
that conforms to the requirements of rules 5123-4-02 and 5123:2-2-05 of the
Administrative Code and shall be coordinated with other services and supports
set forth in the individual service plan. (3) The service and
support administrator shall ensure that documentation is maintained to
demonstrate that the service provided as individual employment support to an
individual enrolled in a waiver is not otherwise available as vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this rule, or as
special education or related services as those terms are defined in section 602
of the Individuals with Disabilities Education Improvement Act of 2004, 20
U.S.C. 1401, as in effect on the effective date of this rule. (4) Individual employment
support, other than services and supports that assist an individual to maintain
self-employment through the operation of a business, shall take place in a
setting separate from the home of the individual receiving the
services. (5) Individual employment
support shall be provided at a ratio of one direct support professional to one
individual. (6) Individual employment support
services may extend to those times when the individual is not physically
present while the provider is performing individual employment support
activities on behalf of the individual (e.g., developing coworker supports or
meeting with a supervisor). (7) A provider of
individual employment support shall complete reports and collect and submit
data via the department's employment tracking system in accordance with
rule 5123:2-2-05 of the Administrative Code. (8) A provider of
individual employment support shall recognize changes in the individual's
condition and behavior, report to the service and support administrator, and
record the changes in the individual's written record. (9) A provider of
individual employment support shall report identified safety and sanitation
hazards that occur at the worksite to employers having the responsibility to
remedy the condition. (E) Documentation of
services Service documentation for individual employment
support shall include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (10) Times the delivered service started
and stopped. (11) Number of units of the delivered
service. (F) Payment standards (1) The billing unit,
service codes, and payment rates for individual employment support are
contained in the appendix to this rule. (2) Payment for adult day
support, career planning, group employment support, individual employment
support, and vocational habilitation, alone or in combination, shall not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (3) Payment rates for
individual employment support shall be modified to reflect the needs of an
individual requiring behavioral support upon determination by the department
that the individual meets the criteria set forth in paragraph (F)(3)(a) of this
rule. The amount of the behavioral support rate modification applied to each
fifteen-minute billing unit of service is contained in the appendix to this
rule. (a) The department shall determine that an individual meets
the criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four
items in question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed,
will result in the individual's engagement in behavior destructive to self
or others. (b) The duration of the behavioral support rate
modification shall be limited to the individual's waiver eligibility span,
may be determined needed or no longer needed within that waiver eligibility
span, and may be renewed annually. (c) The purpose of the behavioral support rate modification
is to provide funding for the implementation of behavioral support strategies
by staff who have the level of training necessary to implement the strategies;
the department retains the right to verity that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (4) Payment rates for
individual employment support shall be modified to reflect the needs of an
individual requiring medical assistance upon determination by the county board
that the individual meets the criteria set forth in paragraph (F)(4)(a) of this
rule. The amount of the medical assistance rate modification applied to each
fifteen-minute billing unit of service is contained in the appendix to this
rule. (a) The county board shall determine that an individual
meets the criteria for the medical assistance rate modification
when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy and/or jejunostomy tube, and/or requires the administration
of routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate
modification shall be limited to the individual's waiver eligibility span,
may be determined needed or no longer needed within that waiver eligibility
span, and may be renewed annually.
View Appendix
Last updated January 3, 2022 at 9:56 AM
|
Rule 5123-9-16 | Home and community-based services waivers - group employment support under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines group employment support and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of group employment support is paid employment and work experience
leading to further career development and competitive integrated
employment. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Budget limitation" has the
same meaning as in rule 5123-9-19 of the Administrative Code. (4) "Career planning" has the
same meaning as in rule 5123-9-13 of the Administrative Code. (5) "Competitive
integrated employment" means work (including self-employment) that is
performed on a full-time or part-time basis: (a) For which an individual is: (i) Compensated: (a) At a rate that shall be not less than the higher of the
rate specified in the Fair Labor Standards Act of 1938, 29 U.S.C. 206(a)(1), as
in effect on the effective date of this rule, or the rate specified in the
applicable state or local minimum wage law and is not less than the customary
rate paid by the employer for the same or similar work performed by other
employees who do not have disabilities, and who are in similar occupations by
the same employer and who have similar training, experience, and skills;
or (b) In the case of an individual who is self-employed,
yields an income that is comparable to the income received by persons without
disabilities, who are self-employed in similar occupations or on similar tasks
and who have similar training, experience, and skills; and (ii) Eligible for the
level of benefits provided to other full-time and part-time
employees; (b) At a location where the individual interacts with
persons without disabilities to the same extent as employees who are not
receiving home and community-based services; (c) That is not performed in: (i) Dispersed enclaves in
which individuals work in a self-contained unit within a company or service
site in the community or perform multiple jobs in the company, but are not
integrated with non-disabled employees of the company; or (ii) Mobile work crews
comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the community;
and (d) That, as appropriate, presents opportunities for
advancement that are similar to those for persons without disabilities who have
similar positions. (6) "County
board" means a county board of developmental disabilities. (7) "Daily billing
unit" means a billing unit that may be used when between five and seven
hours of group employment support are delivered by the same provider to the
same individual during one calendar day in accordance with the conditions
specified in paragraph (F)(2) of this rule. (8) "Department" means the Ohio department of
developmental disabilities. (9) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. (10) "Group employment support"
means services and training activities provided in regular business, industry,
and community settings for groups of two or more workers with
disabilities. (a) Activities that constitute group employment support
include any combination of the following as necessary and appropriate to meet
the community employment goals of the individual: (i) Person-centered
employment planning; (ii) Work
adjustment; (iii) Job
analysis; (iv) Training and
systematic instruction; (v) Job coaching;
and (vi) Training in
independent planning, arranging, and using transportation. (b) Group employment support is provided in two distinct
service arrangements: (i) Dispersed enclaves in
which individuals work in a self-contained unit within a company or service
site in the community or perform multiple jobs in the company, but are not
integrated with non-disabled employees of the company; or (ii) Mobile work crews
comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the
community. (11) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (12) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual
employment support" has the same meaning as in rule 5123-9-15 of the
Administrative Code. (14) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (15) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of group employment support. (16) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (17) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (18) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (19) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Group employment
support shall be provided by an agency provider that meets the requirements of
this rule and that has a medicaid provider agreement with the Ohio department
of medicaid. (2) Group employment
support shall not be provided by an independent provider. (3) An applicant seeking
approval to provide group employment support shall complete and submit an
application through the department's website (http://dodd.ohio.gov/) and
adhere to the requirements of rule 5123-2-08 of the Administrative
Code. (4) An agency provider
shall ensure that direct support professionals who provide group employment
support successfully complete, no later than thirty calendar days after hire,
training in: (a) Services that comprise group employment
support; (b) Signs and symptoms of illness or injury and procedure
for response; (c) Building/site-specific emergency response plans;
and (d) Program-specific transportation safety. (5) An agency provider
shall ensure that direct support professionals who provide group employment
support (other than those who have at least one year of experience providing
group employment support at the point of hire), during the first year after
hire, are assigned and have access to a mentor. (6) An agency provider
shall ensure that direct support professionals who provide group employment
support (other than those who have at least one year of experience providing
group employment support at the point of hire), no later than one year after
hire, successfully complete at least eight hours of training specific to the
provision of group employment support that includes, but is not limited
to: (a) Skill-building in advancement of individuals on the
path to community employment as described in rule 5123:2-2-05 of the
Administrative Code and development of individuals' strengths and skills
necessary for competitive integrated employment; and (b) Self-determination which includes assisting the
individual to develop self-advocacy skills, to exercise his or her civil
rights, to exercise control and responsibility over the services he or she
receives, and to acquire skills that enable him or her to become more
independent, productive, and integrated within the community. (7) Failure to comply
with this rule and rule 5123-2-08 of the Administrative Code may result in
denial, suspension, or revocation of the agency provider's
certification. (D) Requirements for service
delivery (1) The expected outcome
of group employment support is paid employment and work experience leading to
further career development and competitive integrated employment. (2) Group employment
support shall be provided pursuant to a person-centered individual service plan
that conforms to the requirements of rules 5123-4-02 and 5123:2-2-05 of the
Administrative Code and shall be coordinated with other services and supports
set forth in the individual service plan. (3) The service and
support administrator shall ensure that documentation is maintained to
demonstrate that the service provided as group employment support to an
individual enrolled in a waiver is not otherwise available as vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this rule, or as
special education or related services as those terms are defined in section 602
of the Individuals with Disabilities Education Improvement Act of 2004, 20
U.S.C. 1401, as in effect on the effective date of this rule. (4) Group employment
support shall be provided in an integrated setting and support
individuals' access to the greater community, including opportunities to
seek competitive integrated employment, to engage in community life, and to
have control over earned income. (5) Group employment
support shall take place in a setting separate from the home of the individual
receiving the services. (6) Individuals receiving
group employment support shall be compensated in accordance with applicable
federal and state laws and regulations. A determination that an individual
receiving group employment support is eligible to be paid at special minimum
wage rates in accordance with 29 C.F.R. Part 525, "Employment of Workers
with Disabilities Under Special Certificates," as in effect on the
effective date of this rule, shall be based on documented evaluations and
assessments. (7) A provider of group
employment support shall ensure that appropriate staff are knowledgeable about
the Workforce Innovation and Opportunity Act as in effect on the effective date
of this rule, wage and hour laws, benefits, work incentives, and employer tax
credits for individuals with developmental disabilities and ensure that
individuals served receive this information. (8) A provider of group
employment support shall provide the service in a manner that presumes all
participants are capable of working in competitive integrated employment. The
provider shall encourage individuals receiving the service, on an ongoing
basis, and as part of the annual person-centered planning process, to explore
their interests, strengths, and abilities relating to competitive integrated
employment. The provider shall, as a component of the service, assist
individuals to explore, identify, and pursue opportunities that advance them
toward competitive integrated employment. (9) A provider of group
employment support shall complete reports and collect and submit data via the
department's employment tracking system in accordance with rule
5123:2-2-05 of the Administrative Code. (10) A provider of group
employment support shall recognize changes in the individual's condition
and behavior, report to the service and support administrator, and record the
changes in the individual's written record. (11) A provider of group
employment support shall report identified safety and sanitation hazards that
occur at the work site to employers having the responsibility to remedy the
condition. (E) Documentation of
services Service documentation for group employment
support shall include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (10) Times the delivered
service started and stopped. (11) Number of units of the delivered
service. (F) Payment standards (1) The billing units,
service codes, and payment rates for group employment support are contained in
appendix A to this rule. Payment rates are based on individuals' group
assignments determined in accordance with rule 5123-9-19 of the Administrative
Code and the county cost-of-doing-business category. The cost-of-doing-business
category for an individual is the category assigned to the county in which the
service is actually provided for the preponderance of time. The
cost-of-doing-business categories are contained in appendix B to this
rule. (2) A provider of group
employment support may use the daily billing unit when the provider delivers
between five and seven hours of group employment support to the same individual
during one calendar day and: (a) The individual does not qualify for or the provider
elects not to receive the behavioral support rate modification described in
paragraph (F)(6) of this rule; and (b) The individual does not qualify for or the provider
elects not to receive the medical assistance rate modification described in
paragraph (F)(7) of this rule. (3) A provider of group
employment support shall use the fifteen-minute billing unit when: (a) The provider delivers less than five hours or more than
seven hours of group employment support to the same individual during one
calendar day; (b) The individual being served qualifies for and the
provider elects to receive the behavioral support rate modification in
accordance with paragraph (F)(6) of this rule; or (c) The individual being served qualifies for and the
provider elects to receive the medical assistance rate modification in
accordance with paragraph (F)(7) of this rule. (4) A provider of group
employment shall not bill a daily billing unit on the same day the provider
bills fifteen-minute billing units for the same individual. (5) Payment for adult day support, career
planning, group employment support, individual employment support, and
vocational habilitation, alone or in combination, shall not exceed the budget
limitations contained in appendix B to rule 5123-9-19 of the Administrative
Code. (6) Payment rates for group employment
support shall be modified to reflect the needs of an individual requiring
behavioral support upon determination by the department that the individual
meets the criteria set forth in paragraph (F)(6)(a) of this rule. The amount of
the behavioral support rate modification applied to each fifteen-minute billing
unit of service is contained in appendix A to this rule. (a) The department shall determine that an individual meets
the criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four
items in question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed,
will result in the individual's engagement in behavior destructive to self
or others. (b) The duration of the behavioral support rate
modification shall be limited to the individual's waiver eligibility span,
may be determined needed or no longer needed within that waiver eligibility
span, and may be renewed annually. (c) The purpose of the behavioral support rate modification
is to provide funding for the implementation of behavioral support strategies
by staff who have the level of training necessary to implement the strategies;
the department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (7) Payment rates for group employment
support shall be modified to reflect the needs of an individual requiring
medical assistance upon determination by the county board that the individual
meets the criteria set forth in paragraph (F)(7)(a) of this rule. The amount of
the medical assistance rate modification applied to each fifteen-minute billing
unit of service is contained in appendix A to this rule. (a) The county board shall determine that an individual
meets the criteria for the medical assistance rate modification
when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy and/or jejunostomy tube, and/or requires the administration
of routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such nursing procedure or
nursing task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate
modification shall be limited to the individual's waiver eligibility span,
may be determined needed or no longer needed within that waiver eligibility
span, and may be renewed annually.
View AppendixView Appendix
Last updated January 3, 2022 at 9:57 AM
|
Rule 5123-9-17 | Home and community-based services waivers - adult day support under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines adult day support and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of adult day support is development of skills that lead to greater
independence, community membership, relationship-building, self-direction, and
self-advocacy. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" means provision of regularly scheduled activities such as
assistance with acquisition, retention, or improvement of self-help,
socialization, and adaptive skills that enhance the individual's social
development and performance of daily community living. Adult day support shall
be designed to foster the acquisition of skills, build community membership and
independence, and expand personal choice. Adult day support enables the
individual to attain and maintain his or her maximum potential. Activities that
constitute adult day support include, but are not limited to: (a) Activities that may be provided in-person or through virtual
support: (i) Supports to participate in community activities and build
community membership consistent with the individual's interests,
preferences, goals, and outcomes. (ii) Supports to develop and maintain a meaningful social life,
including social skill development which offers opportunities for personal
growth, independence, and natural supports through community involvement,
participation, and relationships. (iii) Supports and opportunities that increase problem-solving
skills to maximize an individual's ability to participate in integrated
community activities independently or with natural supports. (iv) Skill reinforcement including the implementation of
behavioral support strategies, assistance in the use of communication and
mobility devices, and other activities that reinforce skills learned by the
individual that are necessary to ensure his or her initial and continued
participation in community life. (v) Training in self-determination which includes assisting the
individual to develop self-advocacy skills; to exercise his or her civil
rights; to exercise control and responsibility over the services he or she
receives; and to acquire skills that enable him or her to become more
independent, productive, and integrated within the community. (vi) Recreation and leisure including supports identified in the
person-centered individual service plan as being therapeutic in nature, rather
than merely providing a diversion, and/or as being necessary to assist the
individual to develop and/or maintain social relationships and family
contacts. (b) Activities that may only be provided in-person: (i) Personal care
including supports and supervision in the areas of personal hygiene, eating,
communication, mobility, toileting, and dressing to ensure an individual's
ability to experience and participate in community living. (ii) Assisting an
individual with self-medication or health-related activities or performing
medication administration or health-related activities in accordance with
Chapters 5123-6 and 5123:2-6 of the Administrative Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Budget
limitation" has the same meaning as in rule 5123-9-19 of the
Administrative Code. (4) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (5) "County
board" means a county board of developmental disabilities. (6) "Daily billing
unit" means a billing unit that may be used when between five and seven
hours of adult day support are delivered by the same provider to the same
individual during one calendar day in accordance with the conditions specified
in paragraph (F)(2) of this rule. (7) "Department" means the Ohio department of
developmental disabilities. (8) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. (9) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (10) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (11) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (12) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (13) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (14) "Integrated
community setting" means a setting that is integrated in and supports full
access of individuals to the greater community to the same degree of access as
persons not receiving home and community-based services. (15) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of adult day support. (16) "Natural supports" means
the personal associations and relationships typically developed in the
community that enhance the quality of life for individuals. Natural supports
may include family members, friends, neighbors, and others in the community or
organizations that serve the general public who provide voluntary support to
help an individual achieve agreed upon outcomes through the individual service
plan development process. (17) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (18) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (19) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (20) "Virtual
support" means the provision of services by direct support professionals
at a distant site who engage with an individual using interactive technology
that has the capability for two-way, real time audio and video
communication. (21) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (22) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Adult day support
shall be provided by an agency provider that meets the requirements of this
rule and that has a medicaid provider agreement with the Ohio department of
medicaid. (2) Adult day support
shall not be provided by an independent provider. (3) An applicant seeking
approval to provide adult day support shall complete and submit an application
through the department's website (http://dodd.ohio.gov/) and adhere to the
requirements of rule 5123-2-08 of the Administrative Code. (4) An agency provider
shall ensure that direct support professionals who provide adult day support
successfully complete, no later than thirty calendar days after hire, training
in: (a) Services that comprise adult day support; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Site-specific emergency response plans; and (d) Program-specific transportation safety. (5) An agency provider
shall ensure that direct support professionals who provide adult day support
(other than those who have at least one year of experience providing adult day
support at the point of hire), during the first year after hire, are assigned
and have access to a mentor. (6) An agency provider
shall ensure that direct support professionals who provide adult day support
(other than those who have at least one year of experience providing adult day
support at the point of hire), no later than one year after hire, successfully
complete at least eight hours of training specific to the provision of adult
day support that includes, but is not limited to: (a) Skill building in the necessary activities and environments
that build on the strengths of individuals served and foster the development of
skills that lead to greater independence, community membership,
relationship-building, and self-direction; (b) Developing natural supports; and (c) Self-determination which includes assisting the individual to
develop self-advocacy skills, to exercise his or her civil rights, to exercise
control and responsibility over the services he or she receives, and to acquire
skills that enable him or her to become more independent, productive, and
integrated within the community. (7) Failure to comply with this rule and
rule 5123-2-08 of the Administrative Code may result in denial, suspension, or
revocation of the agency provider's certification. (D) Requirements for service
delivery (1) The expected outcome
of adult day support is development of skills that lead to greater
independence, community membership, relationship-building, self-direction, and
self-advocacy. (2) Adult day support is
available to individuals who are no longer eligible for educational services
based on their graduation and/or receipt of a diploma or equivalency
certificate and/or their permanent discontinuation of educational services
within parameters established by the Ohio department of education. (3) Adult day support shall be provided
pursuant to a person-centered individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code and shall be
coordinated with other services and supports set forth in the individual
service plan. (4) Adult day support provided in-person
shall take place in a non-residential setting separate from any
individual's home. An individual participating in adult day support
provided through virtual support may do so from his or her home. (5) Adult day support may
be provided through virtual support under the following
conditions: (a) Virtual support does not have the effect of isolating an
individual from the individual's community or preventing the individual
from interacting with people with or without disabilities. (b) The use of virtual support has been agreed to by an
individual and the individual's team and is specified in the individual
service plan. (c) The use of virtual support complies with applicable laws
governing an individual's right to privacy and the individual's
protected health information. (d) Provision of adult day support through virtual support does
not include: (i) Personal care
including supports and supervision in the areas of personal hygiene, eating,
communication, mobility, toileting, and dressing to ensure an individual's
ability to experience and participate in community living; or (ii) Assisting an
individual with self-medication or health-related activities or performing
medication administration or health-related activities in accordance with
Chapters 5123-6 and 5123:2-6 of the Administrative Code. (6) A provider of adult day support shall
notify the department within fourteen calendar days when there is a change in
the physical address (i.e., adding a new location or closing an existing
location) of any facility where adult day support takes place. (7) A provider of adult day support shall
comply with applicable laws, rules, and regulations of the federal, state, and
local governments pertaining to the physical environment (building and grounds)
where adult day support is provided. A provider of adult day support shall be
informed of and comply with standards applicable to the service
setting. (8) When meals are provided as part of
adult day support, they shall not constitute a full nutritional regimen (i.e.,
three meals per day). (9) A provider of adult day support shall
recognize changes in the individual's condition and behavior as well as
safety and sanitation hazards, report to the service and support administrator,
and record the changes in the individual's written record. (E) Documentation of
services Service documentation for adult day support shall
include each of the following to validate payment for medicaid services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (10) Times the delivered
service started and stopped. (11) Number of units of
the delivered service. (F) Payment standards (1) The billing units,
service codes, and payment rates for adult day support are contained in
appendix A to this rule. Payment rates, except payment rates for adult day
support provided in-person in an integrated community setting for a group of
four or fewer individuals, are based on individuals' group assignments
determined in accordance with rule 5123-9-19 of the Administrative Code and the
county cost-of-doing-business category. Payment rates for adult day support
provided in-person in an integrated community setting for a group of four or
fewer individuals are based on the county cost-of-doing-business category. The
cost-of-doing-business category for an individual is the category assigned to
the county in which the service is actually provided for the preponderance of
time. The cost-of-doing-business categories are contained in appendix B to this
rule. (2) A provider of adult
day support may use the daily billing unit when the provider delivers between
five and seven hours of adult day support in-person to the same individual
during one calendar day and: (a) The individual does not qualify for or the provider elects
not to receive the behavioral support rate modification described in paragraph
(F)(6) of this rule; (b) The individual does not qualify for or the provider elects
not to receive the medical assistance rate modification described in paragraph
(F)(7) of this rule; and (c) The provider does not provide adult day support to the
individual in multiple modes on the same day (i.e., in an integrated community
setting when the individual is part of a group of four or fewer individuals and
in another setting). (3) A provider of adult
day support shall use the fifteen-minute billing unit when: (a) The provider delivers less than five hours or more than seven
hours of adult day support to the same individual during one calendar
day; (b) The individual being served qualifies for and the provider
elects to receive the behavioral support rate modification in accordance with
paragraph (F)(6) of this rule; (c) The individual being served qualifies for and the provider
elects to receive the medical assistance rate modification in accordance with
paragraph (F)(7) of this rule; (d) The provider provides adult day support to the individual in
multiple modes on the same day (i.e., in an integrated community setting when
the individual is part of a group of four or fewer individuals and in another
setting); or (e) The provider provides adult day support to the
individual through virtual support. (4) A provider of adult
day support shall not bill a daily billing unit on the same day the provider
bills fifteen-minute billing units for the same individual. (5) Payment for adult day
support, career planning, group employment support, individual employment
support, and vocational habilitation, alone or in combination, shall not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (6) Payment rates for
adult day support provided in-person at the fifteen-minute billing unit shall
be eligible for adjustment by the behavioral support rate modification to
reflect the needs of an individual requiring behavioral support upon
determination by the department that the individual meets the criteria set
forth in paragraph (F)(6)(a) of this rule. The amount of the behavioral support
rate modification applied to each fifteen-minute billing unit of service is
contained in appendix A to this rule. (a) The department shall determine that an individual meets the
criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four items in
question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed, will
result in the individual's engagement in behavior destructive to self or
others. (b) The duration of the behavioral support rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (7) Payment rates for
adult day support provided in-person at the fifteen-minute billing unit shall
be eligible for adjustment by the medical assistance rate modification to
reflect the needs of an individual requiring medical assistance upon
determination by the county board that the individual meets the criteria set
forth in paragraph (F)(7)(a) of this rule. The amount of the medical assistance
rate modification applied to each fifteen-minute billing unit of service is
contained in appendix A to this rule. (a) The county board shall determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy and/or jejunostomy tube, and/or requires the administration
of routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (G) Providers certified by the Ohio
department of aging (1) An agency provider
certified by the department to provide adult day support may contract with and
reimburse a provider certified by the Ohio department of aging for adult day
support provided to individuals enrolled in individual options, level one, and
self-empowered life funding waivers. (2) A provider certified
by the Ohio department of aging that is under contract with an agency provider
certified by the department to provide adult day support is not subject to the
requirements set forth in paragraph (C) of this rule. (3) A provider certified
by the Ohio department of aging that is under contract with an agency provider
certified by the department to provide adult day support shall: (a) Meet the requirements for an agency provider in accordance
with rule 173-39-02 of the Administrative Code; (b) Be certified to provide enhanced adult day service and/or
intensive adult day service in an adult day service center in accordance with
rule 173-39-02.1 of the Administrative Code; (c) Require all employees and contractors who provide adult day
support to comply with rule 5123-17-02 of the Administrative Code relating to
incidents affecting health and safety; (d) Participate in annual on-site provider structural compliance
reviews conducted by the Ohio department of aging in accordance with rule
173-39-04 of the Administrative Code; and (e) Meet the requirements of rule 173-39-04 of the Administrative
Code within forty-five business days from each date a structural compliance
review report is mailed from the Ohio department of aging
designee. (4) The agency provider
certified by the department to provide adult day support shall retain
documentation that verifies that the provider certified by the Ohio department
of aging complies with the requirements set forth in paragraph (G)(3) of this
rule. (5) A unit of adult day support provided
through contract with a provider certified by the Ohio department of aging does
not include transportation time. (6) Notwithstanding paragraph (E) of this
rule, service documentation for the provision of adult day support provided
through contract with a provider certified by the Ohio department of aging
shall comply with the provisions of rule 173-39-02.1 of the Administrative
Code. (7) Notwithstanding the requirements of
rule 173-39-02.1 of the Administrative Code, a provider certified by the Ohio
department of aging is not required to arrange or provide non-medical
transportation for individuals, but may provide non-medical transportation
directly or through a contract, if selected by the individual. (8) Except as otherwise set forth in this
rule, all of the provisions of this rule and rule 5123-9-19 of the
Administrative Code are applicable to adult day support provided through
contract with a provider certified by the Ohio department of
aging.
