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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5123-9 | Vocational Activities; Administration of Individuals' Funds; Behavior Modification

 
 
 
Rule
Rule 5123-9-01 | Home and community-based services waivers - enrollment, denial of enrollment, disenrollment, and reenrollment.
 

(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.

Supplemental Information

Authorized By: 5123.04
Amplifies: 5123.04, 5126.055, 5166.21
Five Year Review Date: 11/19/2025
Prior Effective Dates: 5/28/1996, 6/11/2020 (Emer.)
Rule 5123-9-04 | Home and community-based services waivers - waiting list.
 

(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

Supplemental Information

Authorized By: 5123.04, 5126.042
Amplifies: 5123.04, 5126.042, 5126.044, 5126.054, 5126.055
Five Year Review Date: 9/1/2023
Prior Effective Dates: 6/2/1995 (Emer.), 12/9/1995, 2/28/1996 (Emer.), 5/28/1996, 7/12/1997, 12/1/2011, 9/1/2018
Rule 5123-9-06 | Home and community-based services waivers - documentation and payment for services under the individual options and level one waivers.
 

(A) Purpose

This rule establishes standards governing documentation and payment for home and community-based services under the individual options waiver and level one waiver components of the medicaid program that 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 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 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.

(3) "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.

(4) "County board" means a county board of developmental disabilities.

(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. 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 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.

(8) "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.

(9) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised 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 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. 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.

(13) "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.

(14) "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.

(15) "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.

(16) "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.

(17) "Provider" means an agency provider or independent provider that:

(a) Is certified by the department to provide home and community-based services; and

(b) Has a medicaid provider agreement with the Ohio department of medicaid.

(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 service-specific rules in Chapters 5123-9 and 5123:2-9 of the Administrative Code to validate payment for medicaid services.

(20) "Team" has the same meaning as in rule 5123-4-02 of the Administrative Code.

(21) "Three-year period" means the three-year period beginning with the individual's initial waiver enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(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) 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) Payment limitations under the level one waiver

(1) Under the level one waiver, payment for community respite, homemaker/personal care, informal respite, money management, participant-directed homemaker/personal care, remote support, residential respite, and transportation, alone or in combination, shall not exceed six thousand seven hundred fifty dollars per waiver eligibility span.

(2) Under the level one waiver, payment for assistive technology, environmental accessibility adaptations, home-delivered meals, and specialized medical equipment and supplies, alone or in combination, shall not exceed seven thousand five hundred dollars within a three-year period.

(3) In accordance with rule 5123-9-27 of the Administrative Code, payment for emergency assistance under the level one waiver shall not exceed eight thousand five hundred twenty dollars within a three-year period.

(E) 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.

(F) 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 Chapters 5123-9 and 5123:2-9 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.

(G) 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 his or her 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 his or her 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 Chapters 5123-9 and 5123:2-9 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.

(H) Service documentation

(1) Providers shall maintain service documentation in accordance with this rule and service-specific rules in Chapters 5123-9 and 5123:2-9 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.

(I) 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 shall establish 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 Chapters 5123-9 and 5123:2-9 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) 5123:2-9-15 (individual employment support under the individual options and level one waivers);

(e) 5123:2-9-16 (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) 5123-9-27 (emergency assistance under the level one waiver);

(o) 5123:2-9-28 (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) 5123:2-9-36 (interpreter services under the individual options waiver);

(x) 5123:2-9-37 (waiver nursing delegation under the individual options and level one waivers);

(y) 5123:2-9-38 (social work under the individual options waiver);

(z) 5123-9-39 (waiver nursing services under the individual options waiver); and

(aa) 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.

(J) 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 Chapters 5123-9 and 5123:2-9 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.

(K) 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.

(L) Ohio department of medicaid authority

The Ohio department of medicaid retains final authority to establish funding ranges for waiver services; to establish payment rates for waiver 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 waiver services through the cost projection and payment authorization.

(M) Authority of director to suspend or modify provisions of this rule

During the COVID-19 state of emergency declared by the governor, the director of the department may:

(1) Suspend the requirement described in paragraph (C)(9) of this rule for an individual to request prior authorization when his or her individual funding level exceeds his or her assigned funding range;

(2) Suspend the level one waiver payment limitations in paragraphs (D)(1) and (D)(2) of this rule;

(3) Suspend the requirement that a county board complete a cost projection pursuant to paragraph (G)(4) of this rule; and/or

(4) Modify the requirements in paragraphs (G)(1), (G)(2), (G)(6), (G)(7), (G)(8), and (G)(9) of this rule to allow use of the cost projection tool to be optional rather than mandatory.

View AppendixView Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.049, 5166.21
Five Year Review Date: 1/1/2024
Prior Effective Dates: 7/1/2007, 4/19/2012, 9/1/2013, 1/1/2016, 4/1/2017, 1/1/2019, 6/11/2020 (Emer.)
Rule 5123-9-07 | Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver.
 

(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.

Supplemental Information

Authorized By: 5123.04
Amplifies: 5123.04, 5166.21
Five Year Review Date: 11/19/2023
Prior Effective Dates: 7/1/2005, 6/11/2020 (Emer.)
Rule 5123-9-11 | Home and community-based services waivers - free choice of providers.
 

(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.