View Appendix
Last updated January 3, 2022 at 9:57 AM
|
Rule 5123-9-18 | Home and community-based services waivers - non-medical transportation under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines non-medical transportation and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Adult day support" has the same meaning as in rule 5123-9-17 of the Administrative Code. (2) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (3) "Budget limitation" has the same meaning as in rule 5123-9-19 of the Administrative Code. (4) "Career planning" has the same meaning as in rule 5123-9-13 of the Administrative Code. (5) "Commercial vehicles" means buses, light rail transit, livery vehicles, and taxicabs that are available for use by the general public. (6) "Commute" means the number of miles driven when one or more individual is riding in a vehicle while non-medical transportation at the per-mile rate is being provided. (7) "County board" means a county board of developmental disabilities. (8) "Department" means the Ohio department of developmental disabilities. (9) "Group employment support" has the same meaning as in rule 5123-9-16 of the Administrative Code. (10) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code. (11) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (13) "Individual employment support" has the same meaning as in rule 5123-9-15 of the Administrative Code. (14) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (15) "Modified vehicle" means: (a) A motor vehicle to be used upon public streets and highways that has been structurally modified in a permanent manner to meet the physical or behavioral needs of the individual being transported; or (b) A motor vehicle that has been designed, constructed, or fabricated and equipped to be used upon public streets and highways for transportation of individuals who require use of a wheelchair and that shall: (i) Have permanent fasteners to secure a wheelchair to the floor or side of the vehicle to prevent wheelchair movement; (ii) Have safety harnesses or belts in the vehicle for the purpose of securing individuals in wheelchairs; (iii) Be equipped with a stable access ramp specifically designed for wheelchairs or a hydraulic lift specifically designed for wheelchairs; and (iv) Be inspected, on each day the vehicle is used to provide non-medical transportation, by the first driver of the vehicle and prior to transporting an individual in a wheelchair, to ensure the permanent fasteners, safety harnesses or belts, and access ramp or hydraulic lift are working. The inspection shall be documented by the driver that conducts the inspection. (16) "Non-medical transportation" means transportation used by an individual to get to, from, between, or among: (a) A place of employment; (b) A location where adult day support, career planning, group employment support, individual employment support, or vocational habilitation is provided to the individual; (c) A volunteer activity; (d) A post-secondary educational program; (e) An internship or practicum; and/or (f) A drop-off or transfer location from which the individual is then transported to or from one of the places specified in paragraphs (B)(16)(a) to (B)(16)(e) of this rule. (17) "Participant-directed homemaker personal care" has the same meaning as in rule 5123-9-32 of the Administrative Code. (18) "Passenger" means a traveler in a vehicle who does not participate in its operation. (19) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (20) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (H) of this rule to validate payment for medicaid services. (21) "Vocational habilitation" has the same meaning as in rule 5123-9-14 of the Administrative Code. (22) "Volunteer activity" means an activity performed by an individual for which the individual receives no payment. (C) Provider qualifications (1) Non-medical transportation shall be provided by an independent provider, an agency provider, or an operator of commercial vehicles that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) An applicant seeking approval to provide non-medical transportation shall complete and submit an application through the department's website (http://dodd.ohio.gov) and adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code. (3) An applicant seeking approval to provide non-medical transportation as an independent provider shall present the applicant's driving record prepared by the bureau of motor vehicles no earlier than fourteen calendar days prior to the date of application for initial or renewal provider certification. A person having six or more points on the person's driving record is prohibited from providing non-medical transportation. (4) An independent provider of non-medical transportation shall: (a) Hold a valid driver's license as specified by Ohio law. (b) Have valid liability insurance as specified by Ohio law. (c) Immediately notify the department, in writing, if the independent provider accumulates six or more points on the independent provider's driving record or has a driver's license suspended or revoked. (d) Complete testing for controlled substances by a laboratory certified for such testing within thirty-two hours and complete testing for blood alcohol level by an entity certified for such testing within eight hours of a motor vehicle accident involving the driver while he or she was providing non-medical transportation when: (i) The accident involves the loss of human life; or (ii) The driver receives a citation under state or local law for a moving traffic violation arising from the accident, if the accident involved: (A) Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or (B) One or more motor vehicles incurred disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle. (5) An agency provider of non-medical transportation shall: (a) Ensure that each driver holds a valid driver's license as specified by Ohio law. (b) Ensure that each driver is covered by valid liability insurance as specified by Ohio law. (c) Obtain, for each driver, a driving record prepared by the bureau of motor vehicles no earlier than fourteen calendar days prior to the date of initial employment as a driver and at least once every three years thereafter. A person having six or more points on the person's driving record is prohibited from providing non-medical transportation. (d) Require each driver to immediately notify the agency provider, in writing, if the driver accumulates six or more points on the driver's driving record or has a driver's license suspended or revoked. (e) Ensure that each driver completes testing for controlled substances by a laboratory certified for such testing within thirty-two hours and completes testing for blood alcohol level by an entity certified for such testing within eight hours of a motor vehicle accident involving the driver while he or she was providing non-medical transportation when: (i) The accident involves the loss of human life; or (ii) The driver receives a citation under state or local law for a moving traffic violation arising from the accident, if the accident involved: (A) Bodily injury to any person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or (B) One or more motor vehicles incurred disabling damage as a result of the accident, requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle. (f) Develop and implement written policies and procedures regarding vehicle accessibility, vehicle maintenance, and requirements for vehicle drivers. (6) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Meeting an individual's needs for non-medical transportation (1) There are three modes of non-medical transportation: (a) Non-medical transportation at the per-trip rate; (b) Non-medical transportation at the per-mile rate; and (c) Non-medical transportation provided by operators of commercial vehicles at the usual and customary fare. (2) An individual's non-medical transportation needs may be met through a combination of non-medical transportation at the per-trip rate, non-medical transportation at the per-mile rate, and/or non-medical transportation provided by operators of commercial vehicles at the usual and customary fare. Unless otherwise specified in an individual service plan: (a) Non-medical transportation at the per-trip rate shall be authorized for transporting an individual between the individual's residence and a location specified in paragraphs (B)(16)(a) to (B)(16)(f) of this rule. (b) Non-medical transportation at the per-mile rate shall be authorized for transporting an individual in circumstances other than circumstances described in paragraph (D)(2)(a) of this rule. (3) Non-medical transportation shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. Whenever possible, family, neighbors, friends, or community agencies that transport people without charge are to be used to meet an individual's needs. The individual service plan of an individual who requires non-medical transportation to be provided in a modified vehicle shall so indicate. (4) The service and support administrator shall ensure that a budget limitation for non-medical transportation is determined in accordance with rule 5123-9-19 of the Administrative Code when the need for non-medical transportation has been identified through development of the individual service plan for an individual enrolled in the individual options waiver. (5) Nothing in this rule shall be interpreted to prohibit a provider of homemaker/personal care or participant-directed homemaker/personal care from transporting an individual to, from, between, or among the venues described in paragraph (B)(16) of this rule and billing for homemaker/personal care in accordance with rule 5123-9-30 of the Administrative Code or participant-directed homemaker/personal care in accordance with rule 5123-9-32 of the Administrative Code and transportation in accordance with rule 5123-9-24 of the Administrative Code. (E) Requirements for service delivery of non-medical transportation at the per-trip rate or non-medical transportation at the per-mile rate in a modified vehicle or a vehicle equipped to transport five or more passengers When a modified vehicle or a vehicle equipped to transport five or more passengers is used for non-medical transportation at the per-trip rate or non-medical transportation at the per-mile rate, the vehicle shall: (1) Be equipped with: (a) Secure storage space for removable equipment and passenger property; (b) A communication system, which may include cellular communication, capable of two-way communication; and (c) A fire extinguisher and an emergency first-aid kit that are safely secured. (2) Be inspected, on each day the vehicle is used to provide non-medical transportation, by the first driver of the vehicle and prior to transporting an individual, to ensure the lights, windshield washer/wipers, emergency equipment, mirrors, horn, tires, and brakes are working. The inspection shall be documented by the driver that conducts the inspection. (3) Be inspected and determined to be in good working condition at a frequency of at least once every twelve months by the Ohio state highway patrol safety inspection unit or by a mechanic certified by an automotive dealership or the national institute for automotive service excellence. (F) Requirements for service delivery of non-medical transportation at the per-trip rate (1) Individuals shall be in the vehicle during the times the provider bills non-medical transportation at the per-trip rate. (2) A provider shall not bill for adult day support, career planning, group employment support, individual employment support, or vocational habilitation during the same time non-medical transportation at the per-trip rate is provided. (3) A provider shall not bill for homemaker/personal care or participant-directed homemaker/personal care provided by the driver during the same time non-medical transportation at the per-trip rate is provided. (G) Requirements for service delivery of non-medical transportation at the per-mile rate (1) Individuals shall be in the vehicle during the times the provider bills non-medical transportation at the per-mile rate except that billing may occur when non-medical transportation is being provided on behalf of an individual who is receiving individual employment support or the job development or worksite accessibility components of career planning. (2) A provider may bill for adult day support, career planning, group employment support, individual employment support, or vocational habilitation during the same time non-medical transportation at the per-mile rate is provided. (3) A provider may bill for homemaker/personal care or participant-directed homemaker/personal care provided by the driver during the same time non-medical transportation at the per-mile rate is provided. (H) Documentation of services (1) Service documentation for non-medical transportation at the per-trip rate and non-medical transportation at the per-mile rate shall include each of the following to validate payment for medicaid services: (a) Type of non-medical transportation service (i.e., per-trip or per-mile) provided. (b) Date of service. (c) License plate number of vehicle used to provide service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving service. (f) Name of provider. (g) Provider identifier/contract number. (h) Signature of driver of the vehicle or initials of driver of the vehicle if the signature and corresponding initials are on file with the provider. (i) Names of all passengers, including paid staff and volunteers, who were in the vehicle during any portion of the trip and/or commute. (j) Times the trip or commute started and stopped. (2) Service documentation for non-medical transportation at the per-mile rate shall include, in addition to the items required in paragraph (H)(1) of this rule, the number of miles in each distinct commute, as indicated by recording beginning and ending odometer readings or via tracking or mapping by a global positioning system. (3) Service documentation for non-medical transportation by operators of commercial vehicles shall include each of the following to validate payment for medicaid services: (a) Type of non-medical transportation service (i.e., by bus, light rail transit, livery vehicle, or taxicab) provided. (b) Date of service or, in the case of a purchase of bus fares, taxicab tokens, or similar types of travel vouchers to be used on more than one date, date of purchase. (c) Name of individual receiving service. (d) Medicaid identification number of individual receiving service. (e) Name of provider. (f) Provider identifier/contract number. (g) Receipt issued by operator of commercial vehicles indicating the amount paid. (I) Payment standards (1) The billing units, service codes, and payment rates for non-medical transportation are contained in appendix A to this rule. (2) Payment rates for non-medical transportation at the per-trip rate are established on a per-person basis, irrespective of the number of individuals being transported simultaneously, and based on the county cost-of-doing-business category for the county in which the preponderance of service was provided. The cost-of-doing-business categories are contained in appendix B to this rule. (3) Payment rates for non-medical transportation at the per-mile rate are established on a per-person basis, depending on the number of individuals being transported, regardless of funding source, and whether the service is provided in a modified vehicle or in a non-modified vehicle. The modified vehicle rate shall be applied for each individual being transported when at least one individual requires the use of a modified vehicle, as specified in the individual service plan. (4) Operators of commercial vehicles shall be paid their usual and customary fares. (5) Payment for non-medical transportation provided to individuals enrolled in the individual options waiver shall not exceed the budget limitations contained in appendix B to rule 5123-9-19 of the Administrative Code.
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Last updated July 1, 2022 at 1:21 PM
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Rule 5123-9-19 | Home and community-based services waivers - general requirements for adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation.
(A) Purpose This rule establishes general requirements governing provision of and payment for adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation provided to individuals enrolled in home and community-based services waivers administered by the department. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Acuity assessment instrument" means the standardized instrument utilized by the department to assess the relative non-residential services needs and circumstances of an adult individual compared to other adult individuals for purposes of receiving adult day support, career planning, group employment support, individual employment support, and vocational habilitation. Scores resulting from administration of the acuity assessment instrument have been grouped into ranges and subsequently linked with staffing expectations that result in four payment rates calibrated on group size that apply to adult day support, group employment support, and vocational habilitation. (2) "Administrative review" means the processes internal to the department and subject to oversight by the Ohio department of medicaid available to individuals who believe that their acuity assessment instrument scores, their placement in group assignment A, A-1, or B, and when applicable, the resulting budget limitation, prohibit their access to or continuation in the adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation services they have selected. Administrative review is not applicable to individuals with placement in group assignment C or to non-medical transportation. (3) "Adult day services" means non-residential services including adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation. (4) "Adult day support" has the same meaning as in rule 5123-9-17 of the Administrative Code. (5) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (6) "Budget limitation" means the funding amount available to enable an individual enrolled in the individual options waiver to receive adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation within each waiver eligibility span. A separate budget limitation enables an individual enrolled in the individual options waiver to receive non-medical transportation within each waiver eligibility span. The budget limitation applicable to adult day support, career planning, group employment support, individual employment support, and vocational habilitation and the budget limitation applicable to non-medical transportation are above and beyond the funding range to which an individual enrolled in the individual options waiver has been assigned. (7) "Career planning" has the same meaning as in rule 5123-9-13 of the Administrative Code. (8) "County board" means a county board of developmental disabilities. (9) "Department" means the Ohio department of developmental disabilities. (10) "Funding range" means one of the dollar ranges contained in appendix A to rule 5123-9-06 of the Administrative Code to which individuals enrolled in the individual options waiver have been assigned for the purpose of funding services other than adult day support, career planning, group employment support, individual employment support, non-medical transportation, vocational habilitation, waiver nursing delegation, and waiver nursing services. (11) "Group employment support" has the same meaning as in rule 5123-9-16 of the Administrative Code. (12) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (13) "Individual employment support" has the same meaning as in rule 5123-9-15 of the Administrative Code. (14) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (15) "Non-medical transportation" has the same meaning as in rule 5123-9-18 of the Administrative Code. (16) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (17) "Vocational habilitation" has the same meaning as in rule 5123-9-14 of the Administrative Code. (18) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (19) "Waiver nursing delegation" has the same meaning as in rule 5123-9-37 of the Administrative Code. (20) "Waiver nursing services" has the same meaning as in rule 5123-9-39 of the Administrative Code. (C) Acuity assessments, group assignments, and budget limitations (1) The service and support administrator shall ensure that an acuity assessment instrument is completed for each individual for whom adult day support, career planning, group employment support, individual employment support, or vocational habilitation has been authorized through the individual service plan development process. (2) Information needed to complete the acuity assessment instrument shall be provided by the individual and informants who know the capabilities and needs of the individual outside of the individual's residence, in the adult day services setting. Informants may include providers, guardians, advocates, and family members. The service and support administrator shall review and approve information contained on the acuity assessment instrument. The service and support administrator and/or a person designated by the service and support administrator shall submit information in electronic format to the department. The information will be automatically scored. (3) The score resulting from administration of the acuity assessment instrument will result in assignment of the individual by the service and support administrator to one of four groups. These group assignments will be applied to determine the rates paid when individuals receive adult day support, group employment support, and/or vocational habilitation. (a) An acuity assessment instrument score of eight to twenty-two results in assignment of the individual to group A or group A-1 based upon the staffing needs of the individual as identified in the individual service plan development process and reflected in the individual service plan. (b) An acuity assessment instrument score of twenty-three to thirty-four results in assignment of the individual to group B. (c) An acuity assessment instrument score of thirty-five to fifty-five results in assignment of the individual to group C. (4) Following assignment of an individual enrolled in the individual options waiver to one of four groups, the service and support administrator shall determine the individual's budget limitation for adult day support, career planning, group employment support, individual employment support, and vocational habilitation. When the need for non-medical transportation has been identified through the individual service plan development process, the service and support administrator shall also determine the individual's budget limitation for non-medical transportation. Budget limitations are based on the cost-of-doing-business category that applies to the county in which the individual receives the preponderance of services. The cost-of-doing-business categories are contained in appendix A to this rule. The budget limitations are contained in appendix B to this rule. The budget limitation for non-medical transportation shall not be combined with the budget limitation for adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation to enable an individual to increase the availability of one or more of these services or for any other purpose. (5) The service and support administrator shall inform each individual of the acuity assessment instrument score, the resulting group assignment, and for an individual enrolled in the individual options waiver, the individual's budget limitations: (a) At the time the acuity assessment instrument is initially administered; (b) At any time the acuity assessment instrument is re-administered and results in a score that places an individual in a different group assignment; and (c) At any time the individual receives the preponderance of adult day services in a county with a different cost-of-doing-business category. (6) A budget limitation established for an individual enrolled in the individual options waiver shall change only when changes in assessment variable scores on the acuity assessment instrument that justify assignment to a new group have occurred and/or the individual receives the preponderance of adult day services in a county with a different cost-of-doing-business category. Responses to any or all acuity assessment instrument variables may be revised at any time at the request of the individual or at the discretion of the service and support administrator, with the individual's consent. (7) The department shall periodically re-examine the scoring of the acuity assessment instrument and the linkage of the scores to group assignments. (D) Individual service plan development process (1) An eligible individual may elect to receive one, some, or all of the adult day services. The services shall be provided pursuant to a person-centered individual service plan that conforms to the requirements of rules 5123-4-02 and 5123:2-2-05 of the Administrative Code. (2) Individual service plans shall indicate the group assignment for provision of adult day support, group employment support, and vocational habilitation in accordance with paragraph (C)(3) of this rule. When an individual who is enrolled in a waiver receives one or more of these services in a group that includes one or more individuals who are not enrolled in a waiver, the group assignment for the individuals who are not enrolled in a waiver shall be identified through the individual service plan development process. Agency providers are not required to use, but may use, the acuity assessment instrument to determine the group assignment for individuals who are not enrolled in a waiver. (3) The county board shall determine whether the annual cost for adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation can be met by or exceeds the assigned budget limitation of an individual enrolled in the individual options waiver, or the funding amount available to meet the assessed needs of an individual enrolled in the level one waiver or the self-empowered life funding waiver. The county board also shall determine whether the annual cost for non-medical transportation can be met by or exceeds the assigned budget limitation of an individual enrolled in the individual options waiver, or the funding amount available to meet the assessed needs of an individual enrolled in the level one waiver or the self-empowered life funding waiver. The service and support administrator shall inform the individual of these determinations in accordance with procedures developed by the department. (4) If an individual requests a change in the frequency and/or duration of adult day support, career planning, group employment support, individual employment support, non-medical transportation, and/or vocational habilitation, the request may result in an increase or decrease in the annual cost for these services, based on the outcome of the individual service plan development process. The county board has the authority and responsibility to make changes which result from the individual service plan development process when the services are within the budget limitations of an individual enrolled in the individual options waiver, or within the funding amount available to meet the assessed needs of an individual enrolled in the level one waiver or the self-empowered life funding waiver. (a) Changes in the assigned budget limitations of an individual enrolled in the individual options waiver made by county boards are subject to review by the department and approval by the Ohio department of medicaid. (b) Neither the department nor the county board shall approve a change in a budget limitation or assign a new budget limitation to an individual enrolled in the individual options waiver after notification that the individual has requested a hearing pursuant to section 5160.31 of the Revised Code concerning the approval, denial, reduction, or termination of services in an individual service plan that has been developed within the funding parameters of this rule. (E) Group assignments, billing units, documentation, and payment conditions (1) Billing for adult day support, group employment support, and vocational habilitation shall correspond to the payment rates for the group assignment of individuals being served. (2) Changes in group assignments, other than changes between group A and group A-1, may be made only as the result of a change in the acuity assessment instrument score of an individual, an administrative review decision made by the department, or receipt of a formal due process appeal decision rendered by the Ohio department of medicaid. (3) Provider qualifications, requirements for service delivery and documentation of services, and payment standards for adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation are set forth in the applicable rule for the specific service provided. (4) Career planning and individual employment support shall be provided at a ratio of one staff to one individual. (5) Agency providers shall ensure and document that sufficient numbers of staff are engaged in provision of adult day support, group employment support, and vocational habilitation to ensure the health and safety and achievement of outcomes identified in the individual service plans of individuals being served; submission of a claim for payment constitutes an attestation by the agency provider that sufficient staff were present to ensure health and safety and achievement of outcomes. No more than sixteen individuals may receive services in one group, irrespective of the funding source for the services being provided to the individual participants. (F) Payment authorization and administrative review (1) The county board shall complete a payment authorization and the service and support administrator shall ensure waiver services are initiated for an individual whose annual cost for adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation and whose annual cost for non-medical transportation are within the budget limitations of an individual enrolled in the individual options waiver or within the funding amount available to meet the assessed needs of an individual enrolled in the level one waiver or the self-empowered life funding waiver. The service and support administrator shall inform the individual in writing in a form and manner the individual understands, of the individual's due process rights and responsibilities as set forth in section 5160.31 of the Revised Code. (2) Applicants for and recipients of waiver services who demonstrate that situational demands associated with the adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation services in which they desire to participate require a group assignment that is different than the group assignment resulting from administration of the acuity assessment instrument may submit a request for administrative review. Administrative review requests shall not be accepted for individuals having group assignment C. (3) The department considers the budget limitations contained in appendix B to this rule sufficient to meet the service requirements of any adult enrolled in the individual options waiver participating in adult day services. Therefore, in no instance will the group assignment and resulting total budget limitation approved through the administrative review process exceed the published amount for group C in the cost-of-doing-business category in which the individual receives the preponderance of the services addressed in this rule. (4) An individual or the county board, with the consent of the individual, may submit a request for administrative review to the department. County boards shall assist an individual to request an administrative review when asked to do so by the individual. (5) The individual or county board requesting administrative review shall submit information requested by the department including but not limited to: (a) The proposed group assignment for each waiver service; (b) The duration of the proposed group assignment for each waiver service; and (c) A statement justifying the proposed group assignment with supporting documentation. (6) The department shall make a determination within thirty calendar days following receipt of the information described in paragraph (F)(5) of this rule and shall notify the individual and county board in writing of the determination. (7) The administrative review approval shall apply to the individual's current waiver eligibility span. The department may extend the approval to one or more months in the consecutive waiver eligibility span. Requests for administrative review may be submitted on an as-needed basis and will be considered for approval if the individual continues to meet the criteria established by the department. (8) Following completion of the administrative review process, the department shall inform the individual in writing in a form and manner the individual understands, of the individual's due process rights and responsibilities as set forth in section 5160.31 of the Revised Code. (9) If, through the administrative review process, the department approves the request for a different group assignment, the county board shall ensure a payment authorization is completed within fifteen calendar days following the determination by the department and shall ensure waiver services are initiated. (10) If, through the administrative review process, the department denies the request for a different group assignment or if the service is not subject to an administrative review, the service and support administrator shall initiate the individual service plan development process to determine if an individual service plan can be developed that is acceptable to the individual and is within the assigned budget limitation or funding amount available. (a) If an individual service plan that meets these conditions is developed, the county board shall ensure a payment authorization is completed and shall ensure waiver services are initiated. (b) If an individual service plan that meets these conditions cannot be developed, the county board shall propose to deny the initial or continuing provision of adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation and inform the individual of the individual's due process rights and responsibilities as set forth in section 5160.31 of the Revised Code. (11) The department shall use the twelve-month period following either an individual's initial individual options waiver enrollment date or the date the individual transitions to one or more of the services addressed in this rule to verify that cumulative payments made for adult day services remain within the approved budget limitations specified in this rule. (12) The Ohio department of medicaid retains the final authority, based on the recommendation of the department, to review, revise, and approve any element of the decision process resulting in a determination made under this rule. (G) Due process rights and responsibilities Applicants for and recipients of waiver services administered by the department shall use the process set forth in section 5160.31 of the Revised Code and rules implementing that statute for any challenge related to the administration and/or scoring of the acuity assessment instrument or to the type, amount, level, scope, or duration of services included or excluded from an individual service plan. A change in staff to waiver recipient service ratios does not necessarily result in a change in the level of services received by an individual.
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Last updated July 1, 2022 at 1:19 PM
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Rule 5123-9-20 | Home and community-based services waivers - money management under the individual options and level one waivers.
(A) Purpose This rule defines money management and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "Authorized representative" means a person or an organization appointed by an individual to discuss and negotiate benefits (e.g., medicaid, social security, or veterans' administration) on behalf of an individual who needs assistance to manage or direct the management of benefits for which the individual is eligible or may be eligible. (3) "County board" means a county board of developmental disabilities. (4) "Department" means the Ohio department of developmental disabilities. (5) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time. Minutes of service delivery time accrued throughout a day shall be added together for the purpose of calculating the number of fifteen-minute billing units for the day. (6) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code. (7) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (8) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (9) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (10) "Money management" means services that provide assistance to individuals who need support managing personal and financial affairs, including training to assist an individual to acquire, retain, or improve related skills. The services meet a continuum of individualized needs, from organizing and keeping track of financial records and health insurance documentation, to assisting with bill-paying and maintaining bank accounts. Money management does not take the place of services provided by professionals in the accounting, investment, or social services fields. Money management complements the work of other professionals by facilitating the completion of the day-to-day tasks rather than determining or executing long-term plans. Money management includes a broad range of tasks determined necessary in the individual service plan. Examples of supports that may be provided as a component of money management include: (a) Bill-paying and preparing checks for individuals to sign; (b) Balancing checkbooks, reconciling bank account statements, and maintaining or organizing bank records; (c) Preparing and delivering bank account deposits; (d) Assisting an individual with applying for benefits such as medicaid buy-in for workers with disabilities and other resources as appropriate; (e) Assisting an individual with maintaining eligibility for benefits such as food stamps; (f) Consulting or making referrals for consultation regarding available benefits; (g) Making referrals as appropriate for establishment of special needs accounts (e.g., a qualified income trust or an account established in accordance with the Achieving a Better Life Experience Act program and section 529A of the Internal Revenue Code); (h) Organizing tax documents and other paperwork; (i) Negotiating with creditors; (j) Deciphering medical insurance papers and verifying proper processing of claims; (k) Providing general organization assistance; (l) Providing referrals to legal, tax, and investment professionals; (m) Notarizing documents; (n) Providing assistance associated with financial tasks when an individual relocates (e.g., transferring bank accounts or updating address with creditors); and (o) Acting as power-of-attorney or authorized representative, when so designated by the individual. (11) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123-9-32 of the Administrative Code. (12) "Payee" means a person, agency, organization, or institution appointed by the social security administration to receive and manage benefits (e.g., medicaid, social security, or supplemental security income) on behalf of an individual who needs assistance to manage or direct the management of benefits. A payee has legal authority to manage the benefits, uses the benefits to pay for the current and future needs of the individual, and properly saves any benefits not needed to meet current needs. A payee is required to keep records of expenses and provide an accounting of how the payee used or saved the benefits. A payee shall adhere to the standards and regulations set forth by the social security administration. (13) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (14) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (15) "Shared living" has the same meaning as in rule 5123-9-33 of the Administrative Code. (16) "Team" has the same meaning as in rule 5123-4-02 of the Administrative Code. (C) Provider qualifications (1) Money management shall be provided by an agency provider or an independent provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) Money management shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards. (3) An applicant seeking approval to provide money management shall complete and submit an application through the department's website (http://dodd.ohio.gov) and adhere to the requirements of rule 5123-2-08 or 5123-2-09 of the Administrative Code, as applicable. (4) Each person providing money management shall: (a) Achieve a score of at least eighty per cent on the department-administered money management competency test; or (b) Hold a degree from an accredited college or university in accounting, business administration, finance, or public administration; or (c) Be authorized by Chapter 4701. of the Revised Code to use the designation of certified public accountant. (5) Each person, prior to providing money management, shall successfully complete training provided by the department or by an entity using department-provided curriculum in: (a) The rights of individuals set forth in section 5123.62 of the Revised Code; (b) The requirements of rule 5123-17-02 of the Administrative Code including a review of health and welfare alerts issued by the department; and (c) Empathy-based care. (6) Each person providing money management shall annually complete at least eight hours of training in accordance with standards established by the department in: (a) The rights of individuals set forth in section 5123.62 of the Revised Code; (b) The requirements of rule 5123-17-02 of the Administrative Code including a review of health and welfare alerts issued by the department since the previous year's training; (c) Empathy-based care; and (d) Topics that enhance the person's skills and competencies relevant to provision of money management. (7) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Money management shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. Providers of money management shall participate in individual service plan development meetings when a request for their participation is made by the individual. (2) The scope and intensity of money management services shall be determined by the team based on the individual's needs. Money management shall be authorized for no more than ten hours per month. (3) Money management shall not duplicate or include activities that help link eligible individuals with medical, social, or educational providers, programs, or services that are functions of targeted case management pursuant to rule 5160-48-01 of the Administrative Code. (4) Money management shall be provided at a ratio of one staff to one individual. (5) Money management services may extend to those times when the individual is not physically present while the provider is performing money management activities on behalf of the individual. (6) A provider of money management shall: (a) Comply with rule 5123:2-2-07 of the Administrative Code; (b) Act in the best interest of and take all reasonable precautions to safeguard the interests and property of each individual the provider serves; (c) Disclose in writing to each individual served and the individual's service and support administrator, any affiliations, associations, or interests that may pose a potential conflict of interest or create the appearance of impropriety; (d) Keep current of issues related to the money management services provided (e.g., health insurance, consumer fraud, or banking fees) and public and private services available to individuals for use in resource referrals; (e) Refer individuals to other service providers or consult with other service providers when additional knowledge and expertise are required; and (f) Maintain detailed and accurate records, documentation, and information (e.g., bank statements, checking account transaction register, savings account balance, spending trends, or income statements) for each individual served which shall be submitted to the individual in accordance with the individual service plan and upon request by the individual or the individual's team. (7) A provider of money management who is also an individual's payee shall: (a) Obtain and maintain the individual's benefits; (b) Pay all of the individual's living expenses prior to providing the individual with discretionary spending money; (c) Take all necessary measures to maintain the individual's eligibility for benefits such as ensuring bank account balances remain within established resource limitations; and (d) Maintain documentation, report information, and comply with all other requirements and standards, including audit protocols, established by the social security administration. (8) A provider of money management who is also the individual's payee shall not request or accept reimbursement through more than one funding source for the services that fall under the responsibilities of a payee. Additional money management tasks beyond the responsibilities of a payee may be determined necessary through the person-centered planning process and authorized in the individual service plan. (9) A provider of money management shall not also provide homemaker/personal care, participant-directed homemaker/personal care, or shared living to the same individual. (10) Providers of money management shall not act or represent themselves as accountants, financial advisors, attorneys, or other licensed professionals unless licensed as such by the state of Ohio. (E) Documentation of services Service documentation for money management shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided. (11) Times the delivered service started and stopped. (F) Payment standards (1) The billing units, service codes, and payment rates for money management are contained in appendix A to this rule. Payment rates are based on the county cost-of-doing-business category. The cost-of-doing-business category for an individual is the category assigned to the county in which the service is actually provided for the preponderance of time. The cost-of-doing-business categories are contained in appendix B to this rule. (2) When services meeting the definition of money management in accordance with paragraph (B)(10) of this rule are the only supports provided to an individual by the provider, the services shall be authorized and billed as money management. (a) When assistance with personal finances is provided to an individual by the provider in conjunction with other components of homemaker/personal care in accordance with paragraph (B)(10)(i) of rule 5123-9-30 of the Administrative Code, the services shall be authorized and billed as homemaker/personal care. (b) When assistance with personal finances is provided to an individual by the provider in conjunction with other components of participant-directed homemaker/personal care in accordance with paragraph (B)(21)(i) of rule 5123-9-32 of the Administrative Code, the services shall be authorized and billed as participant-directed homemaker/personal care.
View Appendix
Last updated July 1, 2022 at 1:19 PM
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Rule 5123-9-21 | Home and community-based services waivers - informal respite under the level one waiver.
Effective:
January 1, 2022
(A) Purpose This rule defines informal respite and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "County board" means a
county board of developmental disabilities. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day shall be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (5) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (7) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (8) "Informal respite" means
services provided to an individual unable to care for himself or herself,
furnished by a person known to the individual, on a short-term basis because of
the absence or need for relief of those persons routinely providing the care.
Informal respite may be provided in the individual's home or place of
residence, home of a friend or family member, or at sites of community
activities. (9) "Major unusual
incident" has the same meaning as in rule 5123-17-02 of the Administrative
Code. (10) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (11) "Unusual incident" has the
same meaning as in rule 5123-17-02 of the Administrative Code. (12) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Informal respite
shall be provided by an independent provider known to the individual
who: (a) Meets the requirements of this rule; (b) Has a medicaid provider agreement with the Ohio department of
medicaid; and (c) Has completed and submitted an application through the
department's website (http://dodd.ohio.gov). (2) Informal respite
shall not be provided by an agency provider, a county board, or a regional
council of governments formed under section 5126.13 of the Revised Code by two
or more county boards. (3) Failure to comply
with this rule and rule 5123-2-09 of the Administrative Code may result in
denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) Informal respite
shall be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) In order to be
eligible for informal respite, the individual or his or her designee must be
able and willing to accept responsibility for training the provider and
monitoring health management activities, behavioral support, major unusual
incident reporting, and other activities required to meet the needs of the
individual as identified in the individual service plan. The individual or his
or her designee shall document the following on forms and according to
procedures prescribed by the department: (a) Orientation and training of the provider, prior to the
delivery of services, about activities required to meet the needs and
preferences of the individual, including any training specified for the
individual in his or her individual service plan and other information related
to health and welfare needs of the individual. (b) Annual training of the provider to ensure that the provider
understands the following: (i) The requirements set
forth in rule 5123-17-02 of the Administrative Code and the reasonable steps
necessary to prevent the occurrence or recurrence of unusual incidents and
major unusual incidents; (ii) The rights of
individuals set forth in section 5123.62 of the Revised Code; and (iii) The activities
required to meet the needs and preferences of the individual, including any
training specified for the individual in his or her individual service plan and
other information related to health and welfare needs of the
individual. (3) The individual or his
or her designee shall: (a) Ensure the provider is delivering informal respite as
specified in the individual service plan. (b) Ensure the provider is documenting the delivery of informal
respite in accordance with paragraph (E) of this rule. (c) Upon knowledge of an unusual incident or a major unusual
incident, take immediate actions as necessary to maintain the health, safety,
and welfare of the individual receiving informal respite. (4) Failure of the
individual or his or her designee to fulfill the requirements of this rule
shall render the individual ineligible for informal respite under the waiver
and, subsequent to prior notice and hearing rights in accordance with section
5160.31 of the Revised Code and rules implementing that statute, informal
respite shall be terminated. (E) Documentation of
services Service documentation for informal respite shall
include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving
service. (5) Medicaid identification number of
individual receiving service. (6) Name of provider. (7) Provider identifier/contract
number. (8) Times the delivered service started
and stopped. (9) Written or electronic signature of
the person delivering the service. (10) Description and details of the
services delivered that directly relate to the services specified in the
approved individual service plan as the services to be provided. (F) Payment standards The billing unit, service code, and payment rate
for informal respite are contained in the appendix to this rule.
View Appendix
Last updated January 3, 2022 at 9:58 AM
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Rule 5123-9-22 | Home and community-based services waivers - community respite under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines community respite and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "Community respite" means
services provided to an individual unable to care for himself or herself
furnished on a short-term basis because of the absence or need for relief of
those persons routinely providing the care. Community respite shall only be
provided outside of an individual's home in a camp, recreation center, or
other place where an organized community program or activity
occurs. (3) "Community respite
fifteen-minute billing unit" means a billing unit that equals fifteen
minutes of service delivery time or is greater or equal to eight minutes and
less than or equal to twenty-two minutes of service delivery time. Minutes of
service delivery time accrued throughout a day shall be added together for the
purpose of calculating the number of community respite fifteen-minute billing
units for the day. (4) "Community respite full day
billing unit" means a billing unit that shall be used when community
respite is provided for more than seven hours during the day and the individual
stays overnight at the community respite service delivery
location. (5) "Community respite partial day
billing unit" means a billing unit that shall be used when community
respite is provided for between five and seven hours during the day and the
individual does not stay overnight at the community respite service delivery
location. (6) "County board" means a
county board of developmental disabilities. (7) "Department" means the Ohio
department of developmental disabilities. (8) "Funding range" means one
of the dollar ranges contained in appendix A to rule 5123-9-06 of the
Administrative Code, to which individuals enrolled in the individual options
waiver have been assigned for the purpose of funding services. The funding
range applicable to an individual is determined by the score derived from the
Ohio developmental disabilities profile that has been completed by a county
board employee qualified to administer the tool. (9) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (10) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (11) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (12) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (13) "Ohio developmental disabilities
profile" means the standardized instrument utilized by the department to
assess the relative needs and circumstances of an individual compared to
others. The individual's responses are scored and the individual is linked
to a funding range, which enables similarly situated individuals to access
comparable waiver services paid in accordance with rules adopted by the
department. (14) "Participant-directed
homemaker/personal care" has the same meaning as in rule 5123-9-32 of the
Administrative Code. (15) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (16) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Community respite
shall be provided by an agency provider that meets the requirements of this
rule and that has a medicaid provider agreement with the Ohio department of
medicaid. (2) Community respite
shall not be provided by an independent provider, a county board, or a regional
council of governments formed under section 5126.13 of the Revised Code by two
or more county boards. (3) An applicant seeking approval to
provide community respite shall complete and submit an application through the
department's website (http://dodd.ohio.gov). (4) Failure of a certified provider to
comply with this rule and rule 5123-2-08 of the Administrative Code may result
in denial, suspension, or revocation of the provider's
certification. (5) Failure of a licensed provider to
comply with this rule and Chapters 5123-3 and 5123:2-3 of the Administrative
Code may result in denial, suspension, or revocation of the provider's
license. (6) The provider shall
provide written assurance and ensure that all employees, contractors, and
employees of contractors delivering community respite shall hold the required
certification or license (e.g., water safety instructor) and be trained for any
specialized activity (e.g., high ropes or archery) in which an individual may
participate. (D) Requirements for service delivery (1) Community respite shall be provided
pursuant to an individual service plan that conforms to the requirements of
rule 5123-4-02 of the Administrative Code. (2) The individual service plan shall
address emergency and replacement coverage should the individual unexpectedly
need to leave the community respite service delivery location. (3) Community respite is
limited to sixty calendar days of service per waiver eligibility
span. (4) Community respite
shall not be simultaneously provided to an individual at the same location
where homemaker/personal care or participant-directed homemaker/personal care
is being provided to that individual. (5) Community respite
shall not be provided in any residence. (6) Community respite
shall not be simultaneously provided at the same location where adult day
services are being provided. (E) Documentation of services Service documentation for community respite shall
include each of the following to validate payment for medicaid services: (1) Type of service (i.e., community
respite full day billing unit, community respite partial day billing unit, or
community respite fifteen-minute billing unit). (2) Date of service. (3) Place of service. (4) Name of individual receiving
service. (5) Medicaid identification number of
individual receiving service. (6) Name of provider. (7) Provider identifier/contract
number. (8) Date and time of the
individual's arrival at and departure from the community respite service
delivery location. (9) Written or electronic signature of
the person delivering the service, or initials of the person delivering the
service if a signature and corresponding initials are on file with the
provider. (10) Description and details of the
services delivered that directly relate to the services specified in the
approved individual service plan as the services to be provided. (F) Payment standards (1) The billing units, service codes, and
payment rates for community respite are contained in appendix A to this
rule. (a) The community respite full day billing unit shall be used
when community respite is provided for more than seven hours during the day and
the individual stays overnight at the community respite service delivery
location. Only one provider of community respite shall use the community
respite full day billing unit on any given day. (b) The community respite partial day billing unit shall be used
when community respite is provided for between five and seven hours on a given
day and the individual does not stay overnight at the community respite service
delivery location. (c) The community respite fifteen-minute billing unit shall be
used for all other community respite scenarios not addressed in paragraph
(F)(1)(a) or (F)(1)(b) of this rule. (d) The community respite full day billing unit, the community
respite partial day billing unit, and the community respite fifteen-minute
billing unit shall not be combined during the same calendar day for the same
individual. (2) Payment rates for
community respite are based on the county cost-of-doing-business category. The
cost-of-doing-business categories are contained in appendix B to this
rule. (3) Payment rates for
community respite shall be adjusted by the behavioral support rate modification
to reflect the needs of an individual requiring behavioral support upon
determination by the department that the individual meets the criteria set
forth in paragraph (F)(3)(a) of this rule. (a) The department shall determine that an individual meets the
criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four items in
question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed, will
result in the individual's engagement in behavior destructive to self or
others. (b) The duration of the behavioral support rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (4) Payment rates for
community respite shall be adjusted by the medical assistance rate modification
to reflect the needs of an individual requiring medical assistance upon
determination by the county board that the individual meets the criteria set
forth in paragraph (F)(4)(a) of this rule. (a) The county board shall determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy or jejunostomy tube, and/or requires the administration of
routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (5) Community respite provided to
individuals enrolled in the individual options waiver is subject to the funding
ranges and individual funding levels set forth in rule 5123-9-06 of the
Administrative Code. (6) Payment for community respite shall
not include payment for room and board or transportation.
View AppendixView Appendix
Last updated January 3, 2022 at 9:58 AM
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Rule 5123-9-23 | Home and community-based services waivers - environmental accessibility adaptations under the individual options and level one waivers.
(A) Purpose This rule defines environmental accessibility adaptations and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Environmental accessibility adaptations" means physical adaptations to an individual's home (e.g., installation of ramps or grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electrical systems to operate an individual's medical equipment) that comply with the following requirements: (a) The physical adaptation to the individual's home must be: (i) Determined by the individual's team necessary to: (A) Support the individual to reside in a community-based setting; and (B) Either: (i) Ensure the health, welfare, and safety of the individual; or (ii) Enable the individual to function with greater independence while at home. (ii) Identified in the individual service plan. (iii) Completed in accordance with applicable state and local building codes. (b) "Environmental accessibility adaptations" does not include physical adaptations to the home that: (i) Add to the total square footage of the home; (ii) Are of general utility; or (iii) Are not of direct medical or remedial benefit to the individual (e.g., carpeting, roof repair, or central air conditioning). (5) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (8) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (9) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (C) Provider qualifications (1) Environmental accessibility adaptations shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide environmental accessibility adaptations only when no other certified provider is willing and able. (3) An applicant seeking approval to provide environmental accessibility adaptations shall complete and submit an application through the department's website (http://dodd.ohio.gov). (4) An applicant seeking approval to provide environmental accessibility adaptations shall submit to the department documentation verifying the applicant's experience in providing environmental accessibility adaptations. (5) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Environmental accessibility adaptations shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) The provider of environmental accessibility adaptations shall comply with all applicable state and local regulations that apply to the operation of the provider's business or trade. (E) Documentation of services Service documentation for environmental accessibility adaptations shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (F) Payment standards (1) The billing unit, service codes, and payment rates for environmental accessibility adaptations are provided in the appendix to this rule. (2) Claims for payment for environmental accessibility adaptations shall be submitted to the department with verification from the county board that the project meets the requirements specified in the approved individual service plan, the project is satisfactorily completed, and the project is in compliance with applicable state and local requirements, including building codes. The verification shall be submitted in the format prescribed by the department. (3) Payment for environmental accessibility adaptations shall not exceed ten thousand dollars per project.
View Appendix
Last updated July 1, 2022 at 1:19 PM
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Rule 5123-9-24 | Home and community-based services waivers - transportation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines transportation and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "Commercial
vehicles" means buses, light rail transit, livery vehicles, and taxicabs
that are available for use by the general public. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (5) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (6) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (7) "Modified
vehicle" means: (a) A motor vehicle to be used upon public streets and highways
that has been structurally modified in a permanent manner to meet the physical
or behavioral needs of the individual being transported; or (b) A motor vehicle that has been designed, constructed, or
fabricated and equipped to be used upon public streets and highways for
transportation of individuals who require use of a wheelchair and that
shall: (i) Have permanent
fasteners to secure a wheelchair to the floor or side of the vehicle to prevent
wheelchair movement; (ii) Have safety
harnesses or belts in the vehicle for the purpose of securing individuals in
wheelchairs; (iii) Be equipped with a
stable access ramp specifically designed for wheelchairs or a hydraulic lift
specifically designed for wheelchairs; and (iv) Be inspected, on
each day the vehicle is used to provide transportation, by the first driver of
the vehicle and prior to transporting an individual in a wheelchair, to ensure
the permanent fasteners, safety harnesses or belts, and access ramp or
hydraulic lift are working. The inspection shall be documented by the driver
that conducts the inspection. (8) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (9) "Transportation" means a
service that enables individuals enrolled in individual options, level one, and
self-empowered life funding waivers to access waiver and other community
services, activities, and resources. This service is offered in addition to,
and shall not replace, medical transportation required under 42 C.F.R. 431.53
as in effect on the effective date of this rule, transportation services under
the medicaid state plan as defined in 42 C.F.R. 440.170(a) as in effect on the
effective date of this rule, if applicable, and non-medical transportation as
defined in rule 5123-9-18 of the Administrative Code. Whenever possible,
family, neighbors, friends, or community agencies that provide transportation
without charge shall be utilized. (10) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Transportation shall
be provided by an independent provider, an agency provider, or an operator of
commercial vehicles that meets the requirements of this rule and that has a
medicaid provider agreement with the Ohio department of medicaid. (2) An applicant seeking
approval to provide transportation shall complete and submit an application
through the department's website (http://dodd.ohio.gov) and adhere to the
requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (3) An applicant seeking
approval to provide transportation as an independent provider shall present his
or her driving record prepared by the bureau of motor vehicles no earlier than
fourteen calendar days prior to the date of his or her application for initial
or renewal provider certification. A person having six or more points on his or
her driving record is prohibited from providing transportation. (4) An independent
provider of transportation shall: (a) Hold a valid driver's license as specified by Ohio
law. (b) Have valid liability insurance as specified by Ohio
law. (c) Immediately notify the department, in writing, if he or she
accumulates six or more points on his or her driving record or if his or her
driver's license is suspended or revoked. (5) An agency provider of
transportation shall: (a) Ensure that each driver holds a valid driver's license
as specified by Ohio law. (b) Ensure that each driver is covered by valid liability
insurance as specified by Ohio law. (c) Obtain, for each driver, a driving record prepared by the
bureau of motor vehicles no earlier than fourteen calendar days prior to the
date of initial employment as a driver and at least once every three years
thereafter. A person having six or more points on his or her driving record is
prohibited from providing transportation. (d) Require each driver to immediately notify the agency
provider, in writing, if the driver accumulates six or more points on his or
her driving record or if his or her driver's license is suspended or
revoked. (e) Develop and implement written policies and procedures
regarding vehicle accessibility, vehicle maintenance, and requirements for
vehicle drivers. (6) Failure to comply
with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in the denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Transportation shall
be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. The individual
service plan of an individual who requires transportation to be provided in a
modified vehicle shall so indicate. (2) Transportation
services may extend to those times when the individual is not physically
present and the provider is performing transportation on behalf of the
individual. (E) Documentation of
services Service documentation for transportation shall
include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) License plate number of vehicle used
to provide service. (4) Name of individual receiving
service. (5) Medicaid identification number of
individual receiving service. (6) Name of provider. (7) Provider identifier/contract
number. (8) Origination and destination points of
transportation provided. (9) Total number of miles of
transportation provided. (10) Number of individuals being
transported. (11) Written or electronic signature of
the person delivering the service, or initials of the person delivering the
service if a signature and corresponding initials are on file with the
provider. (12) Description and details of the
services delivered that directly relate to the services specified in the
approved individual service plan as the services to be provided. (F) Payment standards (1) The billing unit,
service codes, and payment rates for transportation are contained in the
appendix to this rule. (2) Payment rates for
transportation are established on a per-person basis, depending on the number
of individuals being transported, regardless of funding source, and whether the
service is provided in a modified vehicle or in a non-modified vehicle. The
modified vehicle rate shall be applied for each individual being transported
when at least one individual requires the use of a modified vehicle, as
specified in his or her individual service plan.
View Appendix
Last updated January 3, 2022 at 9:58 AM
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Rule 5123-9-25 | Home and community-based services waivers - specialized medical equipment and supplies under the individual options and level one waivers.
(A) Purpose This rule defines specialized medical equipment and supplies and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "Assistive technology" has the same meaning as in rule 5123-9-12 of the Administrative Code. (3) "County board" means a county board of developmental disabilities. (4) "Department" means the Ohio department of developmental disabilities. (5) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (8) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (9) "Specialized medical equipment and supplies" means adaptive and assistive equipment and other specialized medical equipment and supplies such as devices, controls, or appliances, specified in the individual service plan, which enable an individual to increase ability to perform activities of daily living, or to perceive, control, or communicate with the environment in which the individual lives. Specialized medical equipment and supplies includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the medicaid state plan. All items shall meet applicable standards of manufacture, design, and installation. Specialized medical equipment and supplies does not include: (a) Items that are not of direct medical or remedial benefit to the individual; (b) Items otherwise available as assistive technology; or (c) For individuals less than twenty-one years of age, equipment and supplies that are available under the medicaid state plan or covered under the provisions of 1905(r) of the Social Security Act, 42 U.S.C. 1396d, as in effect on the effective date of this rule. (10) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (C) Provider qualifications (1) Specialized medical equipment and supplies shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) A county board or a regional council of governments formed pursuant to section 5126.13 of the Revised Code by two or more county boards may provide specialized medical equipment and supplies only when no other certified provider is willing and able. (3) An applicant seeking approval to provide specialized medical equipment and supplies shall complete and submit an application through the department's website (http://dodd.ohio.gov). (4) An applicant seeking approval to provide specialized medical equipment and supplies shall submit to the department documentation verifying the applicant's experience in providing specialized medical equipment and supplies. (5) A veterinarian who is attending to service animals shall be licensed to engage in the practice of veterinary medicine in accordance with Chapter 4741. of the Revised Code. (6) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Specialized medical equipment and supplies shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) The provider of specialized medical equipment and supplies shall: (a) Ensure proper installation of equipment, if required; (b) Provide training to the individual, family, and other persons, as applicable, in the proper utilization of equipment; (c) Properly maintain rental equipment, if required; (d) Repair equipment as authorized by the county board representative; and (e) Assume full liability for equipment improperly installed or maintained. (E) Documentation of services Service documentation for specialized medical equipment and supplies shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (F) Payment standards (1) The billing unit, service codes, and payment rates for specialized medical equipment and supplies are contained in the appendix to this rule. (2) Payment for specialized medical equipment and supplies shall not exceed ten thousand dollars per item.
View Appendix
Last updated July 1, 2022 at 1:20 PM
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Rule 5123-9-26 | Home and community-based services waivers - self-directed transportation under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines self-directed transportation and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "Department" means the Ohio department of developmental disabilities. (3) "Financial management services entity" means a governmental entity and/or another third-party entity designated by the department to perform necessary financial transactions on behalf of individuals who receive participant-directed services. (4) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (7) "Modified vehicle" means: (a) A motor vehicle to be used upon public streets and highways that has been structurally modified in a permanent manner to meet the physical or behavioral needs of the individual being transported; or (b) A motor vehicle that has been designed, constructed, or fabricated and equipped to be used upon public streets and highways for transportation of individuals who require use of a wheelchair and that shall: (i) Have permanent fasteners to secure a wheelchair to the floor or side of the vehicle to prevent wheelchair movement; (ii) Have safety harnesses or belts in the vehicle for the purpose of securing individuals in wheelchairs; (iii) Be equipped with a stable access ramp specifically designed for wheelchairs or a hydraulic lift specifically designed for wheelchairs; and (iv) Be inspected, on each day the vehicle is used to provide self-directed transportation, by the first driver of the vehicle and prior to transporting an individual in a wheelchair, to ensure the permanent fasteners, safety harnesses or belts, and access ramp or hydraulic lift are working. The inspection shall be documented by the driver that conducts the inspection. (8) "Participant-directed budget" means the total amount of annual waiver funding available for participant-directed services in the individual service plan of an individual who chooses to receive participant-directed services. An individual may reallocate funds among participant-directed services as long as reallocation is preceded by a corresponding revision to the individual service plan. (9) "Self-directed transportation" means a service purchased through the participant-directed budget, that enables an individual to access activities and opportunities available in the broader community such as competitive integrated workplaces, integrated community participation and contribution (e.g., advocacy activities and events), community resources, and businesses consistent with the individual service plan. Self-directed transportation enhances independence as it is available around the clock, including on weekends and holidays, to accommodate an individual's scheduled and spontaneous transportation needs. (a) Self-directed transportation includes: (i) Purchase of prepaid vouchers, cards, passes, or tokens to access modes of ground transportation available to the general public such as modes available from regional transit authorities and ride-hailing services (e.g., taxicab, "Lyft," or "Uber") at the usual and customary rate or fare; and (ii) Per-mile or per-trip reimbursement made to a person who meets the provider qualifications in paragraph (C) of this rule and who has a written agreement for provision of self-directed transportation with the individual being transported. (b) An individual's self-directed transportation budget for a waiver eligibility span is determined based on the individual's needs and consideration of the individual's preferences and available funds. (10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (11) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (C) Provider qualifications (1) Rules 5123-2-08 and 5123-2-09 of the Administrative Code do not apply to providers of self-directed transportation. (2) Self-directed transportation shall be provided by: (a) A vendor of ground transportation available to the general public; or (b) A person who receives per-mile or per-trip reimbursement in accordance with a written agreement for provision of self-directed transportation with the individual being transported; or (c) An agency provider or independent provider certified by the department to provide non-medical transportation in accordance with rule 5123-9-18 of the Administrative Code or transportation in accordance with rule 5123-9-24 of the Administrative Code that agrees to provide self-directed transportation in accordance with this rule. (3) A person or entity that provides self-directed transportation shall: (a) Meet the requirements of this rule; and (b) Be determined qualified to provide self-directed transportation by the financial management services entity; and (c) Hold a medicaid provider agreement with the Ohio department of medicaid or operate under the medicaid provider agreement held by the financial management services entity. (4) A person seeking authorization to receive per-mile or per-trip reimbursement for self-directed transportation shall apply to the financial management services entity in the manner prescribed by the financial management services entity. The financial management services entity is to ensure that each person seeking authorization: (a) Presents the person's driving record prepared by the bureau of motor vehicles no earlier than fourteen calendar days prior to the date of the person's application. A person having six or more points on the person's driving record is prohibited from providing self-directed transportation. (b) Holds a valid driver's license as specified by Ohio law. (c) Has valid liability insurance as specified by Ohio law. (d) Completes a background investigation in accordance with rule 5123-2-02 of the Administrative Code and: (i) Is not included in one or more of the databases described in paragraphs (C)(2)(a) to (C)(2)(f) of rule 5123-2-02 of the Administrative Code; and (ii) Does not have a conviction for, has not pleaded guilty to, or has not been found eligible for intervention in lieu of conviction for any of the offenses listed or described in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code if the corresponding exclusionary period as specified in paragraph (E) of rule 5123-2-02 of the Administrative Code has not elapsed. (5) A person authorized by the financial management services entity to receive per-mile or per-trip reimbursement for self-directed transportation shall immediately notify the financial management services entity, in writing, if the person accumulates six or more points on the person's driving record or if the person's driver's license is suspended or revoked. (6) Failure to comply with this rule may result in denial, suspension, or revocation of authorization to provide self-directed transportation. (D) Requirements for service delivery (1) Self-directed transportation shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) An individual's need for self-directed transportation to be provided in a modified vehicle is to be documented in the individual service plan. (E) Documentation of services (1) Service documentation for self-directed transportation provided by vendors of ground transportation available to the general public shall include each of the following to validate payment for medicaid services: (a) Mode of self-directed transportation for which voucher, card, pass, or token may be used (e.g., bus, light rail transit, livery vehicle, or ride-hailing service) provided. (b) Date of purchase of voucher, card, pass, or token. (c) Name of individual receiving service. (d) Medicaid identification number of individual receiving service. (e) Name of provider. (f) Provider identifier number or provider contract number. (g) Receipt indicating the amount paid. (2) Service documentation for self-directed transportation via per-mile or per-trip reimbursement made to a person who meets the provider qualifications in paragraph (C) of this rule and who has a written agreement for provision of self-directed transportation with the individual being transported shall include each of the following to validate payment for medicaid services: (a) Type of motor vehicle used to provide self-directed transportation (i.e., modified vehicle or non-modified vehicle). (b) Date of service. (c) Name of individual receiving service. (d) Medicaid identification number of individual receiving service. (e) Name of provider. (f) Provider identifier number or provider contract number. (g) Origination and destination points of self-directed transportation provided. (h) Total number of miles of self-directed transportation provided. (i) Number of individuals being transported. (j) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the financial management services entity. (F) Payment standards (1) The billing units, service codes, and payment rates for self-directed transportation are contained in the appendix to this rule. (2) Payment rates for vouchers, cards, passes, or tokens to access modes of ground transportation available to the general public shall be at the usual and customary rate or fare. (3) Reimbursement made to a person who has a written agreement for provision of self-directed transportation with the individual being transported may be per-mile or per-trip: (a) Per-mile reimbursement is established on a per-person basis, depending on the number of individuals being transported, regardless of funding source, and whether the service is provided in a modified vehicle or in a non-modified vehicle. The modified vehicle rate shall be billed for each individual being transported when at least one individual requires the use of a modified vehicle, as specified in the individual service plan. (b) Per-trip reimbursement may be negotiated by an individual being transported and the person providing self-directed transportation up to an amount not to exceed twelve dollars for each one-way trip.