Supplemental Information

Authorized By: 5123.04, 5126.046
Amplifies: 5123.04, 5123.044, 5126.046, 5126.055, 5126.15, 5166.21
Five Year Review Date: 11/19/2025
Prior Effective Dates: 6/11/2020 (Emer.)
Rule 5123-9-12 | Home and community-based services waivers - assistive technology under the individual options, level one, and self-empowered life funding waivers.
 

(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" 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.

(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 and internet service necessary for operation of the equipment comprising the assistive technology. 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 may 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" 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.

(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) "Internet service" means internet access supplied by a commercial internet service provider that is required for assistive technology equipment to function and supplied at a speed that meets the technical requirements of the assistive technology equipment. Internet service includes the monthly fee the commercial internet service provider charges for internet access and fees for initial installation and necessary repairs to internet service equipment.

(15) "Internet service equipment" means hardware and software components required for operation of internet service, including but not limited to, routers, modems, wireless access points, wireless network adapters, signal amplifiers, and range extenders. Internet service equipment does not include structural additions or modifications to real property or components or devices used to access entertainment.

(16) "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.

(17) "Remote support" has the same meaning as in rule 5123-9-35 of the Administrative Code.

(18) "Remote support vendor" has the same meaning as in rule 5123-9-35 of the Administrative Code.

(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 (E) of this rule to validate payment for medicaid services.

(21) "Specialized medical equipment and supplies" has the same meaning as in rule 5123-9-25 of the Administrative Code.

(22) "Team" has the same meaning as in rule 5123:2-1-11 of the Administrative Code.

(23) "Useful life" means two years.

(24) "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 5123:2-2-01 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 5123:2-1-11 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 rental.

(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 rental 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) Items or equipment that are illegal or otherwise prohibited by federal or state statutes or regulations;

(b) Items or equipment used solely for entertainment or recreational purposes;

(c) Items or equipment used solely for the purpose of general utility;

(d) New equipment or repair of previously approved equipment that has been damaged as a result of confirmed misuse, abuse, or negligence; or

(e) Purchase or rental 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) Authorization of assistive technology equipment to be used for remote support may include internet service only when:

(a) The remote support vendor indicates internet service is required for other components of the equipment used for remote support to function. The remote support vendor shall specify the requirements necessary to ensure a reliable connection that minimizes disruption to the remote support service.

(b) To ensure compliance with rule 5123:2-9-02 of the Administrative Code, the team verifies that the internet service is not available through other resources.

(c) The internet service shall be secured by the remote support vendor to ensure appropriate use of the internet service solely for the function of equipment used for remote support.

(d) Use of the internet service for general utility by members of the household, guests, or provider staff is strictly prohibited.

(10) Assistive technology support shall not exceed forty hours per waiver eligibility span.

(11) 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 identified/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.

(c) Name of commercial internet service provider, if applicable.

(d) Invoices demonstrating the monthly cost of commercial internet service and installation and/or repair of internet service equipment.

(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) Under the level one waiver, assistive technology is subject to the payment limitation set forth in paragraph (D)(2) of rule 5123-9-06 of the Administrative Code.

(5) Purchase or rental of assistive technology equipment shall include, as appropriate, internet service fees, monthly fees, and the manufacturer's and seller's warranties.

(6) 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.

(7) 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.

(8) 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.

(9) 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.

View Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 1/1/2024
Rule 5123-9-13 | Home and community-based services waivers - career planning under the individual options, level one, and self-empowered life funding waivers.
 

(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 shall apply:

(1) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(2) "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.

(3) "Budget limitation" has the same meaning as in rule 5123:2-9-19 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 5123:2-9-16 of the Administrative Code.

(11) "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.

(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 5123:2-9-15 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 services staff 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 5123:2-9-14 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) Commencing in the second year of certification, an independent provider shall annually complete at least eight hours of training that enhances his or her skills and competencies relevant to the services he or she provides which shall include, but is not limited to:

(a) An independent provider's role and responsibilities with regard to services including person-centered planning, community integration, self-determination, and self-advocacy;

(b) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(c) 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; and

(d) Services that comprise career planning.

(6) An agency provider shall ensure that direct services staff who provide career planning (except those who provide only the benefits education and analysis or worksite accessibility components of career planning) successfully complete, no later than ninety calendar days after hire, an orientation program of at least eight hours that addresses, but is not limited to:

(a) Organizational background of the agency provider, including:

(i) Mission, vision, values, principles, and goals;

(ii) Organizational structure;

(iii) Key policies, procedures, and work rules;

(iv) Ethical and professional conduct and practice;

(v) Avoiding conflicts of interest; and

(vi) Working effectively with individuals, families, and other team members.

(b) Components of quality care for individuals served, including:

(i) Interpersonal relationships and trust;

(ii) Cultural and personal sensitivity;

(iii) Effective communication;

(iv) Person-centered philosophy, planning, and practice;

(v) Development of individual service plans;

(vi) Roles and responsibilities of team members; and

(vii) Record keeping, including progress notes and incident/accident reports.

(c) Health and safety, including:

(i) Signs and symptoms of illness or injury and procedure for response;

(ii) Building/site-specific emergency response plans; and

(iii) Program-specific transportation safety.

(d) Positive behavioral support, including:

(i) Principles of positive culture;

(ii) Role of direct services staff in creating a positive culture;

(iii) General requirements for intervention and behavioral support strategies and direct services staff role including documentation;

(iv) Human rights committees established in accordance with rule 5123:2-2-06 of the Administrative Code; and

(v) Crisis intervention techniques.

(e) Services that comprise career planning including the expectation that career planning will eventually lead to competitive integrated employment.

(7) An agency provider shall ensure that:

(a) Staff members 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) Staff members 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.

(8) An agency provider shall ensure that direct services staff 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.

(9) An agency provider shall ensure that direct services staff 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.

(10) An agency provider shall ensure that each direct services staff member who provides career planning successfully completes on-the-job training specific to each individual he or she serves that includes:

(a) What is important to the individual and what is important for the individual; and

(b) The individual's support needs including, as applicable, behavioral support strategy, management of the individual's funds, and medication administration/delegated nursing.

(11) An agency provider shall ensure that direct services staff who provide career planning, commencing in the second year of hire by the agency provider, annually complete at least eight hours of training, in accordance with the written plan of training priorities described in paragraph (C)(12) of this rule.

(a) The training shall enhance the skills and competencies of the direct services staff member relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The role and responsibilities of direct services staff with regard to services including person-centered planning, community integration, self-determination, and self-advocacy;

(ii) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(iii) 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;

(iv) The requirements relative to the direct services staff member's role in providing behavioral support to the individuals he or she serves; and

(v) Best practices related to the provision of career planning.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(12) An agency provider shall develop and implement a written plan identifying training priorities for direct services staff who provide career planning. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(13) An agency provider shall ensure that a written record of training completed for direct services staff who provide career planning is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(14) Failure to comply with this rule and rule 5123:2-2-01 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 5123:2-1-11 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 staff 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 5123:2-9-19 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 tubes, and/or requires the administration of routine doses of insulin through subcutaneous injections and insulin pumps; or

(ii) The individual requires oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) 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 or topical prescribed 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

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024
Prior Effective Dates: 4/1/2017
Rule 5123-9-14 | Home and community-based services waivers - vocational habilitation under the individual options, level one, and self-empowered life funding waivers.
 

(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" 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.

(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 5123:2-9-16 of the Administrative Code.

(11) "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.

(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 5123:2-9-15 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 services staff regarding techniques and practices that enhance the effectiveness of the provision of vocational habilitation.

(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" 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 which includes direct supervision, telephone and/or in-person 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) Assisting the individual with self-medication or provision of medication administration for prescribed medication and assisting the individual with or performing health-related activities in accordance with Chapters 5123-6 and 5123:2-6 of the Administrative Code.

(b) Provision of information about or referral to career planning services, disability benefits services, or other appropriate consultative services.

(20) "Waiver eligibility span" means the twelve-month period following either an individual's initial 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 5123:2-2-01 of the Administrative Code.

(4) An agency provider shall ensure that direct services staff who provide vocational habilitation successfully complete, no later than ninety calendar days after hire, an orientation program of at least eight hours that addresses, but is not limited to:

(a) Organizational background of the agency provider, including:

(i) Mission, vision, values, principles, and goals;

(ii) Organizational structure;

(iii) Key policies, procedures, and work rules;

(iv) Ethical and professional conduct and practice;

(v) Avoiding conflicts of interest; and

(vi) Working effectively with individuals, families, and other team members.

(b) Components of quality care for individuals served, including:

(i) Interpersonal relationships and trust;

(ii) Cultural and personal sensitivity;

(iii) Effective communication;

(iv) Person-centered philosophy, planning, and practice;

(v) Development of individual service plans;

(vi) Roles and responsibilities of team members; and

(vii) Record keeping including progress notes and incident/accident reports.

(c) Health and safety, including:

(i) Signs and symptoms of illness or injury and procedure for response;

(ii) Building/site-specific emergency response plans; and

(iii) Program-specific transportation safety.

(d) Positive behavioral support, including:

(i) Principles of positive culture;

(ii) Role of direct services staff in creating a positive culture;

(iii) General requirements for intervention and behavioral support strategies and direct services staff role including documentation;

(iv) Human rights committees established in accordance with rule 5123-2-06 of the Administrative Code; and

(v) Crisis intervention techniques.

(e) Services that comprise vocational habilitation including the expectation that vocational habilitation will eventually lead to competitive integrated employment.

(5) An agency provider shall ensure that direct services staff 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 services staff 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) An agency provider shall ensure that each direct services staff member who provides vocational habilitation successfully completes on-the-job training specific to each individual he or she serves that includes:

(a) What is important to the individual and what is important for the individual; and

(b) The individual's support needs including, as applicable, behavioral support strategy, management of the individual's funds, and medication administration/delegated nursing.

(8) An agency provider shall ensure that direct services staff who provide vocational habilitation, commencing in the second year of hire by the agency provider, annually complete at least eight hours of training, in accordance with the written plan of training priorities described in paragraph (C)(9) of this rule.

(a) The training shall enhance the skills and competencies of the direct services staff member relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The role and responsibilities of direct services staff with regard to services including person-centered planning, community integration, self-determination, and self-advocacy;

(ii) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(iii) 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;

(iv) The requirements relative to the direct services staff member's role in providing behavioral support to the individuals he or she serves; and

(v) Best practices related to the provision of vocational habilitation.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(9) An agency provider shall develop and implement a written plan identifying training priorities for direct services staff who provide vocational habilitation. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(10) An agency provider shall ensure that a written record of training completed for direct services staff who provide vocational habilitation is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(11) Failure to comply with this rule and rule 5123:2-2-01 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 shall take place in a non-residential setting separate from any individual's home.