Last updated July 1, 2022 at 1:22 PM
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Rule 5123-9-28 | Home and community-based services waivers - nutrition services under the individual options waiver.
(A) Purpose This rule defines nutrition services and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code. (6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (7) "Nutrition services" means a nutritional assessment and intervention for individuals who are identified as being at nutritional risk and includes development of a nutrition care plan, including appropriate means of nutrition intervention (i.e., nutrition required, feeding modality, nutrition education, and nutrition counseling). Nutrition services shall not supplant existing services provided by the federal women, infants, and children program. (8) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (C) Provider qualifications (1) Nutrition services shall be provided by a dietitian licensed by the state pursuant to section 4759.06 of the Revised Code who is either an independent provider or the employee of an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) Nutrition services shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards. (3) An applicant seeking approval to provide nutrition services shall complete and submit an application through the department's website (http://dodd.ohio.gov/). (4) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Nutrition services shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) A dietitian providing nutrition services shall: (a) Perform nutritional assessments and evaluations in accordance with the individual service plan; (b) Develop dietary programs, if indicated by the nutritional assessment and the individual service plan; and (c) Train the individual, family members, professionals, paraprofessionals, direct care workers, habilitation specialists, and vocational/school staff regarding the dietary program. (E) Documentation of services Service documentation for nutrition services shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Group size in which the service was provided. (10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (11) Number of units of the delivered service. (12) Times the delivered service started and stopped. (F) Payment standards (1) The billing unit, service codes, and payment rates for nutrition services are contained in appendix A to this rule. (2) Payment rates for nutrition services are based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule. (3) Payment rates for nutrition services are established separately for services provided by independent providers and services provided through agency providers. (4) Payment rates for nutrition services are based on the number of individuals receiving services.
View Appendix
Last updated July 1, 2022 at 1:17 PM
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Rule 5123-9-29 | Home and community-based services waivers - home-delivered meals under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines home-delivered meals and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Home-delivered meals" means meals delivered to individuals who are otherwise unable to prepare or obtain nourishing meals. Meals may be ready-to-eat, frozen, vacuum-packed, modified-atmosphere-packed, or shelf-stable. (a) A maximum of two meals per day may be provided under a home and community-based services waiver. (b) There are three types of home-delivered meals: (i) Kosher meal, meaning a meal certified as kosher by a recognized kosher certification or a kosher establishment under orthodox rabbinic supervision. (ii) Therapeutic meal, meaning a meal that is part of a therapeutic diet ordered by a licensed healthcare professional whose scope of practice includes ordering therapeutic diets: (A) As part of the treatment for a disease or clinical condition; (B) To modify, eliminate, decrease, or increase certain substances in the diet; or (C) To provide mechanically altered food (i.e., the texture of food is altered by chopping, grinding, mashing, or pureeing so that it can be successfully chewed and safely swallowed) when indicated. (iii) Standard meal, meaning a meal that is not a kosher meal or a therapeutic meal. (c) "Home-delivered meals" shall not include meals that are processed, frozen, or pre-packaged and commercially available to the general public. (5) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (8) "Modified-atmosphere-packed" means the atmosphere of a package of food is modified so that its composition is different from air but the atmosphere may change over time due to the permeability of the packaging material or the respiration of the food and includes reduction in the proportion of oxygen, total replacement of oxygen, or an increase in the proportion of other gases such as carbon dioxide or nitrogen. (9) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (10) "Shelf-stable" means non-perishable foods that can be safely stored at room temperature. (11) "Vacuum-packed" means air is removed from a package of food and the package is hermetically sealed so that a vacuum remains inside the package. (C) Provider qualifications (1) Home-delivered meals shall be provided by an independent provider or an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) Home-delivered meals shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards. (3) An applicant seeking approval to provide home-delivered meals shall complete and submit an application through the department's website (http://dodd.ohio.gov). (4) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Home-delivered meals shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code and specifies the type of home-delivered meals (i.e., kosher meals, therapeutic meals, or standard meals) to be provided. (2) The provider shall: (a) Be able to provide two meals per day, seven days per week; (b) Ensure that each meal: (i) Contains at least one-third of the daily recommended dietary allowances in accordance with the "Dietary Guidelines for Americans" published by the United States department of health and human services and the United States department of agriculture (available at https://health.gov/our-work/nutrition-physical-activity/dietary-guidelines); and (ii) Includes clear instructions on how to safely maintain, heat, reheat, and/or assemble the meal; (c) Ensure that a licensed dietitian approves and signs all menus and develops all therapeutic meal menus in accordance with the individual service plan; (d) Ensure handling and delivery of meals meet applicable federal, state, and local food safety, storage, and sanitation requirements; (e) Maintain a roster of delivery drivers who are trained and have available backup staff for scheduled meal deliveries; and (f) Initiate new orders for home-delivered meals within seventy-two hours of referral or as otherwise specified in the individual service plan. (3) The provider shall provide a noontime and/or evening meal as specified in the individual service plan and deliver the meal during the range of time specified in the individual service plan. On condition that appropriate methods exist to ensure proper and safe handling by the provider and safe consumption by the individual, the provider may: (a) Deliver the evening meal with the noontime meal. (b) Deliver all meals for a week at one time during the week when frozen, vacuum-packed, modified-atmosphere-packed, or shelf-stable meals are provided. Each frozen, vacuum-packed, modified-atmosphere-packed, or shelf-stable meal shall be individually packaged and labeled with the words, "use before" or "use by," followed by the month, day, and year by which the meal is to be used. (4) The provider shall not leave meals at a residence unless the individual or the individual's representative is there to receive the meals. (E) Documentation of services Service documentation for home-delivered meals shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Type of meals provided (i.e., kosher meals, therapeutic meals, or standard meals). (3) Date of service. (4) Place of service. (5) Name of individual receiving service. (6) Medicaid identification number of individual receiving service. (7) Name of provider. (8) Provider identifier/contract number. (9) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (10) Number of meals delivered. (11) Time that meals were delivered. (12) Name of person accepting delivery of meals. (F) Payment standards (1) The billing unit, service codes, and payment rates for home-delivered meals are contained in the appendix to this rule. (2) Payment rates for home-delivered meals are based on the type of meal provided (i.e., kosher meal, therapeutic meal, or standard meal).
View Appendix
Last updated July 1, 2022 at 1:21 PM
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Rule 5123-9-30 | Home and community-based services waivers - homemaker/ personal care under the individual options and level one waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines homemaker/personal care and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency provider" has the
same meaning as in rule 5123-2-08 of the Administrative Code. (3) "County board" means a
county board of developmental disabilities. (4) "Department" means the Ohio
department of developmental disabilities. (5) "Developmental center"
means a state-operated intermediate care facility for individuals with
intellectual disabilities. (6) "Fifteen-minute billing
unit" means a billing unit that equals fifteen minutes of service delivery
time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day shall be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (7) "Funding range" means one
of the dollar ranges contained in appendix A to rule 5123-9-06 of the
Administrative Code to which individuals enrolled in the individual options
waiver have been assigned for the purpose of funding services. The funding
range applicable to an individual is determined by the score derived from the
Ohio developmental disabilities profile that has been completed by a county
board employee qualified to administer the tool. (8) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (9) "Group size" means the
number of individuals who are sharing services, regardless of the funding
source for those services. (10) "Homemaker/personal care"
means the coordinated provision of a variety of services, supports, and
supervision necessary to ensure the health and welfare of an individual who
lives in the community. Homemaker/personal care advances the individual's
independence within his or her home and community and helps the individual meet
daily living needs. Examples of supports that may be provided as
homemaker/personal care include: (a) Self-advocacy training to assist in the expression of
personal preferences, self-representation, self-protection from and reporting
of abuse, neglect, and exploitation, asserting individual rights, and making
increasingly responsible choices. (b) Self-direction, including the identification of and response
to dangerous or threatening situations, making decisions and choices affecting
the individual's life, and initiating changes in living arrangements and
life activities. (c) Daily living skills including training in and providing
assistance with routine household tasks, meal preparation, personal care,
self-administration of medication, and other areas of day-to-day living
including proper use of adaptive and assistive devices, appliances, home
safety, first aid, and communication skills such as using the
telephone. (d) Implementation of recommended therapeutic interventions under
the direction of a professional or extension of therapeutic services, which
consist of reinforcing physical, occupational, speech, and other therapeutic
programs for the purpose of increasing the overall effective functioning of the
individual. (e) Behavioral support strategies including training and
assistance in appropriate expressions of emotions or desires, assertiveness,
acquisition of socially-appropriate behaviors, or extension of therapeutic
services for the purpose of increasing the overall effective functioning of the
individual. (f) Medical and health care services that are integral to meeting
the daily needs of the individual such as routine administration of medication
or tending to the needs of individuals who are ill or require attention to
their medical needs on an ongoing basis. (g) Emergency response training including development of
responses in case of emergencies, prevention planning, and training in the use
of equipment or technologies used to access emergency response
systems. (h) Community access services that explore community services
available to all people, natural supports available to the individual, and
develop methods to access additional services, supports, and activities needed
by the individual to be integrated in and have full access to the
community. (i) When provided in conjunction with other components of
homemaker/personal care, assistance with personal finances which may include
training, planning, and decision-making regarding the individual's
personal finances. (11) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (14) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (15) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (16) "Money management" has the
same meaning as in rule 5123-9-20 of the Administrative Code. (17) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (18) "Ohio developmental disabilities
profile" means the standardized instrument utilized by the department to
assess the relative needs and circumstances of an individual compared to
others. The individual's responses are scored and the individual is linked
to a funding range, which enables similarly situated individuals to access
comparable waiver services paid in accordance with rules adopted by the
department. (19) "On-site/on-call" means a rate authorized when no
need for supervision or supports is anticipated because the individual is
expected to be asleep for a continuous period of no less than five hours, and a
provider must be present and readily available to provide homemaker/personal
care if an unanticipated need arises but is not required to remain
awake. (20) "Residential respite" has
the same meaning as in rule 5123-9-34 of the Administrative Code. (21) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (22) "Shared living" has the
same meaning as in rule 5123-9-33 of the Administrative Code. (23) "Team" has the same meaning
as in rule 5123-4-02 of the Administrative Code. (24) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (25) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Homemaker/personal
care shall be provided by an independent provider or an agency provider that
meets the requirements of this rule and that has a medicaid provider agreement
with the Ohio department of medicaid. (2) Homemaker/personal
care shall not be provided by a county board or a regional council of
governments formed under section 5126.13 of the Revised Code by two or more
county boards. (3) An applicant seeking
approval to provide homemaker/personal care shall complete and submit an
application through the department's website
(http://dodd.ohio.gov). (4) Providers licensed
under section 5123.19 of the Revised Code seeking to provide homemaker/personal
care shall: (a) Meet all of the requirements set forth in and maintain a
license issued under section 5123.19 of the Revised Code. (b) Maintain a current medicaid provider agreement with the Ohio
department of medicaid. (5) Failure of a certified provider to
comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (6) Failure of a licensed provider to
comply with this rule and Chapters 5123-3 and 5123:2-3 of the Administrative
Code may result in denial, suspension, or revocation of the provider's
license. (D) Requirements for service
delivery (1) Homemaker/personal
care shall be provided pursuant to an individual service plan that conforms to
the requirements of rule 5123-4-02 of the Administrative Code. Providers shall
participate in individual service plan development meetings when a request for
their participation is made by the individual. (2) A provider of
homemaker/personal care shall not also provide money management or shared
living to the same individual. (3) Homemaker/personal care shall not be
provided to an individual at the same time as residential respite. (4) Homemaker/personal care services may
extend to those times when the individual is not physically present and the
provider is performing homemaker activities on behalf of the
individual. (5) Homemaker/personal care services
involving direct contact with an individual receiving the services shall not be
provided at the same time the individual is receiving adult day support, group
employment support, individual employment support, or vocational
habilitation. (6) A provider shall not bill for
homemaker/personal care provided by the driver during the same time non-medical
transportation at the per-trip rate is provided. (7) A provider of
homemaker/personal care shall arrange for substitute coverage, when necessary,
only from a provider certified or approved by the department and as identified
in the individual service plan; notify as applicable, the individual or legally
responsible person in the event that substitute coverage is necessary; and
notify the person identified in the individual service plan when substitute
coverage is not available to allow such person to make other
arrangements. (8) A provider delivering
homemaker/personal care in fifteen-minute billing units in accordance with this
rule, excluding on-site/on-call, shall utilize electronic visit verification in
accordance with rule 5160-1-40 of the Administrative Code. (9) An agency provider shall develop and
implement a documented process by which it reviews and manages overtime of
staff members who provide homemaker/personal care in a manner that ensures the
health and safety of individuals served and staff members and considers the
specific needs of individuals served, the abilities of staff members, and
patterns of overtime with the goal of reducing overtime. (E) Documentation of
services Service documentation for homemaker/personal care
shall include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Group size in which
the service was provided. (10) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (11) Number of units of
the delivered service or continuous amount of uninterrupted time during which
the service was provided. (12) Times the delivered
service started and stopped. (F) Payment standards (1) The billing units,
service codes, and payment rates for homemaker/personal care are contained in
appendix A to this rule. Payment rates are based on the county
cost-of-doing-business category. The cost-of-doing-business category for an
individual is the category assigned to the county in which the service is
actually provided for the preponderance of time. The cost-of-doing-business
categories are contained in appendix B to this rule. The department may cause
independent providers to be paid a rate that exceeds the payment rates
contained in appendix A to this rule as necessary to comply with increases to
minimum wage pursuant to Section 34a of Article II, Ohio
Constitution. (2) Payment rates for
homemaker/personal care are established separately for services provided by
independent providers and services provided by agency providers. (3) Payment rates for
homemaker/personal care shall be adjusted to reflect the number of individuals
being served and the number of people providing services. (a) When two individuals are being served by one person, the base
rate shall be one hundred seven per cent of the base rate for one-to-one
service. When three individuals are being served by one person, the base rate
shall be one hundred seventeen per cent of the base rate for one-to-one
service. When four or more individuals are being served by one person, the base
rate shall be one hundred thirty per cent of the base rate for one-to-one
service. (b) The base rate is divided by the number of individuals being
served to determine the rate apportioned to each individual. (c) When multiple staff members of an agency provider
simultaneously provide services to more than one individual, the payment rate
is adjusted to reflect the average staff-to-individual ratio at which services
are provided. The calculation of rates apportioned to each individual when
multiple staff members simultaneously provide services to more than one
individual are contained in the "Application of Appendix A to Rule
5123-9-30" (January 1, 2022), which is available at the department's
website (http://dodd.ohio.gov). (4) Payment rates for
routine homemaker/personal care shall be adjusted by the behavioral support
rate modification to reflect the needs of an individual requiring behavioral
support upon determination by the department that the individual meets the
criteria set forth in paragraph (F)(4)(a) of this rule. The amount of the
behavioral support rate modification applied to each fifteen-minute billing
unit of service is contained in appendix A to this rule. (a) The department shall determine that an individual meets the
criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four items in
question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed, will
result in the individual's engagement in behavior destructive to self or
others. (b) The duration of the behavioral support rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (5) Payment rates for
routine homemaker/personal care provided to individuals enrolled in the
individual options waiver shall be adjusted by the complex care rate
modification to reflect the needs of an individual requiring total support from
others upon determination by the county board that the individual meets the
criteria set forth in paragraph (F)(5)(a) of this rule. The amount of the
complex care rate modification applied to each fifteen-minute billing unit of
service is contained in appendix A to this rule. (a) The county board shall determine that an individual meets the
criteria for the complex care rate modification based on the individual's
responses to specific questions on the Ohio developmental disabilities profile
that indicate that the individual: (i) Must be transferred
and moved; and (ii) Cannot walk, roll
from back to stomach, or pull himself or herself to a standing position;
and (iii) Requires total
support in toileting, taking a shower or bath, dressing/undressing, and
eating. (b) The duration of the complex care rate modification shall be
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (6) Payment rates for routine
homemaker/personal care shall be adjusted by the medical assistance rate
modification to reflect the needs of an individual requiring medical assistance
upon determination by the county board that the individual meets the criteria
set forth in paragraph (F)(6)(a) of this rule. The amount of the medical
assistance rate modification applied to each fifteen-minute billing unit of
service is contained in appendix A to this rule. (a) The county board shall determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy or jejunostomy tube, and/or requires the administration of
routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such nursing procedure or
nursing task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (7) Payment rates for
routine homemaker/personal care shall be adjusted by the staff competency rate
modification when homemaker/personal care is provided by independent providers
or staff of agency providers who meet the criteria set forth in paragraph
(F)(7)(a) of this rule and as determined in accordance with, as applicable,
paragraph (F)(7)(b) or (F)(7)(c) of this rule. The amount of the staff
competency rate modification applied to each fifteen-minute billing unit of
service is contained in appendix A to this rule. (a) An independent provider or a staff member of an agency
provider shall be determined eligible for the staff competency rate
modification when he or she: (i) Has successfully
completed at least two years of full-time (or equivalent part-time) paid work
experience providing direct services to individuals; and (ii) Either: (a) Holds a "Professional Advancement Through Training and
Education in Human Services" or "DSPaths" certificate of initial
proficiency or certificate of advanced proficiency; or (b) Within the past five years has successfully completed at
least sixty hours of competency-based training with proof of successful
completion that is available for print, download, or issued to the learner that
includes the name of the learner, the course title, the completion date, and
the number of hours of training completed. For purposes of this paragraph,
"competency-based training" means online or in-person training in
topics not otherwise required by rule 5123-2-08, rule 5123-2-09, rule
5123-17-02, Chapter 5123:2-3, Chapter 5123-3, Chapter 5123:2-9, or Chapter
5123-9 of the Administrative Code that: (i) Is accredited by the
"National Alliance for Direct Support Professionals"; or (ii) Is approved by the
department for purposes of the staff competency rate modification. (b) Eligibility for the staff competency rate modification for an
independent provider shall be determined by the department when documentation
submitted by the independent provider through the department's website
(http://dodd.ohio.gov) demonstrates that the independent provider meets the
criteria set forth in paragraph (F)(7)(a) of this rule. (c) Eligibility for the staff competency rate modification for a
staff member of an agency provider shall be determined by the employing agency
provider. The employing agency provider shall review, verify, and maintain
documentation that demonstrates that the staff member meets the criteria set
forth in paragraph (F)(7)(a) of this rule. (d) The cost of a staff competency rate modification is excluded
from an individual's waiver budget limitation. (8) Payment rates for routine
homemaker/personal care may be modified to reflect the needs of individuals
enrolled in the individual options waiver who formerly resided at developmental
centers when the following conditions are met: (a) The individual was a resident of a developmental center
immediately prior to enrollment in the individual options waiver; (b) Homemaker/personal care is identified in the individual
service plan as a service to be delivered and the individual begins receiving
the service on or after July 1, 2011; and (c) The director of the department determines that the rate
modification is warranted due to time-limited cost increases experienced when
individuals move from institutional settings to community-based
settings. (9) Payment rates for routine
homemaker/personal care may be modified to reflect the needs of individuals
enrolled in the individual options waiver who formerly resided at intermediate
care facilities for individuals with intellectual disabilities when the
following conditions are met: (a) The individual was a resident of an intermediate care
facility for individuals with intellectual disabilities immediately prior to
enrollment in the individual options waiver; (b) As a result of the individual enrolling in the individual
options waiver, the intermediate care facility for individuals with
developmental disabilities has reduced its medicaid-certified
capacity; (c) Homemaker/personal care is identified in the individual
service plan as a service to be delivered and the individual begins receiving
the service on or after April 1, 2013; and (d) The director of the department determines that the rate
modification is warranted due to time-limited cost increases experienced when
individuals move from institutional settings to community-based
settings. (10) The amount of the payment rate
modifications set forth in paragraphs (F)(8) and (F)(9) of this rule shall be
limited to fifty-two cents for each fifteen-minute billing unit of routine
homemaker/personal care provided to the individual during the first year of the
individual's enrollment in the individual options waiver. (11) The team shall use a
department-approved tool to assess and document in the individual service plan
when on-site/on-call may be appropriate. (a) In making the assessment, the team shall
consider: (i) Medical or
psychiatric condition which requires supervision or supports throughout the
night; (ii) Behavioral needs
which require supervision or supports throughout the night; (iii) Sensory or motor
function limitations during sleep hours which require supervision or supports
throughout the night; (iv) Special dietary
needs, restrictions, or interventions which require supervision or supports
throughout the night; (v) Other safety
considerations which require supervision or supports throughout the night;
and (vi) Emergency action
needed to keep the individual safe. (b) A provider shall be paid at the on-site/on-call rate for
homemaker/personal care contained in appendix A to this rule when: (i) Based upon assessed
and documented need, the individual service plan indicates the days of the week
and the beginning and ending times each day when it is anticipated that an
individual will require on-site/on-call; and (ii) On-site/on-call does not exceed eight hours for the
individual in any twenty-four-hour period. (c) During an authorized on-site/on-call period, a provider shall
be paid the routine homemaker/personal care rate instead of the on-site/on-call
rate for a period of time when an individual receives supervision or supports.
In these instances, the provider shall document the date and beginning and
ending times during which supervision or supports were provided to the
individual. (d) The payment rate modifications set forth in paragraphs
(F)(4), (F)(5), (F)(6), (F)(7), (F)(8), and (F)(9) of this rule are not
applicable to the on-site/on-call payment rates for homemaker/personal
care. (12) Payment for homemaker/personal care
shall not include room and board, items of comfort and convenience, or costs
for the maintenance, upkeep, and improvement of the home.
View AppendixView Appendix
Last updated January 3, 2022 at 9:58 AM
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Rule 5123-9-31 | Home and community-based services waivers - homemaker/ personal care daily billing unit for sites where individuals enrolled in the individual options waiver share services.
Effective:
November 19, 2020
(A) Purpose This rule establishes a daily billing unit for
homemaker/personal care when individuals share the services of the same agency
provider at the same site as part of the home and community-based services
individual options waiver administered by the Ohio department of developmental
disabilities. The daily billing unit for individuals/sites that qualify shall
be used by agency providers instead of the fifteen-minute billing unit
established in rule 5123-9-30 of the Administrative Code. Requirements set
forth in paragraphs (C) and (D) of rule 5123-9-30 of the Administrative Code
apply to the homemaker/personal care daily billing unit. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Agency provider" means an
entity that directly employs at least one person in addition to the chief
executive officer for the purpose of providing services for which the entity
must be certified in accordance with rule 5123:2-2-01 of the Administrative
Code. (2) "Cost projection tool"
means the web-based analytical tool, that is a component of the medicaid
services system, developed and administered by the department, used to project
the cost of home and community-based services identified in an individual
service plan. (3) "County board" means a
county board of developmental disabilities. (4) "Daily billing unit" means
an agency provider's payment amount for homemaker/personal care services
for each individual sharing services at a site in a calendar month. The daily
billing unit is calculated based on projected service utilization entered in
the medicaid services system by the county board and direct service hours
entered in the medicaid services system by the agency provider of
homemaker/personal care services. (5) "Date of
service" means a date on which an individual resides at the site where
homemaker/personal care services are shared. "Date of service"
excludes any date on which an individual is admitted to an intermediate care
facility for individuals with intellectual disabilities or a nursing
facility. (6) "Department" means the Ohio
department of developmental disabilities. (7) "Direct service hours"
means the direct staff time spent delivering homemaker/personal care services.