(6) 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.

(7) 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.

(8) 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.

(9) 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.

(10) 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.

(11) 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 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 vocational habilitation may use the daily billing unit when the provider delivers between five and seven hours of vocational habilitation 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 qualify for or elects not to receive the community integration rate modification described in paragraph (F)(8) of this rule.

(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; or

(d) The provider qualifies for and elects to receive the community integration rate modification in accordance with paragraph (F)(8) of this rule.

(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 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 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 tubes, and/or requires the administration of routine doses of insulin through subcutaneous injections and insulin pumps; or

(ii) The individual requires oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) 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 or topical prescribed 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.

(c) Medical assistance rate modifications are subject to review by the department.

(8) Payment rates for vocational habilitation at the fifteen-minute billing unit shall be eligible for adjustment by the community integration rate modification when the service is provided in integrated settings in groups of four or fewer individuals and the staff providing the service have demonstrated enhanced competency by successfully completing a department-administered program of instruction in community integration. The amount of the community integration rate modification applied to each fifteen-minute billing unit of service is contained in appendix A to this rule.

(G) Authority of director to modify or suspend provisions of this rule

During the COVID-19 state of emergency declared by the governor, the director of the department may:

(1) Modify the definition of "vocational habilitation" in paragraph (B)(19) of this rule to allow vocational habilitation to be delivered remotely via technology or on behalf of an individual; and/or

(2) Suspend the requirement in paragraph (D)(5) of this rule to allow vocational habilitation to take place in an individual's home.

View Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 11/19/2025
Prior Effective Dates: 10/1/2007, 7/23/2012
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.
 

(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 in a non-residential setting, 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) Supports to participate in community activities and build community membership consistent with the individual's interests, preferences, goals, and outcomes.

(b) 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.

(c) 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.

(d) 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.

(e) 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.

(f) 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.

(g) 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.

(h) Assisting the individual with self-medication or provision of medication administration for prescribed medication and assisting the individual with or performing health-related activities in accordance with Chapters 5123-6 and 5123:2-6 of the Administrative Code.

(2) "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.

(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 5123:2-9-16 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 employment support" has the same meaning as in rule 5123:2-9-15 of the Administrative Code.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(14) "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 services staff regarding techniques and practices that enhance the effectiveness of the provision of adult day support.

(15) "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.

(16) "Non-medical transportation" has the same meaning as in rule 5123-9-18 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) "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 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 5123:2-2-01 of the Administrative Code.

(4) An agency provider shall ensure that direct services staff who provide adult day support successfully complete, no later than ninety calendar days after hire, an orientation program of at least eight hours that addresses, but is not limited to:

(a) Organizational background of the agency provider, including:

(i) Mission, vision, values, principles, and goals;

(ii) Organizational structure;

(iii) Key policies, procedures, and work rules;

(iv) Ethical and professional conduct and practice;

(v) Avoiding conflicts of interest; and

(vi) Working effectively with individuals, families, and other team members.

(b) Components of quality care for individuals served, including:

(i) Interpersonal relationships and trust;

(ii) Cultural and personal sensitivity;

(iii) Effective communication;

(iv) Person-centered philosophy, planning, and practice;

(v) Development of individual service plans;

(vi) Roles and responsibilities of team members; and

(vii) Record keeping including progress notes and incident/accident reports.

(c) Health and safety, including:

(i) Signs and symptoms of illness or injury and procedure for response;

(ii) Building/site-specific emergency response plans; and

(iii) Program-specific transportation safety.

(d) Positive behavioral support, including:

(i) Principles of positive culture;

(ii) Role of direct services staff in creating a positive culture;

(iii) General requirements for intervention and behavioral support strategies and direct services staff role including documentation;

(iv) Human rights committees established in accordance with rule 5123-2-06 of the Administrative Code; and

(v) Crisis intervention techniques.

(e) Services that comprise adult day support.

(5) An agency provider shall ensure that direct services staff 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 services staff 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 individual's strengths 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) An agency provider shall ensure that each direct services staff member who provides adult day support successfully completes on-the-job training specific to each individual he or she serves that includes:

(a) What is important to the individual and what is important for the individual; and

(b) The individual's support needs including, as applicable, behavioral support strategy, management of the individual's funds, and medication administration/delegated nursing.

(8) An agency provider shall ensure that direct services staff who provide adult day support, commencing in the second year of hire by the agency provider, annually complete at least eight hours of training, in accordance with the written plan of training priorities described in paragraph (C)(9) of this rule.

(a) The training shall enhance the skills and competencies of the direct services staff member relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The role and responsibilities of direct services staff with regard to services including person-centered planning, community integration, self-determination, and self-advocacy;

(ii) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code;

(iii) 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;

(iv) The requirements relative to the direct services staff member's role in providing behavioral support to the individuals he or she serves; and

(v) Best practices related to the provision of adult day support.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(9) An agency provider shall develop and implement a written plan identifying training priorities for direct services staff who provide adult day support. The training priorities shall be consistent with the needs of individuals served, best practice, and the provider's mission, vision, and strategic plan. The written plan of training priorities shall describe the method (e.g., written test, skills demonstration, or documented observation by supervisor) that will be used to establish competency in areas of training. The written plan of training priorities shall be updated at least once every twelve months and shall identify who is responsible for arranging or providing the training and projected timelines for completion of the training.