A direct service hour is comprised of four fifteen-minute billing
units. (8) "Fifteen-minute billing
unit" means a billing unit that equals fifteen minutes of service delivery
time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. (9) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (10) "Independent provider"
means a self-employed person who provides services for which he or she must be
certified in accordance with rule 5123:2-2-01 of the Administrative Code and
does not employ, either directly or through contract, anyone else to provide
the services. (11) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (12) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (13) "Medicaid
services system" means the comprehensive information system that
integrates cost projection, prior authorization, daily rate calculation, and
payment authorization of waiver services. (14) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (15) "Shared
living" has the same meaning as in rule 5123-9-33 of the Administrative
Code. (16) "Site"
means a residence in which two or more individuals share homemaker/ personal
care services of the same agency provider. (17) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Circumstances excluded from the daily
billing unit approach (1) Individuals who
receive services and supports in shared living settings shall do so in
accordance with rule 5123-9-33 of the Administrative Code. (2) Individuals who do not share the
homemaker/personal care services of the same agency provider at the same site
shall remain on the fifteen-minute billing unit approach established in rule
5123-9-30 of the Administrative Code. (3) Individuals who receive
homemaker/personal care services from an independent provider shall remain on
the fifteen-minute billing unit approach established in rule 5123-9-30 of the
Administrative Code. (4) Individuals sharing
homemaker/personal care services of an agency provider at a residential site
may also receive occasional or time-limited homemaker/personal care services
delivered outside of the site by a secondary provider. When this occurs, the
secondary provider shall submit claims for payment using the fifteen-minute
billing unit approach established in rule 5123-9-30 of the Administrative
Code. (5) Individuals who live alone and share
homemaker/personal care services with a neighbor or other eligible person shall
remain on the fifteen-minute billing unit approach established in rule
5123-9-30 of the Administrative Code. (6) The director of the
department reserves the right to allow an agency provider of homemaker/personal
care services to continue to use the fifteen-minute billing unit approach
established in rule 5123-9-30 of the Administrative Code in the event of a
unique and/or extenuating circumstance. This right shall be exercised in
consultation with the Ohio department of medicaid. (D) Calculation of the individual daily
billing unit (1) The process for
assigning a funding range, determining an individual funding level, and
projecting the cost of an individual's services, set forth in rule
5123-9-06 of the Administrative Code, shall be followed. (2) The process for
establishing applicable rate modifications, set forth in paragraph (F) of rule
5123-9-30 of the Administrative Code, shall be followed. (3) Using the cost
projection tool, the service and support administrator or other county board
designee, with input from members of an individual's team, shall project
the service utilization for the full waiver eligibility span of each individual
sharing homemaker/personal care services at a site. The projected service
utilization shall be based on factors including, but not limited
to: (a) The typical usage pattern; (b) Adjustments based on past history, holidays, day service
program closings, and weekends; and (c) Other anticipated changes to direct service
hours. (4) Based on the
projected service utilization entered for the waiver eligibility span of each
individual sharing services at a site, the medicaid services system will
calculate the total projected homemaker/personal care hours and costs for the
site for each calendar month. These projections include any individual's
prior authorization requests that have been approved pursuant to rule 5123-9-07
of the Administrative Code. (5) Using the cost
projection tool, the service and support administrator or other county board
designee, with input from members of an individual's team, may adjust the
projected service utilization for a site only when: (a) An individual moves to or from the site; or (b) An individual living at the site starts or stops day
programming; or (c) Circumstances that cause an increase or decrease of more than
three per cent in the hours of homemaker/personal care provided at the site
during the calendar month. (6) Using the results
from the cost projection tool, the medicaid services system will calculate the
agency provider's daily rate for each individual sharing
homemaker/personal care services at a site. The agency provider shall use that
information to prepare a claim for payment. (7) Within thirty
calendar days of the end of each calendar month, an agency provider shall enter
in the medicaid services system, the direct service hours rendered during the
calendar month and the dates of service for each individual. When the total
direct service hours deviate from projected service utilization by more than
three per cent, the medicaid services system will generate an alert to the
agency provider and the county board. The agency provider may submit a written
request with supporting documentation for a modification to the projected
service utilization for that month and for future months, if the circumstances
causing the increase in direct service hours are not temporary. When the
supporting documentation indicates that an increase in direct service hours is
necessary to meet an individual's needs, the county board shall revise the
individual service plan within thirty calendar days. When circumstances exist
that prevent an agency provider and a county board from making necessary
adjustments to projected service utilization within sixty calendar days of the
end of the calendar month in which services were rendered, a request for a
retroactive adjustment may be submitted to the department by the county board
upon agreement from the team. (E) Documentation of
services Service documentation for homemaker/personal care
when individuals share the services of the same agency provider at the same
site shall include each of following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Names of
individuals. (5) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (6) Medicaid
identification number of the individuals receiving services. (7) Name of
provider. (8) Provider
identifier/contract number. (9) Written or
electronic signature of the person delivering the service or initials of the
person delivering the service if a signature and corresponding initials are on
file with the provider. (F) Payment standards (1) The service codes for
the homemaker/personal care daily billing unit are contained in the appendix to
this rule. (2) The medicaid services
system will calculate the payment rate for the agency provider's daily
billing unit for each date of service for each individual based on projected
service utilization entered by the county board. The medicaid services system
will adjust the payment rate for each individual and generate an alert to the
agency provider and the county board when the total direct service hours
entered by the agency provider in accordance with paragraph (D)(7) of this
rule, are more than three per cent below the original projected service
utilization entered by the county board. (3) Agency providers of
homemaker/personal care may bill for each date of service for each individual
at the site. (4) Payment for homemaker/personal care
shall not include room and board, items of comfort or convenience, or costs for
the maintenance, upkeep, and improvement of the home. (G) Monitoring (1) Agency providers,
county boards, and the department shall have access to both utilization reports
and reports generated by the medicaid services system in order to monitor
projected services and actual services provided at each specific site. This
information shall be made available to the Ohio department of medicaid upon
request. (2) The department shall
monitor the ongoing progress of the daily billing unit approach through a
series of fiscal control and quality assurance procedures including validation
of total expenditures and total hours that are entered by the county board into
the cost projection tool, verification that daily billing units are supported
by appropriate documentation, and verification that agency provider service
hours rendered are reported appropriately. (3) The Ohio department
of medicaid reserves the right to perform independent oversight reviews as part
of its general oversight functions, in addition to the department's
monitoring activities described in paragraph (G)(2) of this rule. (H) Authority of director to suspend
provisions of this rule During the COVID-19 state of emergency declared
by the governor, the director of the department may suspend paragraph (F)(2) of
this rule so that the medicaid services system does not adjust the payment rate
for each individual and generate an alert to an agency provider and a county
board when the total direct service hours entered by the agency provider are
more than three per cent below the original projected service utilization
entered by the county board.
View Appendix
|
Rule 5123-9-32 | Home and community-based services waivers - participant-directed homemaker/personal care under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines participant-directed
homemaker/personal care and sets forth provider qualifications, requirements
for service delivery and documentation of services, and payment standards for
the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Agency with
choice" means an arrangement available to an individual enrolled in the
self-empowered life-funding waiver whereby an agency provider acts as a
co-employer with the individual for purposes of provision of
participant-directed homemaker/personal care. Under this arrangement, the
individual is responsible for recruiting, selecting, training, and supervising
the persons providing participant-directed homemaker/personal care. Agency with
choice enables the individual to exercise choice and control over services
without the burden of carrying out financial matters and other legal
responsibilities associated with the employment of workers. The agency provider
is considered the employer of staff and assumes responsibility
for: (a) Employing and paying staff who have been selected by the
individual; (b) Reimbursing allowable services; (c) Withholding, filing, and paying federal, state, and local
income and employment taxes; and (d) Providing other supports to the individual as described in
the individual service plan. (4) "Co-employer" means an arrangement available to an
individual enrolled in the self-empowered life funding waiver whereby either an
agency with choice or a financial management services entity under contract
with the state functions as the employer of staff recruited by the individual.
The individual directs the staff and is considered their co-employer. The
agency with choice or financial management services entity conducts all
necessary payroll functions and is legally responsible for the
employment-related functions and duties for individual-selected staff based on
the roles and responsibilities identified in the individual service plan for
the two co-employers. (5) "Common law
employee" means a natural person certified by the department to provide
participant-directed homemaker/personal care to an individual who is exercising
employer authority. A common law employee shall not employ, either directly or
through contract, anyone else to provide participant-directed
homemaker/personal care. (6) "Common law
employer" means an arrangement available to an individual enrolled in the
individual options, level one, or self-empowered life funding waiver whereby
the individual is the legally responsible employer of persons selected by the
individual to furnish supports. The individual hires, supervises, and
discharges those persons. The individual is liable for the performance of
necessary employment-related tasks and uses a financial management services
entity under contract with the state to perform necessary payroll and other
employment-related functions as the individual's agent in order to ensure
that the employer-related legal obligations are fulfilled. (7) "County
board" means a county board of developmental disabilities. (8) "Department" means the Ohio department of
developmental disabilities. (9) "Employer
authority" means the individual has the authority to recruit, hire,
supervise, and direct the persons who furnish participant-directed
homemaker/personal care and functions as either the co-employer or the common
law employer of those persons. (10) "Family"
means a person who is related to the individual by blood, marriage, or
adoption. (11) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day shall be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (12) "Financial
management services" means services provided to an individual who directs
some or all of his or her waiver services. When used in conjunction with
employer authority, financial management services includes, but is not limited
to, operating a payroll service for individual-employed staff and making
required payroll withholdings. (13) "Group
employment support" has the same meaning as in rule 5123-9-16 of the
Administrative Code. (14) "Individual" means a person with a developmental
disability or for purposes of giving, refusing to give, or withdrawing consent
for services, his or her guardian in accordance with section 5126.043 of the
Revised Code or other person authorized to give consent. (15) "Individual
employment support" has the same meaning as in rule 5123-9-15 of the
Administrative Code. (16) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (17) "Money
management" has the same meaning as in rule 5123-9-20 of the
Administrative Code. (18) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (19) "Ohio
developmental disabilities profile" means the standardized instrument
utilized by the department to assess the relative needs and circumstances of an
individual compared to other individuals. (20) "On-site/on-call" means a rate authorized when no
need for supervision or supports is anticipated because the individual is
expected to be asleep for a continuous period of no less than five hours, and a
provider must be present and readily available to provide participant-directed
homemaker/personal care if an unanticipated need arises but is not required to
remain awake. (21) "Participant-directed homemaker/personal care"
means the coordinated provision of a variety of services, supports, and
supervision necessary to ensure the health and welfare of an individual who
lives in the community and chooses to exercise employer authority.
Participant-directed homemaker/personal care advances the individual's
independence within his or her home and community and helps the individual meet
daily living needs. Examples of supports that may be provided as
participant-directed homemaker/personal care include: (a) Self-advocacy training to assist in the expression of
personal preferences, self-representation, self-protection from and reporting
of abuse, neglect, and exploitation, asserting individual rights, and making
increasingly responsible choices. (b) Self-direction, including the identification of and response
to dangerous or threatening situations, making decisions and choices affecting
the individual's life, and initiating changes in living arrangements and
life activities. (c) Daily living skills including training in and providing
assistance with routine household tasks, meal preparation, personal care,
self-administration of medication, and other areas of day-to-day living
including proper use of adaptive and assistive devices, appliances, home
safety, first aid, and communication skills such as using the
telephone. (d) Implementation of recommended therapeutic interventions under
the direction of a professional or extension of therapeutic services, which
consist of reinforcing physical, occupational, speech, and other therapeutic
programs for the purpose of increasing the overall effective functioning of the
individual. (e) Behavioral support strategies including training and
assistance in appropriate expressions of emotions or desires, assertiveness,
acquisition of socially-appropriate behaviors, or extension of therapeutic
services for the purpose of increasing the overall effective functioning of the
individual. (f) Medical and health care services that are integral to meeting
the daily needs of the individual such as routine administration of medication
or tending to the needs of individuals who are ill or require attention to
their medical needs on an ongoing basis. (g) Emergency response training including development of
responses in case of emergencies, prevention planning, and training in the use
of equipment or technologies used to access emergency response
systems. (h) Community access services that explore community services
available to all people, natural supports available to the individual, and
develop methods to access additional services, supports, and activities needed
by the individual to be integrated in and have full access to the
community. (i) When provided in conjunction with other components of
participant-directed homemaker/personal care, assistance with personal finances
which may include training, planning, and decision-making regarding the
individual's personal finances. (22) "Provider"
means an agency with choice or a common law employee. (23) "Residential
respite" has the same meaning as in rule 5123-9-34 of the Administrative
Code. (24) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (25) "Shared living" has the
same meaning as in rule 5123-9-33 of the Administrative Code. (26) "Team" has the same meaning
as in rule 5123-4-02 of the Administrative Code. (27) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (28) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Participant-directed
homemaker/personal care provided to an individual enrolled in the individual
options waiver or the level one waiver shall be provided by a common law
employee. (2) Participant-directed
homemaker/personal care provided to an individual enrolled in the
self-empowered life funding waiver shall be provided by a common law employee
or an agency with choice. (3) A provider of
participant-directed homemaker/personal care shall meet the requirements of
this rule and have a medicaid provider agreement with the Ohio department of
medicaid. (4) Neither a county
board nor a regional council of governments formed under section 5126.13 of the
Revised Code by two or more county boards shall provide participant-directed
homemaker/personal care. (5) A provider of
participant-directed homemaker/personal care is subject to the requirements of
rule 5123-2-08 or 5123-2-09 of the Administrative Code, as applicable, except
that: (a) A common law employee need not hold a high school diploma or
certificate of high school equivalence, "American Red Cross" or
equivalent certification in first aid, or "American Red Cross" or
equivalent certification in cardiopulmonary resuscitation unless specifically
required to do so by the individual receiving services; and (b) A common law employee need not complete the eight hours of
annual training described on page two of appendix A to rule 5123-2-09 of the
Administrative Code unless specifically required to do so by the individual
receiving services, but in any case shall annually complete training in
accordance with standards established by the department in: (i) The rights of
individuals set forth in section 5123.62 of the Revised Code; and (ii) Rule 5123-17-02 of
the Administrative Code including a review of health and welfare alerts issued
by the department since the previous year's training. (6) A provider of
participant-directed homemaker/personal care shall not administer medication or
perform health-related activities unless the provider meets the applicable
requirements of Chapters 4723., 5123., and 5126. of the Revised Code and rules
adopted under those chapters. (7) An applicant seeking
certification to provide participant-directed homemaker/ personal care shall
complete and submit an application through the department's website
(http://dodd.ohio.gov). (8) The individual
receiving participant-directed homemaker/personal care shall determine training
to be completed by the common law employee or staff of the agency with choice
as necessary to meet the individual's unique needs. (9) Failure of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) The individual
receiving participant-directed homemaker/personal care or the individual's
guardian or the individual's designee must be willing and able to perform
the duties associated with participant direction. (2) Participant-directed
homemaker/personal care shall be provided pursuant to an individual service
plan that conforms to the requirements of rule 5123-4-02 of the Administrative
Code. (3) An individual
enrolled in the individual options waiver or the level one waiver may receive
participant-directed homemaker/personal care only when living alone or with
family. (4) A provider of
participant-directed homemaker/personal care shall not also provide money
management or shared living to the same individual. (5) Participant-directed
homemaker/personal care shall not be provided to an individual at the same time
as residential respite. (6) Participant-directed
homemaker/personal care services involving direct contact with an individual
receiving the services shall not be provided at the same time the individual is
receiving adult day support, group employment support, individual employment
support, or vocational habilitation. (7) Participant-directed
homemaker/personal care services may extend to those times when the individual
is not physically present and the common law employee is performing homemaker
activities on behalf of the individual. (8) A provider shall not
bill for participant-directed homemaker/personal care provided by the driver
during the same time non-medical transportation at the per-trip rate is
provided. (9) The ratio of persons
providing participant-directed homemaker/personal care to the individuals being
served shall not exceed one to three. (10) A provider of
participant-directed homemaker/personal care shall arrange for substitute
coverage, when necessary, only from a provider certified or approved by the
department and as identified in the individual service plan; notify as
applicable, the individual or legally responsible person in the event that
substitute coverage is necessary; and notify the person identified in the
individual service plan when substitute coverage is not available to allow such
person to make other arrangements. (11) A provider
delivering participant-directed homemaker/personal care in accordance with this
rule, excluding on-site/on-call, shall utilize electronic visit verification in
accordance with rule 5160-1-40 of the Administrative Code. (E) Documentation of
services (1) Service documentation
for participant-directed homemaker/personal care shall include each of the
following to validate payment for medicaid services: (a) Type of service. (b) Date of service. (c) Place of service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving
service. (f) Name of provider. (g) Provider identifier/contract number. (h) Written or electronic signature of the person delivering the
service. (i) Group size in which the service was provided. (j) Description and details of the services delivered that
directly relate to the services specified in the approved individual service
plan as the services to be provided. (k) Number of units of the delivered service or continuous amount
of uninterrupted time during which the service was provided. (l) Times the delivered service started and stopped. (2) A common law employee
shall prepare an accurate timesheet to be verified by the individual receiving
participant-directed homemaker/personal care prior to submission to the
financial management services entity. (F) Payment standards (1) The billing unit,
service codes, and payment rates for participant-directed homemaker/personal
care are contained in the appendix to this rule. (2) The payment rates for
participant-directed homemaker/personal care provided by a common law employee
shall be negotiated by the individual and the common law employee subject to
the minimum and maximum payment rates contained in the appendix to this rule
and shall be recorded in the individual service plan. An individual who meets
the criteria for a rate modification described in paragraph (F)(4), (F)(5), or
(F)(6) of this rule may choose to add the applicable rate modification to the
negotiated base payment rate. (3) The payment rates for
participant-directed homemaker/personal care shall be adjusted to reflect the
number of individuals being served and the number of persons providing
services. (4) Payment rates for
routine participant-directed homemaker/personal care may be adjusted by the
behavioral support rate modification to reflect the needs of an individual
requiring behavioral support upon determination by the department that the
individual meets the criteria set forth in paragraph (F)(4)(a) of this rule.
The amount of the behavioral support rate modification applied to each
fifteen-minute billing unit of service is contained in the appendix to this
rule. (a) The department shall determine that an individual meets the
criteria for the behavioral support rate modification when: (i) The individual has
been assessed within the last twelve months to present a danger to self or
others or have the potential to present a danger to self or others;
and (ii) A behavioral support
strategy that is a component of the individual service plan has been developed
in accordance with the requirements in rules established by the department;
and (iii) The individual
either: (a) Has a response of "yes" to at least four items in
question thirty-two of the behavioral domain of the Ohio developmental
disabilities profile; or (b) Requires a structured environment that, if removed, will
result in the individual's engagement in behavior destructive to self or
others. (b) The duration of the behavioral support rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (5) Payment rates for
routine participant-directed homemaker/personal care may be adjusted by the
medical assistance rate modification to reflect the needs of an individual
requiring medical assistance upon determination by the county board that the
individual meets the criteria set forth in paragraph (F)(5)(a) of this rule.
The amount of the medical assistance rate modification applied to each
fifteen-minute billing unit of service is contained in the appendix to this
rule. (a) The county board shall determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires routine feeding and/or the administration of prescribed medication
through gastrostomy or jejunostomy tube, and/or requires the administration of
routine doses of insulin through subcutaneous injection or insulin pump;
or (ii) The individual requires a nursing procedure or nursing
task that a licensed nurse agrees to delegate in accordance with rules in
Chapter 4723-13 of the Administrative Code, which is provided in accordance
with section 5123.42 of the Revised Code, and when such nursing procedure or
nursing task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123:2-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification
shall be limited to the individual's waiver eligibility span, may be
determined needed or no longer needed within that waiver eligibility span, and
may be renewed annually. (6) Payment rates for
routine participant-directed homemaker/personal care provided to individuals
enrolled in the individual options waiver may be adjusted by the complex care
rate modification to reflect the needs of an individual requiring total support
from others upon determination by the county board that the individual meets
the criteria set forth in paragraph (F)(6)(a) of this rule. The amount of the
complex care rate modification applied to each fifteen-minute billing unit of
service is contained in the appendix to this rule. (a) The county board shall determine that an individual meets the
criteria for the complex care rate modification based on the individual's
responses to specific questions on the Ohio developmental disabilities profile
that indicate that the individual: (i) Must be transferred
and moved; and (ii) Cannot walk, roll
from back to stomach, or pull himself or herself to a standing position;
and (iii) Requires total
support in toileting, taking a shower or bath, dressing/undressing, and
eating. (b) The duration of the complex care rate modification shall be
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (7) The team shall use a
department-approved tool to assess and document in the individual service plan
when on-site/on-call may be appropriate. (a) In making the assessment, the team shall
consider: (i) Medical or
psychiatric condition which requires supervision or supports throughout the
night; (ii) Behavioral needs
which require supervision or supports throughout the night; (iii) Sensory or motor
function limitations during sleep hours which require supervision or supports
throughout the night; (iv) Special dietary
needs, restrictions, or interventions which require supervision or supports
throughout the night; (v) Other safety
considerations which require supervision or supports throughout the night;
and (vi) Emergency action
needed to keep the individual safe. (b) A provider shall be paid at the on-site/on-call rate for
participant-directed homemaker/personal care contained in the appendix to this
rule when: (i) Based upon assessed
and documented need, the individual service plan indicates the days of the week
and the beginning and ending times each day when it is anticipated that an
individual will require on-site/on-call; and (ii) On-site/on-call does not exceed eight hours for the
individual in any twenty-four-hour period. (c) During an authorized on-site/on-call period, a provider shall
be paid the routine participant-directed homemaker/personal care rate instead
of the on-site/on-call rate for a period of time when an individual receives
supports. In these instances, the provider shall document the date and
beginning and ending times during which supports were provided to the
individual. (d) The payment rate modifications described in paragraphs
(F)(4), (F)(5), and (F)(6) of this rule are not applicable to the
on-site/on-call payment rates for participant-directed homemaker/personal
care. (8) Payment for
participant-directed homemaker/personal care shall not include room and board,
items of comfort and convenience, or costs for the maintenance, upkeep, and
improvement of the home.
View Appendix
Last updated January 3, 2022 at 9:59 AM
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Rule 5123-9-33 | Home and community-based services waivers - shared living under the individual options waiver.
Effective:
January 1, 2022
(A) Purpose This rule defines shared living and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult"
means a person eighteen years of age or older. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Community
respite" has the same meaning as in rule 5123-9-22 of the Administrative
Code. (4) "County
board" means a county board of developmental disabilities. (5) "Department" means the Ohio department of
developmental disabilities. (6) "Group
size" means the number of individuals who are sharing services, regardless
of the funding source for those services. (7) "Homemaker/personal care" has the same meaning as
in rule 5123-9-30 of the Administrative Code. (8) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (9) "Individual" means a person with a developmental
disability or for purposes of giving, refusing to give, or withdrawing consent
for services, his or her guardian in accordance with section 5126.043 of the
Revised Code. (10) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (11) "Ohio
developmental disabilities profile" has the same meaning as in rule
5123-9-06 of the Administrative Code. (12) "Related
to" means the caregiver is, by blood, marriage, or adoption, the
individual's: (a) Parent or stepparent; (b) Sibling or stepsibling; (c) Grandparent; (d) Aunt, uncle, nephew, or niece; (e) Cousin; or (f) Child or stepchild. (13) "Residential respite" has
the same meaning as in rule 5123-9-34 of the Administrative Code. (14) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (15) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (16) "Shared living" means
individual-specific personal care and support necessary to meet the day-to-day
needs of an adult enrolled in the individual options waiver, by an adult
caregiver who resides in the same home as the individual receiving the
services. Shared living is provided in conjunction with residing in the home
and is part of the rhythm of life that naturally occurs when people live
together in the same home. Due to the environment provided by living together
in the same home, segregating these activities into discrete services is
impractical. (a) Shared living: (i) Enables the
individual to experience genuine community life; (ii) Nurtures stability
of long-term relationships within the home and the broader
community; (iii) Contributes to
development of life routines chosen by the individual; (iv) Assists the
individual to routinely participate in and make positive contributions to his
or her community; (v) Supports shared
decision-making between the individual and other members of the household;
and (vi) Enhances, rather
than replaces, existing family relationships and other community
connections. (b) Examples of supports that may be provided as shared living
include: (i) Basic personal care and grooming, including bathing, care of
the hair, and assistance with clothing; (ii) Assistance with bladder and/or bowel requirements or
problems, including helping the individual to and from the bathroom or
assisting the individual with bedpan routines; (iii) Assisting the individual with self-medication or provision of
medication administration and assisting the individual with, or performing,
health care activities; (iv) Performing household services essential to the
individual's health and comfort in the home (e.g., necessary changing of
bed linens or rearranging of furniture to enable the individual to move about
more easily in his or her home); (v) Assessing, monitoring, and supervising the individual to
ensure the individual's safety, health, and welfare; (vi) Light cleaning tasks in areas of the home used by the
individual; (vii) Preparation of a shopping list appropriate to the
individual's dietary needs and financial circumstances, performance of
grocery shopping activities as necessary, and preparation of
meals; (viii) Personal laundry; (ix) Incidental neighborhood errands as necessary, including
accompanying the individual to medical and other appropriate appointments and
accompanying the individual for walks outside the home; (x) Skill development to prevent the loss of skills and enhance
skills that are already present that lead to greater independence and community
integration; (xi) Exploration of community resources and natural supports and
development of methods to access additional resources and supports to ensure
the individual is integrated in and has full access to the community to pursue
interests and activities of his or her choosing; and (xii) When provided in conjunction with other components of shared
living, assistance with personal finances which may include training, planning,
and decision-making regarding the individual's personal
finances. (17) "Significant change" means
a change experienced by an individual including but not limited
to: (a) A change in health status or caregiver status; (b) Referral to or active involvement on the part of a protective
services agency; or (c) Institutionalization. (C) Provider qualifications (1) Shared living shall
be provided by an agency provider or an independent provider that meets the
requirements of this rule and that has a medicaid provider agreement with the
Ohio department of medicaid. (2) Shared living shall
not be provided by a county board or a regional council of governments formed
under section 5126.13 of the Revised Code by two or more county
boards. (3) An individual's
legal guardian may provide shared living to that individual only when the legal
guardian is related to the individual. (4) An applicant seeking approval to
provide shared living shall complete and submit an application through the
department's website (http://dodd.ohio.gov/). (5) Failure of an agency provider or an
independent provider to comply with this rule and as applicable, rule 5123-2-08
or 5123-2-09 of the Administrative Code, may result in denial, suspension, or
revocation of the provider's certification. (6) Failure of a licensed residential
facility to comply with this rule and Chapters 5123-3 and 5123:2-3 of the
Administrative Code may result in denial, suspension, or revocation of the
residential facility's license. (D) Requirements for service
delivery (1) Shared living shall
be authorized for an individual when one or more adult caregivers who reside
with the individual provide twenty per cent or more of the individual's
personal care and support services. (2) Shared living shall be provided
pursuant to an individual service plan that conforms to the requirements of
rule 5123-4-02 of the Administrative Code. (3) The total number of persons with
developmental disabilities living in a home in which an individual receives
shared living shall not exceed four. (4) Except as provided in
paragraph (G) of this rule, only shared living may be authorized for an
individual enrolled in the individual options waiver who receives services
meeting the definition of shared living as set forth in this rule. (5) An independent
provider shall reside in the home where shared living is provided and that home
shall be the independent provider's primary, legal residence. (6) An agency provider
shall employ or contract with a person to be the caregiver who shall reside in
the home where shared living is provided and that home shall be the
person's primary, legal residence. (7) Shared living shall
not be provided to an individual who is receiving foster care services funded
through Title IV-E of the Social Security Act as in effect on the effective
date of this rule. (8) An independent
provider of shared living shall not bill homemaker/personal care or deliver
state plan home health aide services as an employee of an agency to an
individual for whom he or she provides shared living. (9) An individual who
receives shared living may also choose to receive community respite or
residential respite during a short-term absence or need for relief of the
shared living caregiver. (10) An individual who
receives shared living may receive homemaker/personal care on the same day as
long as the services are not delivered at the same time or by the same
person. (11) In circumstances
where a shared living caregiver is temporarily unavailable to provide services,
substitute coverage may be provided in the individual's shared living home
or in another community setting agreed to by the individual. (a) For independent providers, a provider of homemaker/personal
care is arranged to deliver substitute coverage and the service is billed as
homemaker/personal care. Independent providers shall work with the
individual's service and support administrator to arrange for substitute
coverage when needed. (b) For agency providers, a provider of shared living is arranged
to deliver substitute coverage and the service is billed as shared
living. (12) A provider of shared
living shall develop, maintain, and implement for each individual for whom
shared living is provided, a detailed written protocol to be followed in the
event that substitute coverage is necessary. The protocol shall include contact
information for and a requirement to notify: (a) As applicable, the
individual or legally responsible person in the event that substitute coverage
is necessary; and (b) The person identified
in the individual service plan when substitute coverage is not available to
allow such person to make other arrangements. (E) Documentation of
services Service documentation for shared living shall
include each of the following to validate payment for medicaid services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Group size in which
the service was provided. (10) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (F) Payment standards (1) The billing unit,
service codes, and payment rates for shared living are contained in appendix A
to this rule. (2) Payment for shared
living shall be at a daily rate. Payment rates are adjusted based on the county
cost-of-doing-business category. The cost-of-doing-business categories are
contained in appendix B to this rule. (3) Payment rates for
shared living are established separately for independent providers and agency
providers. (4) The rate paid to a
provider of shared living shall be adjusted to reflect the group
size: (a) Payment for one individual shall be at one hundred per cent
of the daily rate for the individual's Ohio developmental disabilities
profile range. (b) Payment for a group size of two shall be at eighty-five per
cent of the daily rate for the Ohio developmental disabilities profile range
for each individual. (c) Payment for a group size of three shall be at seventy-five
per cent of the daily rate for the Ohio developmental disabilities profile
range for each individual. (d) Payment for a group size of four shall be at sixty-five per
cent of the daily rate for the Ohio developmental disabilities profile range
for each individual. (5) Shared living shall not be billed on
the same day as community respite at the full day billing unit or residential
respite. (6) Only one provider per day may bill
for providing shared living to a specific individual. (7) An individual who receives shared
living may request prior authorization in accordance with rule 5123-9-07 of the
Administrative Code for services other than shared living. In no instance shall
prior authorization result in a daily rate in excess of the highest rate within
the applicable county cost-of-doing-business category as set forth in appendix
A to this rule. (8) Payment for shared living does not
include room and board, items of comfort or convenience, or costs for the
maintenance, upkeep, and improvement of the home in which shared living is
provided. (G) Exemption An individual who, on July 15, 2011, was
receiving homemaker/personal care under the individual options waiver provided
by a caregiver related to the individual and residing in the same home as the
individual may continue to receive homemaker/personal care from that same
caregiver, unless the individual experiences a significant change.
View AppendixView Appendix
Last updated January 3, 2022 at 9:59 AM
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Rule 5123-9-34 | Home and community-based services waivers - residential respite under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2022
(A) Purpose This rule defines residential respite and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "County board" means a
county board of developmental disabilities. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (5) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (7) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (8) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (9) "Participant-directed
homemaker/personal care" has the same meaning as in rule 5123-9-32 of the
Administrative Code. (10) "Residential respite" means
services provided to an individual unable to care for himself or herself
furnished on a short-term basis because of the absence or need for relief of
those persons routinely providing care. Residential respite shall only be
provided in: (a) An intermediate care facility for individuals with
intellectual disabilities; (b) A residential facility licensed by the department pursuant to
section 5123.19 of the Revised Code; or (c) A residence, other than an intermediate care facility for
individuals with intellectual disabilities or a residential facility licensed
by the department pursuant to section 5123.19 of the Revised Code, where
residential respite is provided by an agency provider. (11) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (12) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Residential respite
shall be provided by one of the following entities that meets the requirements
of this rule and that has a medicaid provider agreement with the Ohio
department of medicaid: (a) An intermediate care facility for individuals with
intellectual disabilities; (b) A residential facility licensed by the department pursuant to
section 5123.19 of the Revised Code; or (c) An agency provider that is approved to provide residential
respite in accordance with this rule. (2) An applicant seeking approval to
provide residential respite shall complete and submit an application through
the department's website (http://dodd.ohio.gov). (3) Failure of a certified provider to
comply with this rule and rule 5123-2-08 of the Administrative Code may result
in denial, suspension, or revocation of the provider's
certification. (4) Failure of a licensed provider to
comply with this rule and Chapters 5123-3 and 5123:2-3 of the Administrative
Code may result in denial, suspension, or revocation of the provider's
license. (D) Requirements for service delivery (1) Residential respite shall be provided
pursuant to an individual service plan that conforms to the requirements of
rule 5123-4-02 of the Administrative Code. (2) The individual service plan shall
address emergency and replacement coverage should the individual unexpectedly
need to leave the residential respite service delivery location. (3) Residential respite
may be provided at a residence other than an intermediate care facility for
individuals with intellectual disabilities or a residential facility licensed
by the department pursuant to section 5123.19 of the Revised Code only
when: (a) Each individual who receives homemaker/personal care or
participant-directed homemaker/personal care and permanently resides at the
residence consents to the provision of residential respite at the residence;
and (b) The total number of persons with developmental disabilities
being served at the residence does not exceed four. (4) Residential respite is limited to
ninety calendar days of service per waiver eligibility span. (5) Residential respite shall not be
provided to an individual at the same time as homemaker/personal care or
participant-directed homemaker/personal care. (E) Documentation of services Service documentation for residential respite
shall include each of the following to validate payment for medicaid
services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving
service. (5) Medicaid identification number of
individual receiving service. (6) Name of provider. (7) Provider identifier/contract
number. (8) Written or electronic signature of
the person delivering the service, or initials of the person delivering the
service if a signature and corresponding initials are on file with the
provider. (9) Description and details of the
services delivered that directly relate to the services specified in the
approved individual service plan as the services to be provided. (F) Payment standards (1) The billing units, service codes, and
payment rates for residential respite are contained in the appendix to this
rule. (2) Only one provider
shall bill residential respite for the same individual on any given
day. (3) Residential respite provided to
individuals enrolled in the individual options waiver is subject to the funding
ranges and individual funding levels set forth in rule 5123-9-06 of the
Administrative Code. (4) Payment for residential respite shall
not include payment for room and board or transportation.
View Appendix
Last updated January 3, 2022 at 9:59 AM
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Rule 5123-9-35 | Home and community-based services waivers - remote support under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines remote support and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "Backup support person" means the person who is responsible for responding in the event of an emergency or when an individual receiving remote support otherwise needs assistance or the equipment used for delivery of remote support stops working for any reason. Backup support may be provided on an unpaid basis by a family member, friend, or other person selected by the individual or on a paid basis by an agency provider of homemaker/personal care for an individual enrolled in the individual options waiver or level one waiver or in an agency-with-choice arrangement for participant-directed homemaker/personal care provided to an individual enrolled in the self-empowered life funding waiver, as applicable. When backup support is provided on a paid basis by an agency provider or in an agency-with-choice arrangement, the agency provider shall be the primary contact for the remote support vendor. (3) "County board" means a county board of developmental disabilities. (4) "Department" means the Ohio department of developmental disabilities. (5) "Group size" means the number of individuals who are sharing services, regardless of the funding source for those services. (6) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code. (7) "Hourly billing unit" means a billing unit and corresponding payment rate that shall be used when forty-five to sixty minutes of remote support are provided by the same provider to the same individual during one calendar day. (8) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (9) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (10) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (11) "Monitoring base" means the off-site location from which the remote support staff monitor an individual. (12) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123-9-32 of the Administrative Code. (13) "Remote support" means the provision of supports by staff of an agency provider at a remote location who are engaged with an individual through equipment with the capability for live two-way communication. Equipment used to meet this requirement shall include one or more of the following components: (a) Motion sensing system; (b) Radio frequency identification; (c) Live video feed; (d) Live audio feed; (e) Web-based monitoring system; or (f) Another device that facilitates live two-way communication. (14) "Remote support provider" means the agency provider identified in the individual service plan as the provider of remote support. The remote support provider may be either: (a) A remote support vendor with unpaid backup support; or (b) A provider of homemaker/personal care or participant-directed homemaker/personal care who also acts as a remote support vendor or maintains a contract with a remote support vendor to provide paid backup support. (15) "Remote support vendor" means the agency provider that supplies the monitoring base, the remote support staff who monitor an individual from the monitoring base, and the equipment used in the delivery of remote support. (16) "Sensor" means equipment used to notify the remote support staff or other persons designated in the individual service plan of a situation that requires attention or activity which may indicate deviations from routine activity and/or future needs. Examples include, but are not limited to, seizure mats, door sensors, floor sensors, motion detectors, heat detectors, and smoke detectors. (17) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (18) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (19) "Shared living" has the same meaning as in rule 5123-9-33 of the Administrative Code. (20) "Team" has the same meaning as in rule 5123-4-02 of the Administrative Code. (21) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (C) Provider qualifications (1) Remote support shall be provided by an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) Remote support shall not be provided by an independent provider, a county board, or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards. (3) An applicant seeking approval to provide remote support shall complete and submit an application through the department's website (http://dodd.ohio.gov). (4) Staff of agency providers and entities under contract with agency providers who monitor individuals from the monitoring base shall complete the training specified in appendix C to rule 5123-2-08 of the Administrative Code. (5) Failure of a certified provider to comply with this rule and rule 5123-2-08 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification. (6) Failure of a licensed provider to comply with this rule and Chapters 5123-3 and 5123:2-3 of the Administrative Code may result in denial, suspension, or revocation of the provider's license. (D) Requirements for service delivery (1) Remote support is intended to address an individual's assessed needs in a manner that promotes autonomy and minimizes dependence on paid support staff and should be explored prior to authorizing services that may be more intrusive, including homemaker/personal care or participant-directed homemaker/personal care, as applicable. (2) An individual's service and support administrator, in consultation with the individual and the individual's team, shall assess whether remote support is sufficient to ensure the individual's health and welfare. (3) Remote support shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (4) Remote support shall be provided in real time, not via a recording, by awake staff at a monitoring base using the appropriate connection. While remote support is being provided, the remote support staff shall not have duties other than remote support. (5) Remote support shall not be provided in shared living or non-residential settings. (6) When remote support involves the use of audio and/or video equipment that permits remote support staff to view activities and/or listen to conversations in the residence, the individual who receives the service and each person who lives with the individual shall consent in writing after being fully informed of what remote support entails including, but not limited to, that the remote support staff will observe their activities and/or listen to their conversations in the residence, where in the residence the remote support will take place, and whether or not recordings will be made. If the individual or a person who lives with the individual has a guardian, the guardian shall consent in writing. The individual's service and support administrator shall keep a copy of each signed consent form with the individual service plan. (7) The remote support vendor shall provide initial and ongoing training to its staff to ensure they know how to use the monitoring base system. (8) The remote support vendor shall have a backup power system (such as battery power and/or generator) in place at the monitoring base in the event of electrical outages. The remote support vendor shall have other backup systems and additional safeguards in place which shall include, but are not limited to, contacting the backup support person in the event the monitoring base system stops working for any reason. (9) The remote support vendor shall comply with all federal, state, and local regulations that apply to the operation of its business or trade, including but not limited to, 18 U.S.C. section 2510 to section 2522 as in effect on the effective date of this rule and section 2933.52 of the Revised Code. (10) The remote support vendor shall have an effective system for notifying emergency personnel such as police, fire, emergency medical services, and psychiatric crisis response entities. (11) The remote support vendor shall provide an individual who receives remote support with initial and ongoing training on how to use the remote support system as specified in the individual service plan. (12) If a known or reported emergency involving an individual arises, the remote support staff shall immediately assess the situation and call emergency personnel first, if that is deemed necessary, and then contact the backup support person. The remote support staff shall stay engaged with the individual during an emergency until emergency personnel or the backup support person arrives. (a) The backup support person shall verbally acknowledge receipt of a request for assistance from the remote support staff. (b) The backup support person shall arrive at the individual's location within a reasonable amount of time (to be specified in the individual service plan) when a request for in-person assistance is made. (13) When an individual needs assistance but the situation is not an emergency, the remote support staff shall: (a) Address the situation as specified in the individual service plan for an individual who receives remote support with unpaid backup support; or (b) Contact the paid backup support for an individual who receives remote support with paid backup support. (14) The remote support staff shall have detailed and current written protocols for responding to an individual's needs as specified in the individual service plan, including contact information for the backup support person to provide assistance when necessary. The individual service plan shall set forth the protocol to be followed should the individual request that the equipment used for delivery of remote support be turned off. (15) A monitoring base shall not be located at the residence of an individual who receives remote support. (16) A secure network system requiring authentication, authorization, and encryption of data that complies with 45 C.F.R. section 164.102 to section 164.534 as in effect on the effective date of this rule shall be in place to ensure that access to computer, video, audio, sensor, and written information is limited to authorized persons. (17) If an unusual incident or a major unusual incident as defined in rule 5123-17-02 of the Administrative Code occurs while an individual is being monitored, the remote support provider shall retain or ensure the retention of any video and/or audio recordings and any sensor and written information pertaining to the incident for at least seven years from the date of the incident. (E) Documentation of services Service documentation for remote support shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Begin and end time of the remote support service when the backup support person is needed on site. (9) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (10) Number of units of the delivered service per calendar day. (11) Group size in which the service was provided. (12) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (F) Payment standards (1) The billing units, service codes, and payment rates for remote support are contained in the appendix to this rule. (2) There are two payment rates for remote support, which differ depending on whether an individual is receiving remote support with unpaid backup support or with paid backup support. (a) When an individual receives remote support with unpaid backup support, the remote support vendor shall bill for the remote support. (b) When an individual receives remote support with paid backup support, the remote support provider shall bill for the remote support and provide the remote support directly or through a contract with a remote support vendor that meets the requirements of this rule. In the event that the remote support staff contact the remote support provider to request emergency or in-person assistance, the paid backup support person's time shall be billed as homemaker/personal care or participant-directed homemaker/personal care, as applicable. (3) When remote support is provided to multiple individuals who live in the same residence, the payment rate for remote support shall be divided equally among the individuals concurrently receiving remote support.
View Appendix
Last updated July 1, 2022 at 1:19 PM
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Rule 5123-9-36 | Home and community-based services waivers - interpreter services under the individual options waiver.
(A) Purpose This rule defines interpreter services and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (5) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code. (6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (7) "Interpreter services" means the process by which one person's message is conveyed to another in a manner that incorporates both the message and attitude of the communicator. (8) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (C) Provider qualifications (1) Interpreter services shall be provided by a person who: (a) Holds a certification recognized by the registry of interpreters for the deaf; (b) Is either an independent provider or the employee of an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid; and (c) Meets one of the following standards: (i) Has graduated from an interpreter training program (of a minimum of two-years) and has at least one year of documented experience providing interpreter services; (ii) Has successfully completed a written test administered by the registry of interpreters for the deaf and has at least one year of documented experience providing interpreter services; or (iii) Has at least two years of documented experience interpreting for persons who are deaf or hard of hearing. (2) An applicant seeking approval to provide interpreter services shall complete and submit an application through the department's website (http://dodd.ohio.gov/). (3) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Interpreter services shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) A person providing interpreter services shall: (a) Maintain a role of facilitator of communication rather than the initiator of communication; and (b) Render the message faithfully, always conveying the content and spirit of the individual being served, using language most readily understood by the individual. (3) A person providing interpreter services shall not counsel, advise, or interject personal opinions. (E) Documentation of services Service documentation for interpreter services shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Group size in which the service was provided. (10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (11) Number of units of the delivered service. (12) Times the delivered service started and stopped. (F) Payment standards (1) The billing unit, service code, and payment rates for interpreter services are contained in appendix A to this rule. (2) Payment rates for interpreter services are based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule. (3) Payment rates for interpreter services are established separately for services provided by independent providers and services provided through agency providers. (4) Payment rates for interpreter services are based on the number of individuals receiving services.
View Appendix
Last updated July 1, 2022 at 1:18 PM
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Rule 5123-9-37 | Home and community-based services waivers - waiver nursing delegation under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines waiver nursing delegation and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Adult day services" means adult day support, career planning, group employment support, individual employment support, and vocational habilitation as those services are defined in Chapter 5123-9 of the Administrative Code. (2) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (3) "County board" means a county board of developmental disabilities. (4) "Delegating nurse" means the nurse who delegates a nursing task or assumes responsibility for individuals who are receiving delegated nursing care in accordance with Chapter 4723-13, 5123:2-6, or 5123-6 of the Administrative Code. (5) "Department" means the Ohio department of developmental disabilities. (6) "Fifteen-minute billing unit" means a billing unit that equals fifteen minutes of service delivery time or is greater or equal to eight minutes and less than or equal to twenty-two minutes of service delivery time. (7) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (8) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (9) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (10) "Licensed nurse" means a registered nurse or a licensed practical nurse. (11) "Licensed practical nurse" has the same meaning as in section 4723.01 of the Revised Code and for purposes of this rule, may practice waiver nursing delegation only at the direction of a registered nurse. (12) "Provider" means an agency provider or an independent provider. (13) "Registered nurse" has the same meaning as in section 4723.01 of the Revised Code. (14) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (15) "Significant change" means a decline or improvement in an individual's medical condition or a change in location of service delivery. (16) "Team" has the same meaning as in rule 5123-4-02 of the Administrative Code. (17) "Unlicensed personnel" means a person not currently licensed by the board of nursing as a registered nurse or licensed practical nurse, or a person who does not hold a current valid certificate to practice as a dialysis technician or administer medications as a medication aide. (18) "Waiver nursing delegation" means activities related to the transfer of responsibility for performance of a specific nursing task from a licensed nurse authorized to perform the task to unlicensed personnel. Waiver nursing delegation has two distinct components: (a) Waiver nursing delegation/assessment, when the delegating nurse who shall be a registered nurse, conducts a comprehensive assessment of an individual's health for the purpose of determining the appropriateness of delegating nursing tasks to be performed for the individual. (b) Waiver nursing delegation/consultation, when the delegating nurse who shall be either a registered nurse or a licensed practical nurse at the direction of a registered nurse in accordance with rule 4723-13-05 of the Administrative Code, consults with an individual, a physician who ordered a delegated nursing task, or unlicensed personnel to whom the delegating nurse has delegated responsibility for a nursing task. Waiver nursing delegation/consultation includes: (i) Evaluation of the ability of unlicensed personnel to perform the delegated task such as: (A) Verifying that unlicensed personnel have successfully completed prerequisite training; or (B) Observing a return demonstration of a delegated task performed by unlicensed personnel. (ii) Development and implementation of a delegation plan such as: (A) Verifying medications and treatments ordered by physicians; (B) Creating or modifying individual-specific instructions for performing delegated nursing tasks; (C) Identifying expected outcomes of delegated nursing tasks; (D) Identifying possible side effects of prescribed medication being administered under nursing delegation; (E) Providing instructions for documenting when a delegated task is completed or omitted; (F) Confirming medications/supplies necessary for the delegated tasks are available in the service setting; or (G) Completing delegation-related documentation such as medication administration records. (iii) Evaluation of progress of nursing delegation such as: (A) Consulting with the individual receiving services, physicians, or unlicensed personnel performing delegated nursing tasks via in-person contact, telephone calls, teleconferencing, videoconferencing, or other means; or (B) Reviewing delegation-related documentation such as medication administration records, progress notes, physician's orders, or hospital discharge records. (C) Provider qualifications (1) Waiver nursing delegation shall be provided by an agency provider or an independent provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid. (2) The person providing waiver nursing delegation shall: (a) Be a registered nurse or a licensed practical nurse and possess a current, valid, unrestricted license issued by the Ohio board of nursing; and (b) Be working within the scope of practice as set forth in Chapter 4723. of the Revised Code and administrative rules adopted thereunder. (3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide waiver nursing delegation only when no other certified provider is willing and able. (4) A family member who lives with an individual is not eligible to be paid for waiver nursing delegation provided to that individual. (5) An applicant seeking approval to provide waiver nursing delegation shall complete and submit an application through the department's website (http://dodd.ohio.gov/). (6) Failure of a provider to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Waiver nursing delegation shall be provided pursuant to a person-centered individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. The individual service plan shall identify the providers that may provide waiver nursing delegation. When an individual receives waiver nursing delegation in multiple settings and/or from multiple providers, the team shall determine and specify in the individual service plan, the allocation of waiver nursing delegation/assessment and/or waiver nursing delegation/consultation services to each provider. (2) An individual may receive up to: (a) One waiver nursing delegation/assessment every sixty days in the individual's residential setting; and (b) One waiver nursing delegation/assessment every sixty days in the individual's adult day services setting. (3) An individual may receive up to ten hours of waiver nursing delegation/consultation each month, regardless of the number of providers delivering the service. (4) Waiver nursing delegation/assessment may be billed sequentially to, but not concurrently with, waiver nursing delegation/consultation. (5) Waiver nursing delegation does not include time spent by a licensed nurse: (a) Participating in individual service plan development meetings; (b) Consulting with an individual's team on matters not specifically related to waiver nursing delegation for that individual; (c) Directly providing nursing services; (d) Coordinating an individual's health care; (e) Conducting general health-related training for unlicensed personnel; or (f) Conducting training described in Chapter 5123:2-6 or 5123-6 of the Administrative Code. (E) Documentation of services (1) Service documentation for waiver nursing delegation/assessment and waiver nursing delegation/consultation shall include each of the following to validate payment for medicaid services: (a) Type of service (i.e., waiver nursing delegation/assessment or waiver nursing delegation/consultation). (b) Date of service. (c) Place of service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving service. (f) Name of provider. (g) Provider identifier/contract number. (h) Written or electronic signature of the person delivering the service or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (i) Description and details of the service delivered that directly relate to the services specified in the approved individual service plan as the services to be provided, including the name of the unlicensed person for whom a supervisory visit was performed. (j) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided. (k) Beginning and ending times of the delivered service. (2) In addition to service documentation specified in paragraph (E)(1) of this rule, service documentation for waiver nursing delegation/assessment shall include the precipitating factor indicating why an assessment was needed, that is: (a) The individual was discharged from hospital; (b) The individual has experienced a significant change; or (c) Initiation of waiver nursing delegation for an individual who has not previously received waiver nursing delegation. (3) In addition to service documentation specified in paragraph (E)(1) of this rule, service documentation for waiver nursing delegation/consultation shall include a description and details of the consultation purpose and outcomes, including the name of the person with whom the delegating nurse was consulting. (F) Payment standards The billing units, procedure codes, and payment rates for waiver nursing delegation are contained in the appendix to this rule.
Last updated July 1, 2022 at 1:18 PM
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Rule 5123-9-38 | Home and community-based services waivers - social work under the individual options waiver.
(A) Purpose This rule defines social work and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Family member" means a person who is related to the individual by blood, marriage, or adoption. (5) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code. (7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (8) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (9) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (10) "Social work" means the application of specialized knowledge of human development and behavior as well as social, economic, and cultural systems. This knowledge is used to assist individuals and their families to improve and/or restore their capacity for social functioning. Social work includes the provision of counseling and active participation in problem-solving with individuals and family members; counseling to meet the psychosocial needs of individuals; collaboration with healthcare professionals and other providers to assist them to understand and support the social and emotional needs and problems experienced by individuals and their families; advocacy; referral to community-based and specialized services; development of social work/counseling plans of treatment; and assisting providers of services and family members to understand and implement activities related to implementation of the plan of treatment. Social work is not intended to duplicate the efforts of the service and support administrator. (C) Provider qualifications (1) Social work shall be provided by one of the following persons who is either an independent provider or the employee of an agency provider that meets the requirements of this rule and that has a medicaid provider agreement with the Ohio department of medicaid: (a) An independent social worker licensed by the state pursuant to section 4757.27 of the Revised Code; (b) A social worker licensed by the state pursuant to section 4757.28 of the Revised Code; (c) A professional clinical counselor licensed by the state pursuant to section 4757.22 of the Revised Code; or (d) A professional counselor licensed by the state pursuant to section 4757.23 of the Revised Code. (2) Social work shall not be provided by a county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards. (3) Social work shall not be provided to an individual by the individual's family member. (4) An applicant seeking approval to provide social work shall complete and submit an application through the department's website (http://dodd.ohio.gov/). (5) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery (1) Social work shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) A person providing social work shall: (a) Document the individual's social needs and develop a social work/counseling plan of treatment; (b) Provide direct service in the form of counseling and actively participate in resolving problems; (c) Counsel the individual and involved family members with regard to the individual's psychosocial needs; (d) Collaborate with the individual's physician and assist various providers of services in understanding emotional and social needs of the individual being served; (e) Recognize the social needs of the individual and caregiver and take appropriate therapeutic intervention; (f) Act as an advocate for the individual's social needs; (g) Assist the individual, staff, and family to resolve challenges which prevent the individual's adjustment or any other challenges which affect the individual's ability to benefit from medical treatment; (h) Assist the individual to develop self-help, social, and adaptive skills that enable the individual to remain functional within the community; (i) Arrange individual and caregiver counseling and other supportive services to alleviate the pressures of estrangement from social support systems such as family, employment, and residential placement; and (j) Refer individuals/families to the service and support administrator for financial matters or interagency collaboration and follow-up. (E) Documentation of services Service documentation for social work shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Group size in which the service was provided. (10) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (11) Number of units of the delivered service. (12) Times the delivered service started and stopped. (F) Payment standards (1) The billing unit, service codes, and payment rates for social work are contained in appendix A to this rule. (2) Payment rates for social work are based on the county cost-of-doing-business category. The cost-of-doing-business categories are contained in appendix B to this rule. (3) Payment rates for social work are established separately for services provided by independent providers and services provided through agency providers. (4) Payment rates for social work are based on the number of individuals receiving services.