(10) An agency provider shall ensure that a written record of training completed for direct services staff who provide adult day support is maintained. The written record shall include a description of the training completed including a training syllabus and copies of training materials, the date of training, the duration of training, and the instructor's name, if applicable.

(11) Failure to comply with this rule and rule 5123:2-2-01 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 shall take place in a non-residential setting separate from any individual's home.

(5) 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.

(6) 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.

(7) When meals are provided as part of adult day support, they shall not constitute a full nutritional regimen (i.e., three meals per day).

(8) 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 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 adult day support may use the daily billing unit when the provider delivers between five and seven hours of adult day 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;

(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 qualify for or elects not to receive the community integration rate modification described in paragraph (F)(8) of this rule.

(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; or

(d) The provider qualifies for and elects to receive the community integration rate modification in accordance with paragraph (F)(8) of this rule.

(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 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 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 tubes, and/or requires the administration of routine doses of insulin through subcutaneous injections and insulin pumps; or

(ii) The individual requires oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) 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 or topical prescribed 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.

(c) Medical assistance rate modifications are subject to review by the department.

(8) Payment rates for adult day support at the fifteen-minute billing unit shall be eligible for adjustment by the community integration rate modification when the service is provided in integrated settings in groups of four or fewer individuals and the staff providing the service have demonstrated enhanced competency by successfully completing a department-approved program of instruction in community integration. The amount of the community integration rate modification applied to each fifteen-minute billing unit of service is contained in appendix A to this rule.

(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.

(H) Authority of director to modify or suspend provisions of this rule

During the COVID-19 state of emergency declared by the governor, the director of the department may:

(1) Modify the definition of "adult day support" in paragraph (B)(1) of this rule to allow adult day support to be delivered remotely via technology or on behalf of an individual; and/or

(2) Suspend the requirement in paragraph (D)(4) of this rule to allow adult day support to take place in an individual's home.

View Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 11/19/2025
Prior Effective Dates: 1/1/2007, 10/1/2007, 12/21/2007 (Emer.), 7/23/2012, 6/11/2020 (Emer.)
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 shall apply:

(1) "Adult day support" has the same meaning as in rule 5123:2-9-17 of the Administrative Code.

(2) "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.

(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 5123:2-9-16 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" 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.

(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 5123:2-9-15 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 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) "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 5123:2-9-14 of the Administrative Code.

(23) "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 rule 5123:2-2-01 of the Administrative Code except that paragraphs (D)(1), (D)(2), (D)(5), (D)(8), and (D)(17) of that rule do not apply to operators of commercial vehicles.

(3) An applicant seeking approval to provide non-medical 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 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 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.

(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 his or her 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 his or her driving record or if his or her driver's license is 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 applicable provisions of rule 5123:2-2-01 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 5123:2-1-11 of the Administrative Code. 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. Whenever possible, family, neighbors, friends, or community agencies that transport people without charge shall be utilized to meet an individual's needs.

(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 his or her individual service plan.

(4) Operators of commercial vehicles shall be paid their usual and customary fares.

(5) Payment for non-medical transportation shall not exceed the budget limitations contained in appendix B to rule 5123-9-19 of the Administrative Code.

View AppendixView Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 2/1/2025
Prior Effective Dates: 10/1/2007, 4/1/2017
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 shall 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 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. This 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 5123:2-9-17 of the Administrative Code.

(5) "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.

(6) "Budget limitation" means the funding amount available to enable an individual 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 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 5123:2-9-16 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, 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 5123:2-9-15 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 5123:2-9-14 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 5123:2-9-37 of the Administrative Code.

(20) "Waiver nursing services" has the same meaning as in rule 5123:2-9-39 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 his or her 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 the individual 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 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 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 5123:2-1-11 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 for the individual. The county board also shall determine whether the annual cost for non-medical transportation can be met by or exceeds the assigned budget limitation for the individual. 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 determined in accordance with paragraph (C) of this rule.

(5) Prior state level review shall not be required for the initiation and/or changes in services that can occur within the budget limitation resulting from a revision to the individual service plan that has been agreed to by an individual through the individual service plan development process.

(6) Changes in budget limitations made by county boards are subject to review by the department and approval by the Ohio department of medicaid.

(7) Neither the department nor the county board shall approve a change in a budget limitation or assign a new budget limitation 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 or below the budget limitations determined in accordance with this rule. The service and support administrator shall inform the individual in writing in a form and manner the individual understands, of his or her due process rights and responsibilities as set forth in section 5160.31 of the Revised Code.

(2) When the annual cost for adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation exceeds the assigned budget limitation, the service and support administrator shall inform the individual of his or her right to request an administrative review to obtain adult day support, career planning, group employment support, individual employment support, and/or vocational habilitation services that result in a new group assignment and budget limitation that exceeds the budget limitation determined initially by the county board in accordance with paragraph (C) of this rule.

(3) 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 and resulting budget limitation that is greater 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.

(4) The department considers the budget limitations contained in appendix B to this rule sufficient to meet the service requirements of any adult 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.

(5) 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.

(6) 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.

(7) The department shall make a determination within thirty calendar days following receipt of the information described in paragraph (F)(6) of this rule and shall notify the individual and county board in writing of the determination.

(8) 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.