Last updated July 1, 2022 at 1:18 PM
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Rule 5123-9-39 | Home and community-based services waivers - waiver nursing services under the individual options waiver.
Effective:
January 1, 2022
(A) Purpose This rule defines waiver nursing services and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency provider" has the
same meaning as in rule 5123-2-08 of the Administrative Code. (3) "Community
respite" has the same meaning as in rule 5123-9-22 of the Administrative
Code. (4) "County board" means a
county board of developmental disabilities. (5) "Department" means the Ohio
department of developmental disabilities. (6) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (7) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (8) "Individual" means a person
with a developmental disability or for the purposes of giving, refusing to
give, or withdrawing consent for services, his or her guardian in accordance
with section 5126.043 of the Revised Code or other person authorized to give
consent. (9) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (10) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (11) "Licensed practical nurse"
has the same meaning as in section 4723.01 of the Revised Code. (12) "Medically
necessary" has the same meaning as "medical necessity" described
in rule 5160-1-01 of the Administrative Code. (13) "Plan of care" means the
medical treatment plan that is established, approved, and signed by the
treating physician. The plan of care must be signed and dated by the treating
physician prior to requesting payment for a service. The plan of care is not
the same as the individual service plan. (14) "Registered nurse" has the
same meaning as in section 4723.01 of the Revised Code. (15) "Residential respite" has
the same meaning as in rule 5123-9-34 of the Administrative Code. (16) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (F) of this rule to validate
payment for medicaid services. (17) "Significant change" means
a change experienced by an individual including but not limited to, a change in
health status, caregiver status, or location/residence; referral to or active
involvement on the part of a protective services agency; or
institutionalization. (18) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (19) "Waiver nursing services"
means services provided to an individual who requires the skills of a
registered nurse or licensed practical nurse working at the direction of a
registered nurse. Waiver nursing services shall not include: (a) Services delegated in accordance with Chapter 4723. of the
Revised Code and rules adopted thereunder, and performed by persons 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 purpose of conducting a registered
nurse assessment as set forth in rule 5160-12-08 of the Administrative Code
including but not limited to, an outcome and assessment information set or any
other assessment; (d) Registered nurse consultations as set forth in rule
5160-12-08 of the Administrative Code including but not limited to, those
performed by registered nurses for the sole purpose of directing licensed
practical nurses in the performance of waiver nursing services or directing
personal care aides or home health aides employed by a medicare-certified home
health agency or otherwise-accredited agency; (e) Visits performed for the sole purpose of meeting the home
care attendant service registered nurse visit requirements set forth in rules
173-39-02.24 and 5160-46-04.1 of the Administrative Code; (f) Services performed in excess of the number of hours approved
pursuant to, and as specified in, the individual service plan; or (g) Services performed that meet the definition of waiver
nursing delegation/assessment or waiver nursing delegation/consultation set
forth in rule 5123:2-9-37 of the Administrative Code. (C) Provider qualifications (1) Waiver nursing services shall be
provided by an independent provider or an agency provider that meets the
requirements of this rule and that has a medicaid provider agreement with the
Ohio department of medicaid. (2) Waiver nursing
services shall be provided by a registered nurse or by a licensed practical
nurse working at the direction of a registered nurse who: (a) Possesses a current, valid, and unrestricted license issued
by the Ohio board of nursing; and (b) Is working within his or her scope of practice as set forth
in Chapter 4723. of the Revised Code and rules adopted thereunder. (3) Nursing tasks and
activities that shall be performed only by a registered nurse include but are
not limited to: (a) Intravenous insertion, removal, or
discontinuation; (b) Intravenous medication administration; (c) Programming of a pump to deliver medication including but not
limited to, epidural, subcutaneous, and intravenous (except routine doses of
insulin through a programmed pump); (d) Insertion or initiation of infusion therapies; (e) Central line dressing changes; and (f) Blood product administration. (4) Waiver nursing services shall not be
provided by a county board or a regional council of governments formed in
accordance with section 5126.13 of the Revised Code by two or more county
boards. (5) An applicant seeking approval to
provide waiver nursing services shall complete and submit an application
through the department's website and adhere to the requirements of as
applicable, rule 5123-2-08 or 5123-2-09 of the Administrative
Code. (6) Failure of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Service authorization (1) A county board or its
contracted agent shall complete and submit a service authorization request for
waiver nursing services to the department for review and approval at least
annually and upon identification of a significant change that affects a service
authorization. Each service authorization request shall include: (a) An assessment of resources available to address each skilled
nursing task ordered by a physician; (b) A proposed weekly schedule with corresponding budget;
and (c) A nursing task inventory that identifies the nursing
tasks to be performed, the frequency and duration of each nursing task to be
performed, and the current method by which each nursing task is
performed. (2) Waiver nursing
services shall be authorized only when an individual's needs cannot be met
by developmental disabilities personnel holding certification issued in
accordance with rule 5123-6-06 of the Administrative Code and when applicable,
through nursing delegation in accordance with rules adopted by the Ohio board
of nursing pursuant to Chapter 4723. of the Revised Code, and/or state plan
nursing services as defined in Chapter 5160-12 of the Administrative
Code. (3) The department shall
review a service authorization request to determine whether the requested
services are medically necessary. When the department or the Ohio department of
medicaid has determined within the previous twelve months that the requested
services are not medically necessary, the department may without further review
accept the Ohio department of medicaid determination. The department shall
determine the services to be medically necessary if the services: (a) Are appropriate for the individual's health and welfare
needs, living arrangement, circumstances, and expected outcomes;
and (b) Are of an appropriate type, amount, duration, scope, and
intensity; and (c) Are the most efficient, effective, and lowest cost
alternative that, when combined with non-waiver services, ensure the health and
welfare of the individual receiving the services; and (d) In accordance with rule 5123-9-02 of the Administrative Code,
are not otherwise available through other resources. (4) The department may
approve a service authorization request in its entirety or may partially
approve a service authorization request if it determines that the services are
medically necessary. A service authorization request shall not be denied
without review by a registered nurse. (5) The individual shall
be afforded notice and hearing rights regarding service authorizations in
accordance with section 5101.35 of the Revised Code. Providers shall have no
standing in appeals under this paragraph. A change in staffing ratios does not
necessarily result in a change in the level of services received by an
individual which would affect the annual service authorization. (E) Requirements for service delivery (1) Waiver nursing
services shall be provided pursuant to an individual service plan that conforms
to the requirements of rule 5123-4-02 of the Administrative Code. (2) Waiver nursing
services shall not be provided to an individual during the same time the
individual is receiving adult day support, community respite, residential
respite being provided at an intermediate care facility for individuals with
intellectual disabilities, or vocational habilitation. (3) A provider of waiver nursing services
shall be identified as the provider and have specified in the individual
service plan the number of hours for which the provider is authorized to
furnish waiver nursing services. (4) A registered nurse or licensed
practical nurse working at the direction of a registered nurse may provide
services for no more than three individuals in a group setting during a
face-to-face waiver nursing services visit. (5) A waiver nursing
services visit by a registered nurse or a licensed practical nurse working at
the direction of a registered nurse shall not exceed twelve hours in length
during a twenty-four hour period unless an unforeseen event causes a medically
necessary scheduled visit to extend beyond twelve hours, in which case the
visit shall not exceed sixteen hours. (6) Individuals who
receive waiver nursing services must be under the supervision of a treating
physician, physician's assistant, or advanced practice nurse who is
directly providing care and treatment to the individual (and not merely engaged
to authorize plans of care for waiver nursing services). (7) A provider of waiver nursing services
who is a licensed practical nurse working at the direction of a registered
nurse shall conduct a face-to-face visit with the individual and the directing
registered nurse prior to initiating services and at least once every one
hundred twenty days for the purpose of evaluating the provision of waiver
nursing services, the individual's satisfaction with care delivery and
performance of the licensed practical nurse, and to ensure that waiver nursing
services are being provided in accordance with the approved plan of
care. (8) In all instances, when a treating
physician gives verbal orders to the registered nurse or licensed practical
nurse working at the direction of a registered nurse, the nurse shall record in
writing, the physician's orders, the date and time the orders were given,
and sign the entry in the service documentation. The nurse shall subsequently
secure documentation of the verbal orders signed and dated by the treating
physician. (9) In all instances, when an independent
provider who is a licensed practical nurse working at the direction of a
registered nurse is providing waiver nursing services, the licensed practical
nurse shall provide clinical notes, signed and dated by the licensed practical
nurse, documenting all consultations between the licensed practical nurse and
the directing registered nurse, documenting the face-to-face visits between the
licensed practical nurse and the directing registered nurse, and documenting
the face-to-face visits between the licensed practical nurse, the individual
receiving waiver nursing services, and the directing registered nurse. The
clinical notes may be collected and maintained in electronic software
programs. (10) Waiver nursing services may be
provided on the same day as, but not concurrently with, a registered nurse
assessment and/or registered nurse consultation as set forth in rule 5160-12-08
of the Administrative Code. (F) Documentation of services (1) Service documentation
for waiver nursing services shall include each of the following to validate
payment for medicaid services: (a) Type of service. (b) Date of service. (c) Place of service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving
service. (f) Name of provider. (g) Provider identifier/contract number. (h) Written or electronic signature of the person delivering the
service or initials of the person delivering the service if a signature and
corresponding initials are on file with the provider. (i) Group size in which the service was provided. (j) Description and details of the service delivered that
directly relate to the services specified in the approved individual service
plan as the services to be provided, including the individual's response
to each medication, treatment, or procedure performed in accordance with the
physician's orders or plan of care. (k) Begin and end times of the delivered service. (l) Number of units of the delivered service or continuous amount
of uninterrupted time during which the service was provided. (2) In addition to
service documentation specified in paragraph (F)(1) of this rule, providers of
waiver nursing services shall maintain a clinical record for each individual
which includes: (a) Individual's medical history. (b) Name and national provider identifier number of
individual's treating physician. (c) A copy of all individual service plans in effect when the
provider provides services. (d) A copy of the initial and all subsequent plans of care,
specifying the type, frequency, scope, and duration of the waiver nursing
services being performed. When waiver nursing services are performed by a
licensed practical nurse working at the direction of a registered nurse, the
record shall include documentation that the registered nurse has reviewed the
plan of care with the licensed practical nurse. The plan of care shall be
certified by the treating physician initially and recertified at least annually
thereafter, or more frequently if there is a significant change in the
individual's condition. (e) Documentation of verbal orders from the treating physician in
accordance with paragraph (E)(8) of this rule. (f) The clinical notes of an independent provider who is a
licensed practical nurse working at the direction of a registered nurse in
accordance with paragraph (E)(9) of this rule. (g) A copy of any advance directives including but not limited
to, a "do not resuscitate" order or medical power of attorney, if
they exist. (h) Documentation of drug and food interactions, allergies, and
dietary restrictions. (i) Clinical notes signed and dated by the registered nurse or
licensed practical nurse working at the direction of a registered nurse,
documenting all communications with the treating physician and other members of
the multidisciplinary team. (3) Providers of waiver
nursing services shall maintain, in a confidential manner for at least thirty
days at the individual's residence, medication and/or treatment records
which indicate the person who prescribed the medication and/or treatment and
the date, time, and person who administered the medication and/or
treatment. (G) Payment standards (1) The billing units,
service codes, and payment rates for waiver nursing services are contained in
the appendix to this rule. (2) Services meeting the definition of
"homemaker/personal care" may be reimbursed as waiver nursing
services when provided incidental to waiver nursing services performed during
an authorized waiver nursing services visit.
View Appendix
Last updated January 3, 2022 at 9:59 AM
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Rule 5123-9-40 | Home and community-based services waivers - administration of the self-empowered life funding waiver.
Effective:
September 16, 2022
(A) Purpose This rule implements the self-empowered life
funding waiver, a component of the medicaid home and community-based services
program administered by the department pursuant to section 5166.21 of the
Revised Code. Individuals enrolled in the self-empowered life funding waiver
exercise participant direction through budget authority and/or employer
authority. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult"
means an individual who is at least twenty-two years old or an individual who
is under twenty-two years old and no longer eligible for educational services
based on graduation, receipt of a diploma or equivalency certificate, or
permanent discontinuation of educational services within parameters established
by the Ohio department of education. (2) "Agency with
choice" means a service arrangement in which an agency provider acts as a
co-employer with an individual. Under this arrangement, the individual is
responsible for hiring, managing, and dismissing staff. The agency with choice
enables the individual to exercise choice and control over services while
relieving the individual of the burden of carrying out financial matters and
other legal responsibilities associated with the employment of workers. The
agency with choice is considered the employer of staff who are selected, hired,
and trained by the individual and assumes responsibility for: (a) Employing and paying staff who have been selected by
the individual; (b) Reimbursing allowable services; (c) Withholding, filing, and paying federal, state, and
local income and employment taxes; and (d) Providing other supports to the individual as described
in the individual service plan. (3) "Budget
authority" means an individual has the authority and responsibility to
manage the individual's budget for participant-directed services. This
authority supports the individual in determining the budgeted dollar amount for
each participant-directed waiver service that will be provided to the
individual and making decisions about the acquisition of participant-directed
waiver services that are authorized in the individual service plan (e.g.,
negotiating payment rates to providers within the applicable range as specified
in rules adopted by the department). (4) "Child"
means an individual who is under twenty-two years old and eligible for
educational services. (5) "Co-employer" means an individual who
recruits and directs staff providing services to the individual and either an
agency with choice or a financial management services entity under contract
with the state that functions as the employer of the staff recruited and
directed by the individual. The agency with choice or a financial management
services entity conducts all necessary payroll functions and is legally
responsible for the employment-related functions and duties for
individual-selected staff with the individual based on the roles and
responsibilities identified in the individual service plan for the two
co-employers. The agency with choice or financial management services entity
serving as co-employer may function solely to support the individual's
employment of workers or it may provide other employer-related supports to the
individual, including providing traditional agency-based staff. (6) "Common law
employer" means the individual is the legally responsible and liable
employer of staff selected by the individual. The individual hires, supervises,
and discharges staff. The individual is liable for the performance of necessary
employment-related tasks and uses a financial management services entity under
contract with the state to perform necessary payroll and other
employment-related functions as the individual's agent in order to ensure
that the employer-related legal obligations are fulfilled. (7) "County
board" means a county board of developmental disabilities. (8) "Department" means the Ohio department of
developmental disabilities. (9) "Employer
authority" means an individual has the authority to recruit, hire,
supervise, and direct the staff who furnish supports. The individual functions
as the common law employer or the co-employer of these staff. (10) "Financial
management services" means services provided to an individual who directs
some or all of the individual's waiver services. When used in conjunction
with budget authority, financial management services includes, but is not
limited to, paying invoices for waiver goods and services and tracking
expenditures against the individual's budget for participant-directed
services. When used in conjunction with employer authority, financial
management services includes, but is not limited to, operating a payroll
service for individual-employed staff and making required payroll withholdings.
Financial management services also includes acting as the employer of staff on
behalf of an individual under the co-employer model of employer
authority. (11) "Financial
management services entity" means a governmental entity and/or another
third-party entity designated by the department to perform necessary financial
transactions on behalf of individuals who receive participant-directed
services. (12) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (13) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. An individual may designate another person to assist with development
of the individual service plan and budget, selection of residence and
providers, and negotiation of payment rates for services; the individual's
designee shall not be employed by a county board or a provider, or a contractor
of either. (14) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (15) "Participant
direction" means an individual has authority to make decisions about the
individual's waiver services and accepts responsibility for taking a
direct role in managing the services. Participant direction includes the
exercise of budget authority and/or employer authority as set forth in
paragraph (G) of this rule. (16) "Provider"
means a person or entity certified or licensed by the department that has met
the provider qualification requirements to provide specific home and
community-based services and holds a valid medicaid provider agreement with the
Ohio department of medicaid or a person or entity that has been determined by
the financial management services entity to be qualified to provide
participant-directed goods and services or self-directed
transportation. (17) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123:2-5-02 of the Administrative Code. (18) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
redetermination date. (C) Application for the self-empowered
life funding waiver The county board is responsible for explaining to
individuals requesting home and community-based services the services available
through the self-empowered life funding waiver benefit package including the
type, amount, scope, and duration of services and any applicable benefit
package limitations. (D) Criteria for enrolling in the
self-empowered life funding waiver To be enrolled in the self-empowered life funding
waiver: (1) The individual or the
individual's guardian or the individual's designee must be willing
and able to perform the duties associated with participant direction;
and (2) The individual or the
individual's guardian or the individual's designee is required to
exercise budget authority or employer authority, in accordance with paragraph
(G)(1) or (G)(2) of this rule, for at least one service the individual receives
under the waiver. (E) Self-empowered life funding waiver
enrollment, continued enrollment, and disenrollment An individual who meets the criteria specified in
paragraph (D) of this rule or the individual's guardian or the
individual's designee, as applicable, shall be informed by the county
board of: (1) All services
available under the self-empowered life funding waiver, as delineated in
paragraph (F) of this rule, and any choices that the individual may make
regarding those services; (2) Any feasible
alternative to the waiver; and (3) The right to choose
either institutional care or home and community-based services. (F) Self-empowered life funding waiver
benefit package The self-empowered life funding waiver benefit
package is comprised of: (1) Adult day support in
accordance with rule 5123-9-17 of the Administrative Code; (2) Assistive technology
in accordance with rule 5123-9-12 of the Administrative Code; (3) Career planning in
accordance with rule 5123-9-13 of the Administrative Code; (4) Clinical/therapeutic
intervention in accordance with rule 5123-9-41 of the Administrative
Code; (5) Community respite in
accordance with rule 5123-9-22 of the Administrative Code; (6) Functional behavioral
assessment in accordance with rule 5123-9-43 of the Administrative
Code; (7) Group employment
support in accordance with rule 5123-9-16 of the Administrative
Code; (8) Home-delivered meals
in accordance with rule 5123-9-29 of the Administrative Code; (9) Individual employment
support in accordance with rule 5123-9-15 of the Administrative
Code; (10) Non-medical
transportation in accordance with rule 5123-9-18 of the Administrative
Code; (11) Participant-directed
goods and services in accordance with rule 5123-9-45 of the Administrative
Code; (12) Participant-directed
homemaker/personal care in accordance with rule 5123-9-32 of the Administrative
Code; (13) Participant/family
stability assistance in accordance with rule 5123-9-46 of the Administrative
Code; (14) Remote support in
accordance with rule 5123-9-35 of the Administrative Code; (15) Residential respite
in accordance with rule 5123-9-34 of the Administrative Code; (16) Self-directed
transportation in accordance with rule 5123-9-26 of the Administrative
Code; (17) Support brokerage in
accordance with rule 5123-9-47 of the Administrative Code; (18) Transportation in
accordance with rule 5123-9-24 of the Administrative Code; (19) Vocational
habilitation in accordance with rule 5123-9-14 of the Administrative Code;
and (20) Waiver nursing
delegation in accordance with rule 5123-9-37 of the Administrative
Code. (G) Participant direction The self-empowered life funding waiver is
designed to support individuals who want to direct their services through
exercise of budget authority and/or employer authority. (1) Individuals enrolled
in the self-empowered life funding waiver may exercise budget authority
for: (a) Clinical/therapeutic intervention; (b) Participant-directed goods and services; (c) Participant-directed homemaker/personal
care; (d) Self-directed transportation; and (e) Support brokerage. (2) Individuals enrolled
in the self-empowered life funding waiver may exercise employer authority
for: (a) Participant-directed homemaker/personal
care; (b) Self-directed transportation; and (c) Support
brokerage. (H) Benefit limitations (1) The cost of services
available under the self-empowered life funding waiver shall not
exceed: (a) Forty-five thousand dollars per waiver eligibility span
for an adult; or (b) Thirty thousand dollars per waiver eligibility span for
a child. (2) The following
services are subject to specific benefit limitations: (a) Payment for support brokerage shall not exceed eight
thousand dollars per waiver eligibility span. (b) An individual may receive only one functional
behavioral assessment per waiver eligibility span, the cost of which shall not
exceed one thousand five hundred dollars. (I) Individual service plan
requirements (1) All services shall be
provided to an individual enrolled in the self-empowered life funding waiver
pursuant to a written individual service plan that meets the requirements set
forth in rule 5123-4-02 of the Administrative Code. (2) The individual
service plan is subject to approval by the department and the Ohio department
of medicaid pursuant to section 5166.21 of the Revised Code. Notwithstanding
the procedures set forth in this rule, the Ohio department of medicaid may in
its sole discretion, and in accordance with section 5166.05 of the Revised
Code, direct the department or a county board to amend the individual service
plan for an individual. (J) Service documentation (1) Services under the
self-empowered life funding waiver shall not be considered delivered unless the
provider maintains service documentation. (2) A provider shall
maintain all service documentation in an accessible location. The service
documentation shall be available, upon request, for review by the centers for
medicare and medicaid services, the Ohio department of medicaid, the
department, a county board or regional council of governments that submits to
the department payment authorization for the service, and those designated or
assigned authority by the Ohio department of medicaid or the department to
review service documentation. (3) A provider shall
maintain all service documentation for a period of six years from the date of
receipt of payment for the service or until an initiated audit is resolved,
whichever is longer. (4) If a provider
discontinues operations, the provider shall, within seven calendar days of
discontinuance, notify the county boards for the counties in which individuals
to whom the provider has provided services reside, of the location where the
service documentation will be stored, and provide each such county board with
the name and telephone number of the person responsible for maintaining the
records. (5) Claims for payment a
provider submits for services delivered shall not be considered service
documentation. Any information contained on the submitted claim shall not be
substituted for any required service documentation information that the
provider is required to maintain to validate payment for medicaid
services. (K) Payment standards (1) Services provided
under the self-empowered life funding waiver shall be subject to the payment
standards set forth in rules adopted by the department. (2) Rule 5123-9-06 of the
Administrative Code does not apply to services provided under the
self-empowered life funding waiver. (3) Payment for services
constitutes payment in full. Payment shall be made when: (a) The service is identified in an approved individual
service plan; (b) The service is recommended for payment through the
payment authorization process; and (c) The service is provided by a provider selected by an
individual enrolled in the self-empowered life funding waiver. (4) Payment for services
shall not exceed amounts authorized through the payment authorization process
for the individual's corresponding waiver eligibility span. (5) When a service is
also available on the state plan, state plan services shall be billed first.
Only services in excess of what is covered under the state plan shall be
authorized. (6) Claims for payment
shall be submitted to the department or the financial management services
entity in the format prescribed by the department. The department or the
financial management services entity, as applicable, shall inform county boards
of the billing information submitted by providers in a manner and at the
frequency necessary to assist the county boards to manage the waiver
expenditures being authorized. (7) Claims for payment
shall be submitted within three hundred thirty calendar days after the service
is provided. Payment shall be made in accordance with the requirements of rule
5160-1-19 of the Administrative Code. Claims for payment shall include the
number of units of service. (8) Providers shall take
reasonable measures to identify any third-party health care coverage available
to the individual and file a claim with that third party in accordance with the
requirements of rule 5160-1-08 of the Administrative Code. (9) For individuals with
a monthly patient liability for the cost of home and community-based services,
as described in rule 5160:1-6-07.1 of the Administrative Code, and determined
by the county department of job and family services for the county in which the
individual resides, payment is available only for the home and community-based
services delivered to the individual that exceed the amount of the
individual's monthly patient liability. Verification that patient
liability has been satisfied shall be accomplished as follows: (a) The department shall provide notification to the
appropriate county board identifying each individual who has a patient
liability for home and community-based services and the monthly amount of the
patient liability. (b) The county board shall assign the home and
community-based services to which each individual's patient liability
shall be applied and assign the corresponding monthly patient liability amount
to the provider that provides the preponderance of home and community-based
services. The county board shall notify each individual and provider, in
writing, of this assignment. (c) Upon submission of a claim for payment, the designated
provider shall report the home and community-based services to which the
patient liability was assigned and the applicable patient liability amount on
the claim for payment using the format prescribed by the
department. (10) The department, the
Ohio department of medicaid, the centers for medicare and medicaid services,
and/or the auditor of state may audit any funds a provider of home and
community-based services receives pursuant to this rule, including any source
documentation supporting the claiming and/or receipt of such
funds. (11) Overpayments,
duplicate payments, payments for services not rendered, payments for which
there is no documentation of services delivered or the documentation does not
include all required items as set forth in rules adopted by the department, or
payments for services not in accordance with an approved individual service
plan are recoverable by the department, the Ohio department of medicaid, the
auditor of state, or the office of the attorney general. All recoverable
amounts are subject to the application of interest in accordance with rule
5160-1-25 of the Administrative Code. (L) Due process rights and
responsibilities (1) An applicant for or
recipient of self-empowered life funding waiver services may use the process
set forth in section 5160.31 of the Revised Code and rules implementing that
statute, for any purpose authorized by that statute. The process set forth in
section 5160.31 of the Revised Code is available only to applicants,
recipients, and their lawfully appointed authorized representatives. Providers
shall have no standing in an appeal under this section. (2) An applicant for or
recipient of self-empowered life funding waiver services shall use the process
set forth in section 5160.31 of the Revised Code and rules implementing that
statute for any challenge related to the type, amount, scope, or duration of
services included in or excluded from an individual service plan. (M) Ohio department of medicaid
authority The Ohio department of medicaid retains final
authority to establish payment rates for self-empowered life funding waiver
services; to review and approve each service identified in an individual
service plan that is funded through the self-empowered life funding waiver and
the payment rate for the service; and to authorize the provision of and payment
for waiver services through the payment authorization process. (N) Monitoring, compliance, and quality
assurance The Ohio department of medicaid shall conduct
periodic monitoring and compliance reviews related to the self-empowered life
funding waiver in accordance with Chapter 5166. of the Revised Code. Reviews
may consist of, but are not limited to, physical inspections of records and
sites where services are provided and interviews of providers, recipients, and
administrators of waiver services. The financial management services entity
under contract with the state, a self-empowered life funding waiver provider,
the department, and a county board shall furnish to the Ohio department of
medicaid, the centers for medicare and medicaid services, and the medicaid
fraud control unit or their designees any records related to the administration
and/or provision of self-empowered life funding waiver services. An individual
enrolled in the self-empowered life funding waiver shall cooperate with all
monitoring, compliance, and quality assurance reviews conducted by the Ohio
department of medicaid, the department, a county board, the centers for
medicare and medicaid services, and the medicaid fraud control unit or their
designees.