(9) Following completion of the administrative review process, the department shall inform the individual in writing in a form and manner the individual understands, of his or her due process rights and responsibilities as set forth in section 5160.31 of the Revised Code.

(10) If, through the administrative review process, the department approves the request for an increased budget limitation, 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.

(11) If, through the administrative review process, the department denies the request for an increased budget limitation 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.

(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 his or her due process rights and responsibilities as set forth in section 5160.31 of the Revised Code.

(12) The department shall use the twelve-month period following either an individual's initial 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 waiver services remain within the approved budget limitations specified in this rule.

(13) 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.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.049, 5166.21
Five Year Review Date: 2/1/2025
Prior Effective Dates: 1/1/2007, 7/23/2012
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 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) "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 he or she 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 may 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" 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.

(8) "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.

(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 of 2014);

(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 his or her 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 he or she 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 5123:2-9-33 of the Administrative Code.

(16) "Team" has the same meaning as in rule 5123:2-1-11 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 5123:2-2-01 of the Administrative Code except that persons providing money management shall not be required to:

(a) Hold valid "American Red Cross" or equivalent certification in first aid;

(b) Hold valid "American Red Cross" or equivalent certification in cardiopulmonary resuscitation; or

(c) Complete eight hours of training in accordance with paragraph (C)(2)(b) or (D)(17)(g) of rule 5123:2-2-01 of the Administrative Code.

(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 in accordance with standards established by the department in:

(a) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(b) The requirements of rule 5123-17-02 of the Administrative Code including a review of health and welfare alerts issued by the department.

(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 sections 5123.62 to 5123.64 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; and

(c) Topics that enhance his or her skills and competencies relevant to provision of money management.

(7) Failure to comply with this rule and applicable provisions of rule 5123:2-2-01 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 5123:2-1-11 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 he or she serves;

(c) Disclose in writing to the individual he or she serves 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 he or she provides (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) A provider of money management shall not act or represent himself or herself as an accountant, financial advisor, attorney, or other licensed professional unless he or she is 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)(20)(i) of rule 5123-9-32 of the Administrative Code, the services shall be authorized and billed as participant-directed homemaker/personal care.

(3) Under the level one waiver, money management is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024
Prior Effective Dates: 4/1/2017
Rule 5123-9-21 | Home and community-based services waivers - informal respite under the level one waiver.
 

(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" 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) "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.

(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 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 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.

(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) "Unusual incident" has the same meaning as in rule 5123-17-02 of the Administrative Code.

(13) "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 5123:2-2-01 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 5123:2-1-11 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 sections 5123.62 to 5123.64 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

(1) The billing unit, service code, and payment rate for informal respite are contained in the appendix to this rule.

(2) Informal respite is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

View Appendix

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024
Prior Effective Dates: 7/1/2006, 9/1/2013, 4/1/2017
Rule 5123-9-22 | Home and community-based services waivers - community respite under the individual options, level one, and self-empowered life funding waivers.
 

(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 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) "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 may 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" 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) "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 5123:2-2-01 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 Chapter 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 5123:2-1-11 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 oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) 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 or topical prescribed 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) Under the level one waiver, community respite is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

(7) Payment for community respite shall not include payment for room and board or transportation.

View AppendixView Appendix

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.045, 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049
Five Year Review Date: 7/5/2023
Prior Effective Dates: 1/1/2016, 7/5/2018
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 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) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Environmental accessibility adaptations" means those physical adaptations to the home, required by the individual service plan, which are necessary to ensure the health, welfare, and safety of the individual, or which enable the individual to function with greater independence in the home, and without which, the individual would require institutionalization. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual. Excluded are adaptations that add to the total square footage of the home and adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, or central air conditioning. All adaptations shall be provided in accordance with applicable state or local building codes.

(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 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) "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) "Three-year period" means the three-year period beginning with the individual's initial waiver enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(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) 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 rule 5123:2-2-01 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 5123:2-1-11 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) Under the individual options waiver, payment for environmental accessibility adaptations shall not exceed ten thousand dollars per project.

(4) Under the level one waiver, environmental accessibility adaptations is subject to the payment limitation set forth in paragraph (D)(2) of rule 5123-9-06 of the Administrative Code.

View Appendix

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024
Prior Effective Dates: 7/1/2006, 9/1/2017
Rule 5123-9-24 | Home and community-based services waivers - transportation under the individual options, level one, and self-empowered life funding waivers.
 

(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" means an entity that 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) "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" 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.

(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 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 rule 5123:2-2-01 of the Administrative Code except that paragraphs (D)(1), (D)(2), (D)(5), (D)(8), and (D)(17) of that rule do not apply to operators of commercial vehicles.

(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 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

(1) Transportation shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 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.

(3) Under the level one waiver, transportation is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

View AppendixView Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 1/1/2024
Prior Effective Dates: 7/1/2006, 3/19/2012, 1/1/2019
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 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) "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) "Environmental accessibility adaptations" has the same meaning as in rule 5123-9-23 of the Administrative Code.

(6) "Home-delivered meals" has the same meaning as in rule 5123-9-29 of the Administrative Code.

(7) "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.

(8) "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.

(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) "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 his or her ability to perform activities of daily living, or to perceive, control, or communicate with the environment in which he or she 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.