Last updated September 16, 2022 at 8:28 AM
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Rule 5123-9-41 | Home and community-based services waivers - clinical/therapeutic intervention under the level one and self-empowered life funding waivers.
(A) Purpose This rule defines clinical/therapeutic intervention and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "Clinical/therapeutic intervention" means services that are necessary to reduce an individual's intensive behaviors and to improve the individual's independence and inclusion in the community and that are not otherwise available under the medicaid state plan. Clinical/therapeutic intervention includes consultation activities that are provided by professionals in psychology, counseling, special education, and behavior management. The service includes the development of a treatment/support plan, training and technical assistance to assist unpaid caregivers and/or paid support staff in carrying out the plan, delivery of the services described in the plan, and monitoring of the individual and the provider in the implementation of the plan. Clinical/therapeutic intervention may be delivered in the individual's home or in the community as described in the individual service plan. Clinical/therapeutic intervention must be determined necessary to reduce an individual's intensive behaviors by a functional behavioral assessment conducted by a licensed psychologist, licensed professional clinical counselor, licensed professional counselor, licensed independent social worker, licensed social worker working under the supervision of a licensed independent social worker, or certified Ohio behavior analyst. Experimental treatments are prohibited. (3) "County board" means a county board of developmental disabilities. (4) "Department" means the Ohio department of developmental disabilities. (5) "Family member" means a person who is related to the individual by blood, marriage, or adoption. (6) "Functional behavioral assessment" means an assessment not otherwise available under the medicaid state plan to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. A functional behavioral assessment describes the relationship between a skill or performance problem and the variables that contribute to its occurrence. A functional behavioral assessment may provide information to develop a hypothesis as to why an individual engages in a behavior, when the individual is most likely to demonstrate the behavior, and situations in which the behavior is least likely to occur. (7) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (8) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual may designate another person to assist with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either. (9) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (11) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility redetermination date. (C) Provider qualifications (1) Clinical/therapeutic intervention shall be provided by an independent provider or an agency provider that: (a) Meets the requirements of this rule; (b) Has a medicaid provider agreement with the Ohio department of medicaid; and (c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov). (2) Clinical/therapeutic intervention shall be provided by senior level specialized clinical/therapeutic interventionists, specialized clinical/therapeutic interventionists, and clinical/therapeutic interventionists. (a) A senior level specialized clinical/therapeutic interventionist shall have a doctoral degree in psychology, special education, medicine, or a related discipline; be licensed or certified under the laws of the state to practice in that field; and have at least three months of experience and/or training in the implementation and oversight of comprehensive interventions for individuals with developmental disabilities who need significant behaviorally-focused interventions. (b) A specialized clinical/therapeutic interventionist shall: (i) Have a master's degree in psychology, special education, or a related discipline and be licensed or certified under the laws of the state to practice in that field or be registered with the state board of psychology as an aide or a psychology aide working under psychological work supervision in accordance with rule 4732-13-03 of the Administrative Code; and (ii) Have at least three months of experience and/or training in the implementation and oversight of comprehensive interventions for individuals with developmental disabilities who need significant behaviorally-focused interventions. (c) A clinical/therapeutic interventionist shall work under the supervision of a senior level specialized clinical/therapeutic interventionist or a specialized clinical/therapeutic interventionist and shall: (i) Have experience providing one-to-one care for an individual with developmental disabilities who needs significant behaviorally-focused interventions; (ii) Have undergone two monitored sessions with an individual with developmental disabilities who needs significant behaviorally-focused interventions; (iii) Hold a "Registered Behavior Technician" credential issued by the behavior analyst certification board; or (iv) Hold a "Board Certified Assistant Behavior Analyst" credential issued by the behavior analyst certification board. (3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide clinical/therapeutic intervention by senior level specialized clinical/therapeutic interventionists only when no other certified provider is willing and able. Neither a county board nor a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards shall provide clinical/therapeutic intervention by specialized clinical/therapeutic interventionists or clinical/therapeutic interventionists. (4) Clinical/therapeutic intervention shall not be provided to an individual by the individual's family member. (5) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery Clinical/therapeutic intervention shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (E) Documentation of services Service documentation for clinical/therapeutic intervention shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided and details of the individual's response to the services, including progress toward achieving outcomes specified in the individual service plan. (10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided. (11) Times the delivered service started and stopped. (F) Payment standards (1) The billing unit, service codes, and payment rates for clinical/therapeutic intervention are contained in the appendix to this rule. (2) The payment rate for clinical/therapeutic intervention provided by an independent provider shall be negotiated by the individual and the independent provider subject to the minimum and maximum payment rates contained in the appendix to this rule and shall be identified in the individual service plan. (3) The payment rate for clinical/therapeutic intervention provided by an agency provider shall be the lesser of the agency provider's usual and customary charge or the statewide payment rate contained in the appendix to this rule.
View Appendix
Last updated July 1, 2022 at 1:20 PM
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Rule 5123-9-43 | Home and community-based services waivers - functional behavioral assessment under the level one and self-empowered life funding waivers.
(A) Purpose This rule defines functional behavioral assessment and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Family member" means a person who is related to the individual by blood, marriage, or adoption. (5) "Functional behavioral assessment" means an assessment not otherwise available under the medicaid state plan to determine why an individual engages in intensive behaviors and how the individual's behaviors relate to the environment. A functional behavioral assessment describes the relationship between a skill or performance problem and the variables that contribute to its occurrence. A functional behavioral assessment may provide information to develop a hypothesis as to why an individual engages in a behavior, when the individual is most likely to demonstrate the behavior, and situations in which the behavior is least likely to occur. (6) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (7) "Individual" means a person with a developmental disability or for purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual may designate another person to assist with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either. (8) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (9) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E) of this rule to validate payment for medicaid services. (10) "Usual and customary charge" means the amount charged to other persons for the same service. (11) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility redetermination date. (C) Provider qualifications (1) Functional behavioral assessment shall be provided by an independent provider or an agency provider that: (a) Meets the requirements of this rule; (b) Has a medicaid provider agreement with the Ohio department of medicaid; and (c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov). (2) Functional behavioral assessment shall be provided by a person who has the experience necessary to perform psychometric tests that assess an individual's functional behavioral level and who is a: (a) Psychologist licensed by the state pursuant to Chapter 4732. of the Revised Code; (b) Professional clinical counselor licensed by the state pursuant to section 4757.22 of the Revised Code; (c) Professional counselor licensed by the state pursuant to section 4757.23 of the Revised Code; (d) Independent social worker licensed by the state pursuant to section 4757.27 of the Revised Code; (e) Social worker licensed by the state pursuant to section 4757.28 of the Revised Code working under the supervision of a licensed independent social worker; or (f) Certified Ohio behavior analyst certified by the state pursuant to section 4783.04 of the Revised Code. (3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide functional behavioral assessment only when no other certified provider is willing and able. (4) Functional behavioral assessment shall not be provided to an individual by the individual's family member. (5) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Requirements for service delivery Functional behavioral assessment shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (E) Documentation of services Service documentation for functional behavioral assessment shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (F) Payment standards (1) The billing unit, service code, and payment rate for functional behavioral assessment are contained in the appendix to this rule. (2) Providers of functional behavioral assessment shall be paid no more than their usual and customary charge for the service. (3) An individual may receive only one functional behavioral assessment in a waiver eligibility span, the cost of which shall not exceed one thousand five hundred dollars. (4) Providers of functional behavioral assessment are prohibited from submitting claims under both a home and community-based services waiver and the medicaid state plan for the same functional behavioral assessment.
View Appendix
Last updated July 1, 2022 at 1:21 PM
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Rule 5123-9-45 | Home and community-based services waivers - participant-directed goods and services under the level one and self-empowered life funding waivers.
(A) Purpose This rule defines participant-directed goods and services and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Community respite" has the same meaning as in rule 5123-9-22 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Financial management services entity" means a governmental entity and/or another third-party entity designated by the department to perform necessary financial transactions on behalf of individuals who receive participant-directed services. (5) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual may designate another person to assist with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either. (6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (7) "Participant-directed budget" means the total amount of annual waiver funding available for participant-directed services in the individual service plan of an individual who chooses to receive participant-directed services. An individual may reallocate funds among participant-directed services as long as reallocation is preceded by a corresponding revision to the individual service plan. (8) "Participant-directed goods and services" means services, equipment, or supplies not otherwise provided through the individual's waiver or through the medicaid state plan that are purchased through the participant-directed budget, address a need clearly identified through assessment of the individual, are specified in the individual service plan, and meet all of the following requirements: (a) The services, equipment, or supplies are required to: (i) Decrease the individual's need for other medicaid home and community-based services; (ii) Advance the individual's participation in the community; (iii) Increase the individual's safety in the home; (iv) Increase the individual's independence; (v) Improve or maintain the individual's cognitive, social, or behavioral functions; or (vi) Assist the individual to develop or maintain personal, social, or physical skills. (b) The individual does not have funds to purchase the services, equipment, or supplies, and they are not available through another source. (c) The services, equipment, or supplies are required to ensure the health and welfare of the individual. (d) The services, equipment, or supplies are directly linked in the individual service plan as addressing a need clearly identified through assessment of the individual. (e) The services, equipment, or supplies are for the direct medical or remedial benefit of the individual. (9) "Service and support administrator" means a person, regardless of title, employed by or under contract with a county board to perform the functions of service and support administration and who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code. (10) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (E)(2) of this rule to validate payment for medicaid services. (11) "Specialized services" means any program or service designed and operated to serve primarily a person with a developmental disability, including a program or service provided by an entity licensed or certified by the department. Programs or services available to the general public are not specialized services. (12) "Usual and customary charge" means the amount charged to other persons for the same service. (13) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility redetermination date. (C) Provider qualifications (1) Rules 5123-2-08 and 5123-2-09 do not apply to providers of participant-directed goods and services. (2) Provision of participant-directed goods and services shall be coordinated by a financial management services entity. (D) Requirements for service delivery (1) Participant-directed goods and services shall be provided pursuant to the assessed needs of a individual and an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (2) Participant-directed goods and services shall not be specialized services. If there is a question as to whether participant-directed goods and services are specialized services, the director of the department may make a determination. The director's determination is not subject to appeal. (3) Participant-directed goods and services shall not include: (a) Experimental treatments, including items considered by the federal food and drug administration as experimental or investigational or not approved to treat a specific condition; (b) Items used solely for entertainment or recreational purposes; (c) Pools, spas, or saunas; (d) Tobacco products or alcohol; (e) Food; (f) Internet service; (g) Items of general utility; (h) New equipment or supplies or repair of previously approved equipment or supplies that have been damaged as a result of confirmed misuse, abuse, or negligence; (i) Equipment, supplies, and devices of the same type for the same individual, unless there is a documented change in the individual's condition that warrants the replacement; (j) Home modifications that are of general utility or that add to the total square footage of the home; or (k) Items that are illegal or otherwise prohibited through federal or state regulations. (4) Prior to authorizing services, equipment, or supplies as participant-directed goods and services in the individual service plan or submitting a request for processing to the financial management services entity, an individual's service and support administrator shall ensure that: (a) The services, equipment, or supplies meet the definition of participant-directed goods and services set forth in paragraph (B)(8) of this rule; (b) A person-centered assessment of the individual has been conducted and supports the need for the services, equipment, or supplies for one or more of the reasons delineated in paragraph (B)(8)(a) of this rule; (c) The individual does not have funds to purchase the services, equipment, or supplies; and (d) Documentation on hand demonstrates that the requirements of paragraphs (D)(4)(a) to (D)(4)(c) of this rule are met. (5) A county board shall submit requests for the following services, equipment, or supplies to the department for review prior to authorizing them as participant-directed goods and services in the individual service plan: (a) Generators; (b) Fences; (c) Play sets or other generic equipment typically for the purpose of recreation or entertainment requested for the therapeutic or habilitative benefit of the individual; (d) Home modifications exceeding ten thousand dollars; (e) Services, equipment, or supplies that may otherwise be available to the individual through the individual's waiver (e.g., as community respite) or the medicaid state plan; and (f) Services, equipment, or supplies that may otherwise be available to the individual through Ohio's early and periodic screening, diagnostic, and treatment (i.e., "Healthchek") program or pursuant to the Individuals with Disabilities Education Act. (6) The department shall review requests submitted in accordance with paragraph (D)(5) of this rule and issue a determination within thirty calendar days of receiving all requested information. When the department determines that the request shall be denied, the department shall notify the county board and the individual in writing. The notice shall advise the individual of the individual's right to due process. (7) Requests submitted to the department in accordance with paragraph (D)(5) of this rule less than forty-five days in advance of the last day of an individual's waiver eligibility span may not be resolved with sufficient time to purchase the services, equipment, or supplies within that waiver eligibility span. (E) Documentation of services (1) Paragraph (J) of rule 5123-9-40 of the Administrative Code does not apply to participant-directed goods and services. (2) Service documentation for participant-directed goods and services shall consist of a written invoice that contains the individual's name and medicaid identification number, a description of the item or service provided, the provider's name, the date the item or service was provided, and the provider's charge for the item or service. (3) The financial management services entity shall maintain all service documentation for a period of six years from the date of receipt of payment for the service or until an initiated audit is resolved, whichever is longer. (F) Payment standards (1) The billing unit, service codes, and payment rate for participant-directed goods and services are contained in the appendix to this rule. (2) Providers of participant-directed goods and services shall be paid no more than their usual and customary charge for the services, equipment, or supplies provided. (3) Under the level one waiver, participant-directed goods and services shall not exceed two thousand five hundred dollars during a waiver eligibility span.
View Appendix
Last updated July 1, 2022 at 1:21 PM
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Rule 5123-9-46 | Home and community-based services waivers - participant/family stability assistance under the level one and self-empowered life funding waivers.
(A) Purpose This rule defines participant/family stability assistance and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service. (B) Definitions (1) "Agency provider" has the same meaning as in rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Family member" means a person who is related to the individual by blood, marriage, or adoption. (5) "Independent provider" has the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person with a developmental disability or for the purposes of giving, refusing to give, or withdrawing consent for services, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. An individual may designate another person to assist with development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services; the individual's designee shall not be employed by a county board or a provider, or a contractor of either. (7) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (8) "Participant/family stability assistance" means training (including education and instruction) and counseling (including consultation) that enhance an individual's ability to direct services received and/or enable an individual and/or family members who reside with the individual to understand how best to support the individual in order that the individual and the individual's family members may live as much like other families as possible and to prevent or delay unwanted out-of-home placement. (a) Participant/family stability assistance may be utilized only by the individual and family members who reside with the individual and shall be outcome-based, meaning that there is a specific goal for the service which is recorded in the individual service plan. (b) Participant/family stability assistance includes training and counseling related to accommodating the individual's disability in the home, accessing supports offered in the community, effectively supporting the individual so that the individual may be fully engaged in the life of the family, and supporting the unique needs of the individual. (c) Participant/family stability assistance includes the cost of enrollment fees and materials, but does not cover travel expenses or experimental and prohibited treatments. (9) "Service documentation" means all records and information on one or more documents, including documents that may be created or maintained in electronic software programs, created and maintained contemporaneously with the delivery of services, and kept in a manner as to fully disclose the nature and extent of services delivered that shall include the items delineated in paragraph (F) of this rule to validate payment for medicaid services. (10) "Usual and customary charge" means the amount charged to other persons for the same service. (C) Provider qualifications for participant/family stability assistance-training (1) Participant/family stability assistance-training shall be provided by an independent provider or an agency provider that: (a) Meets the requirements of this rule; (b) Has a medicaid provider agreement with the Ohio department of medicaid; and (c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov). (2) An individual may determine additional qualifications for a provider of participant/family stability assistance-training; additional qualifications determined by the individual shall be recorded in the individual service plan. (3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide participant/family stability assistance-training only when no other certified provider is willing and able. (4) Participant/family stability assistance-training shall not be provided to an individual by the individual's family member. (5) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (D) Provider qualifications for participant/family stability assistance-counseling (1) Participant/family stability assistance-counseling shall be provided by an independent provider or an agency provider that: (a) Meets the requirements of this rule; (b) Has a medicaid provider agreement with the Ohio department of medicaid; and (c) Has completed and submitted an application through the department's website (http://dodd.ohio.gov). (2) Participant/family stability assistance-counseling shall be provided by a person who is a: (a) Psychologist licensed by the state pursuant to Chapter 4732. of the Revised Code; (b) Professional clinical counselor licensed by the state pursuant to section 4757.22 of the Revised Code; (c) Professional counselor licensed by the state pursuant to section 4757.23 of the Revised Code; (d) Independent social worker licensed by the state pursuant to section 4757.27 of the Revised Code; (e) Social worker licensed by the state pursuant to section 4757.28 of the Revised Code working under the supervision of a licensed independent social worker; or (f) Marriage and family therapist licensed by the state pursuant to section 4757.30 of the Revised Code. (3) A county board or a regional council of governments formed under section 5126.13 of the Revised Code by two or more county boards may provide participant/family stability assistance-counseling only when no other certified provider is willing and able. (4) Participant/family stability assistance-counseling shall not be provided to an individual by the individual's family member. (5) Failure to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may result in denial, suspension, or revocation of the provider's certification. (E) Requirements for service delivery Participant/family stability assistance shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123-4-02 of the Administrative Code. (F) Documentation of services Service documentation for participant/family stability assistance shall include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving service. (5) Medicaid identification number of individual receiving service. (6) Name of provider. (7) Provider identifier/contract number. (8) Written or electronic signature of the person delivering the service, or initials of the person delivering the service if a signature and corresponding initials are on file with the provider. (9) Description and details of the services delivered that directly relate to the services specified in the approved individual service plan as the services to be provided. (10) Number of units of the delivered service or continuous amount of uninterrupted time during which the service was provided. (11) Times the delivered service started and stopped. (G) Payment standards (1) The billing unit, service codes, and payment rate for participant/family stability assistance are contained in the appendix to this rule. (2) Providers of participant/family stability assistance shall be paid no more than their usual and customary charge for the service.
View Appendix
Last updated July 1, 2022 at 1:19 PM
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Rule 5123-9-47 | Home and community-based services waivers - support brokerage under the self-empowered life funding waiver.
Effective:
September 23, 2018
(A) Purpose This rule defines support brokerage and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions (1) "Agency
provider" means an entity that directly employs at least one person in
addition to the chief executive officer for the purpose of providing services
for which the entity must be certified in accordance with rule 5123:2-2-01 of
the Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Family
member" means a person who is related to the individual by blood,
marriage, or adoption. (5) "Independent
provider" means a self-employed person who provides services for which he
or she must be certified in accordance with rule 5123:2-2-01 of the
Administrative Code and does not employ, either directly or through contract,
anyone else to provide the services. (6) "Individual" means a person with a
developmental disability or for the purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. An individual may designate another person to assist with development
of the individual service plan and budget, selection of residence and
providers, and negotiation of payment rates for services; the individual's
designee shall not be employed by a county board or a provider, or a contractor
of either. (7) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (8) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123:2-5-02 of the Administrative Code. (9) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (10) "Support broker" means a
person who is responsible, on a continuing basis, for providing an individual
with representation, advocacy, advice, and assistance related to the day-to-day
coordination of services (particularly those associated with participant
direction) in accordance with the individual service plan. The support broker
assists the individual with the individual's responsibilities regarding
participant direction, including understanding employer authority and budget
authority, locating and selecting providers, negotiating payment rates, and
keeping the focus of the services and support delivery on the individual and
his or her desired outcomes. The support broker, working in conjunction with
the service and support administrator, assists the individual with creating the
individual service plan, developing the waiver budget, and doing day-to-day
monitoring of the provision of services as specified in the individual service
plan. (11) "Support brokerage" means
the services of a support broker. (12) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility redetermination
date. (C) Provider qualifications (1) Support brokerage
shall be provided by one of the following: (a) An independent provider or an agency provider
that: (i) Meets the
requirements of this rule; (ii) Has a medicaid
provider agreement with the Ohio department of medicaid; and (iii) Has completed and
submitted an application through the department's website
(http://dodd.ohio.gov). (b) An unpaid volunteer who has the qualifications
specified in paragraph (C)(2) of this rule. (2) Support brokerage
shall be provided by a person who: (a) Has at least an associate's degree from an
accredited college or university or at least two years of experience providing
one-to-one support for a person with a developmental disability;
and (b) Prior to providing support brokerage, has successfully
completed the support broker training established by the
department. (3) An individual may
determine additional qualifications for a provider of support brokerage;
additional qualifications determined by the individual shall be recorded in the
individual service plan. (4) The following persons or entities
shall not provide support brokerage: (a) A county board. (b) An employee of a county board. (c) A housing or adult services nonprofit corporation
affiliated with a county board. (d) An employee of a housing or adult services nonprofit
corporation affiliated with a county board. (e) A regional council of governments formed under section
5126.13 of the Revised Code by two or more county boards. (f) An employee of a regional council of governments formed
under section 5126.13 of the Revised Code by two or more county
boards. (g) A certified provider of any other self-empowered life
funding waiver service. (h) A related entity affiliated with a certified provider
of any other self-empowered life funding waiver service including, but not
limited to, contractors of the provider. (5) Support brokerage shall not be
provided on a paid basis by an individual's: (a) Guardian; (b) Spouse; (c) Parent when the individual is less than eighteen years
of age; or (d) Family member when the family member resides with the
individual. (6) Failure to comply with this rule and
applicable provisions of rule 5123:2-2-01 of the Administrative Code may result
in the denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery Support brokerage shall be provided pursuant to
an individual service plan that conforms to the requirements of rule
5123:2-1-11 of the Administrative Code. (E) Documentation of
services Service documentation for support brokerage shall
include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving
service. (5) Medicaid identification number of
individual receiving service. (6) Name of provider. (7) Provider identifier/contract
number. (8) Written or electronic signature of
the person delivering the service, or initials of the person delivering the
service if a signature and corresponding initials are on file with the
provider. (9) Description and details of the
services delivered that directly relate to the services specified in the
approved individual service plan as the services to be provided. (10) Number of units of the delivered
service or continuous amount of uninterrupted time during which the service was
provided. (11) Times the delivered service started
and stopped. (F) Payment standards (1) The billing unit, service codes, and
payment rates for support brokerage are contained in the appendix to this
rule. (2) Payment for support brokerage shall
not exceed eight thousand dollars per waiver eligibility span.
View Appendix
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Rule 5123-9-48 | Home and community-based services waivers - community transition under the under the individual options waiver.
Effective:
October 15, 2021
(A) Purpose This rule defines community transition and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "Community
transition" means reimbursement for non-recurring household start-up
expenses for which an individual who previously resided in an intermediate care
facility for individuals with intellectual disabilities or a nursing facility
for at least ninety days and is transitioning to enrollment in the individual
options waiver is directly responsible. (a) Community transition includes expenses that do not constitute
room and board, necessary to enable an individual to establish a basic
household. Community transition includes, but is not limited to: (i) Security deposits and
rental start-up expenses required to obtain a lease on an apartment or
house; (ii) Essential household
furnishings required to occupy and use a community domicile such as furniture,
window coverings, food preparation items, and bed or bath linens; (iii) Start-up fees or
deposits for utility or service access such as telephone, electricity, heating,
and water; (iv) Moving
expenses; (v) Pre-transition
transportation services necessary to secure housing and benefits;
and (vi) Initial cleaning
products and household supplies. (b) Community transition does not include: (i) Grocery expenses; (ii) Internet expenses; (iii) Ongoing monthly rent or mortgage expenses; (iv) Ongoing utility or service charges; (v) Items intended for
entertainment or recreational purposes; or (vi) Tobacco products or
alcohol. (3) "County
board" means a county board of developmental disabilities. (4) "Department" means the Ohio
department of developmental disabilities. (5) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (6) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (7) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (8) "Intermediate
care facility for individuals with intellectual disabilities" has the same
meaning as in section 5124.01 of the Revised Code. (9) "Nursing facility" has the
same meaning as in section 5165.01 of the Revised Code. (10) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
shall include the items delineated in paragraph (E) of this rule to validate
payment for medicaid services. (C) Provider qualifications (1) Community transition
shall be provided by an agency provider that meets the requirements of this
rule and that has a medicaid provider agreement with the Ohio department of
medicaid. (2) An applicant seeking
to provide community transition shall complete and submit an application
through the department's website (http://dodd.ohio.gov). (3) A county board or a
regional council of governments formed under section 5126.13 of the Revised
Code by two or more county boards may provide community transition only when no
other qualified provider is available. (4) Community transition
shall not be provided by an independent provider. (D) Requirements for service
delivery (1) Community transition
shall be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) Community transition may be
authorized for up to one hundred eighty calendar days prior to the date on
which an individual enrolls in the individual options waiver. (3) Community transition
may be authorized for up to thirty calendar days after the date on which an
individual enrolls in the individual options waiver. (4) Expenses are reimbursable as
community transition only to the extent: (a) No other person, including a landlord, has a legal or
contractual responsibility to provide the item or service or pay the
expense; (b) They are reasonable and necessary as determined through the
person-centered planning process and clearly identified in the individual
service plan; (c) The individual is unable to pay such expenses and the item or
service cannot be obtained from other sources such as family, friends,
neighbors, or community agencies; and (d) They take into consideration the appropriateness and
availability of a lower cost alternative for comparable services that meet the
individual's needs. (5) An individual shall be involved in
selection of any item or service authorized as community transition and
purchased on his or her behalf. (E) Documentation of
services Service documentation for community transition
shall include each of the following to validate payment for medicaid
services: (1) Type of service. (2) Date of service. (3) Name of individual receiving
service. (4) Medicaid identification number of
individual receiving service. (5) Name of provider. (6) Provider identifier/contract
number. (7) Written or electronic signature of
the person delivering the service, or initials of the person delivering the
service if a signature and corresponding initials are on file with the
provider. (8) A detailed description of each
expense. (9) A receipt for each
expense with the individual's signature, mark, stamp, or other method
identified in the individual service plan to verify his or her receipt of the
purchased item or service. (F) Payment standards (1) The billing unit,
service code, and payment rate for community transition are contained in the
appendix to this rule. (2) Community transition shall not exceed
two thousand dollars per individual. (3) Pre-transition transportation
services covered as community transition shall not exceed five hundred
dollars. (4) The date of service
for purposes of reimbursement shall be the date an individual enrolls in the
individual options waiver upon discharge from the intermediate care facility
for individuals with intellectual disabilities or the nursing
facility. (5) If for any unforeseen
reason an individual does not enroll in the individual options waiver and
transition to the community as planned (e.g., due to death or significant
change in condition), the county board shall submit the individual's
expenses to the department within one year. Expenses incurred in these
circumstances are reimbursable to the county board by the department and to the
department by the Ohio department of medicaid.
Last updated October 15, 2021 at 8:31 AM
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