(12) "Three-year period" means the three-year period beginning with the individual's initial waiver enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(13) "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 rule 5123:2-2-01 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 5123:2-1-11 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) Under the level one waiver, specialized medical equipment and supplies is subject to the payment limitation set forth in paragraph (D)(2) of rule 5123-9-06 of the Administrative Code.

View Appendix

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 6/1/2023
Prior Effective Dates: 3/19/2012, 9/1/2013
Rule 5123-9-27 | Home and community-based services waivers - emergency assistance under the level one waiver.
 

(A) Purpose

This rule sets forth coverage and eligibility for emergency assistance provided to individuals enrolled in the level one waiver.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Assistive technology" has the same meaning as in rule 5123-9-12 of the Administrative Code.

(2) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Emergency assistance" means an increased amount of assistive technology, environmental accessibility adaptations, homemaker/personal care, informal respite, participant-directed homemaker/personal care, remote support, residential respite, specialized medical equipment and supplies, or transportation necessary to support an individual in an emergency situation.

(5) "Environmental accessibility adaptations" has the same meaning as in rule 5123-9-23 of the Administrative Code.

(6) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 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, his or her 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) "Informal respite" has the same meaning as in rule 5123-9-21 of the Administrative Code.

(10) "Intermediate care facility for individuals with intellectual disabilities" has the same meaning as in section 5124.01 of the Revised Code.

(11) "Participant-directed homemaker/personal care" has the same meaning as in rule 5123-9-32 of the Administrative Code.

(12) "Remote support" has the same meaning as in rule 5123-9-35 of the Administrative Code.

(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 who holds the appropriate certification in accordance with rule 5123:2-5-02 of the Administrative Code.

(15) "Specialized medical equipment and supplies" has the same meaning as in rule 5123-9-25 of the Administrative Code.

(16) "Three-year period" means the three-year period beginning with an individual's initial waiver enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(17) "Transportation" has the same meaning as in rule 5123-9-24 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.

(C) Eligibility for emergency assistance

(1) An individual enrolled in the level one waiver shall be eligible for emergency assistance if he or she:

(a) Has lost his or her present residence for any reason including legal action;

(b) Has lost his or her present caregiver for any reason, including death of caregiver or change in caregiver's mental or physical status resulting in the caregiver's inability to perform effectively for the individual;

(c) Has been the victim of abuse, neglect, or exploitation;

(d) Has health and welfare conditions that pose a serious risk to the individual of immediate harm or death; or

(e) Has significant changes in his or her emotional or physical condition that necessitate substantial, expanded accommodations that cannot be reasonably provided by the individual's present caregiver.

(2) Eligibility for emergency assistance shall be determined through the individual service plan development process.

(3) If an individual is determined to be eligible for emergency assistance, the service and support administrator, through the individual service plan development process, shall recommend emergency assistance funds in an amount not to exceed eight thousand five hundred twenty dollars within a three-year period.

(4) If an individual's request for emergency assistance is denied, the county board shall give the individual notice of the individual's due process and hearing rights under section 5160.31 of the Revised Code and Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(D) Requirements for service delivery

(1) Emergency assistance shall be provided pursuant to an individual service plan that conforms to the requirements of rule 5123:2-1-11 of the Administrative Code.

(2) Emergency assistance shall only be used to support an individual on an interim basis until nonrecurring circumstances that present a threat to the individual's health and welfare are resolved.

(3) Assistive technology, environmental accessibility adaptations, homemaker/personal care, informal respite, participant-directed homemaker/personal care, remote support, residential respite, specialized medical equipment and supplies, or transportation provided as emergency assistance shall be provided in accordance with Chapter 5123-9 of the Administrative Code.

(E) Payment standards

(1) The service codes to be used for assistive technology, environmental accessibility adaptations, homemaker/personal care, informal respite, participant-directed homemaker/personal care, remote support, residential respite, specialized medical equipment and supplies, and transportation when these services are provided as emergency assistance are contained in the appendix to this rule.

(2) Payment rates for routine homemaker/personal care provided as emergency assistance may be adjusted by the staff competency rate modification described in paragraph (F)(7) of rule 5123-9-30 of the Administrative Code when the requirements of that paragraph are satisfied.

(3) Emergency assistance shall not exceed eight thousand five hundred twenty dollars within a three-year period.

View Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5166.21
Five Year Review Date: 11/19/2023
Prior Effective Dates: 4/28/2003, 3/19/2012, 9/1/2013, 1/1/2016, 7/25/2019
Rule 5123-9-29 | Home and community-based services waivers - home-delivered meals under the individual options and level one 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 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) "County board" means a county board of developmental disabilities.

(3) "Department" means the Ohio department of developmental disabilities.

(4) "Home-delivered meals" means the preparation, packaging, and delivery of one or more meals to individuals who are unable to prepare or obtain nourishing meals. A maximum of two meals per day shall be provided under the individual options or level one waivers.

(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 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) "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) "Three-year period" means the three-year period beginning with the individual's initial waiver enrollment date and ending three years later. Subsequent three-year periods begin with the ending date of the previous three-year period and end three years later.

(C) Provider qualifications

(1) Home-delivered meals shall be provided by an independent provider or an agency provider that meets all applicable regulatory requirements for the preparation, packaging, and delivery of home-delivered meals as defined by the Ohio department of aging 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 rule 5123:2-2-01 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 5123:2-1-11 of the Administrative Code.

(2) The provider shall:

(a) Be able to provide two meals per day, seven days per week;

(b) Be able to provide special diets, including but not limited to, low sodium and low sugar;

(c) Ensure that each meal contains at least one-third of the daily recommended dietary allowance as established by the food and nutrition board of the national academy of sciences national research council;

(d) Ensure that a licensed dietitian approves and signs all menus and develops all special menus in accordance with the individual service plan;

(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 prepare and deliver a noontime and/or evening meal as specified in the individual service plan.

(a) Noontime meals shall be delivered within one hour of noon.

(b) Evening meals shall be delivered within one hour of five-thirty p.m. or, on condition that appropriate methods exist to ensure proper and safe handling by the provider and safe consumption by the individual, may be delivered with the noontime meals.

(c) Notwithstanding paragraphs (D)(3)(a) and (D)(3)(b) of this rule, if frozen meals are used, all meals for a week may be delivered at one time during the week on condition that appropriate methods exist to ensure proper and safe handling by the provider and safe consumption by the individual. Each frozen meal shall be individually packaged and labeled with the words, "use before," followed by the month, day, and year by which the meal is to be used.

(4) The provider shall not:

(a) Leave food unrefrigerated or unattended; or

(b) Leave food at a residence unless the individual or his or her representative is there to receive the food.

(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) 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 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 rate for home-delivered meals are contained in the appendix to this rule.

(2) Under the level one waiver, home-delivered meals is subject to the payment limitation set forth in paragraph (D)(2) of rule 5123-9-06 of the Administrative Code.

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024
Prior Effective Dates: 9/1/2013
Rule 5123-9-30 | Home and community-based services waivers - homemaker/ personal care under the individual options and level one waivers.
 

(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" 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.

(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 5123:2-9-16 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" 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.

(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 5123:2-9-15 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) Each direct services staff member of an agency provider shall successfully complete on-the-job training specific to each individual he or she serves that includes:

(a) What is important to the individual and what is important for the individual; and

(b) The individual's support needs including, as applicable, behavioral support strategy, management of the individual's funds, and medication administration/delegated nursing.

(6) Each independent provider and each direct services staff member of an agency provider shall annually complete at least eight hours of training, in accordance with standards established by the department.

(a) The training shall enhance the skills and competencies of the independent provider or direct services staff member relevant to his or her job responsibilities and shall include, but is not limited to:

(i) The role and responsibilities of the independent provider or direct services staff member with regard to services including person-centered planning, community integration, self-determination, and self-advocacy.

(ii) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code.

(iii) 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.

(iv) The requirements relative to the independent provider's or direct services staff member's role in providing behavioral support to the individuals he or she serves.

(b) The training may be structured or unstructured and may include, but is not limited to, lectures, seminars, formal coursework, workshops, conferences, demonstrations, visitations or observations of other services/programs, distance and other means of electronic learning, video and audio-visual training, and staff meetings.

(c) The provider shall maintain a written record, which may include an electronic record, of training. This information shall be presented upon request by the Ohio department of medicaid, the department, or the county board. Documentation shall include the name of the person receiving the training, date of training, training topic, duration of training, instructor's name if applicable, and a brief description of the training.

(7) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 of the Administrative Code may result in denial, suspension, or revocation of the provider's certification.

(8) Failure of a licensed provider to comply with this rule and Chapter 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 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, 2021), 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 oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) 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 or topical prescribed 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 5123:2-2-01, rule 5123-17-02, Chapter 5123:2-3, 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.

(13) Under the level one waiver, homemaker/personal care is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

View AppendixView AppendixView Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 7/5/2023
Prior Effective Dates: 7/1/2007, 12/21/2007 (Emer.), 7/1/2010, 9/1/2013, 1/1/2014, 4/1/2017, 9/1/2017, 2/15/2018, 1/1/2019, 1/1/2020
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.
 

(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

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 1/1/2024
Prior Effective Dates: 3/20/2008, 1/1/2016, 2/15/2018, 6/11/2020 (Emer.)
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.
 

(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" 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.

(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 5123:2-9-16 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 5123:2-9-15 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 5123:2-2-01 of the Administrative Code except that:

(a) A common law employee need not hold a high school diploma or general education development certificate, "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 training described in paragraph (C)(2)(b) of that rule unless specifically required to do so by the individual receiving services, but in any case shall complete, prior to providing participant-directed homemaker/personal care and annually thereafter, training in accordance with standards established by the department in:

(i) The rights of individuals set forth in sections 5123.62 to 5123.64 of the Revised Code; and

(ii) The requirements of rule 5123-17-02 of the Administrative Code including a review of health and welfare alerts issued by the department.

(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 applicable provisions of rule 5123:2-2-01 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 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 and/or jejunostomy tubes, and/or requires the administration of routine doses of insulin through subcutaneous injections and insulin pumps; or

(ii) The individual requires oxygen administration that a licensed nurse agrees to delegate in accordance with rules in Chapter 4723-13 of the Administrative Code; or

(iii) 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 or topical prescribed 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.

(9) Under the level one waiver, participant-directed homemaker/personal care is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

View Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 1/1/2024
Prior Effective Dates: 2/1/2018
Rule 5123-9-33 | Home and community-based services waivers - shared living under the individual options waiver.
 

(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" 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.

(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" 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.

(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 rule 5123:2-2-01 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 Chapter 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. When more than three persons with developmental disabilities receive shared living or other supported living services in the same home, the home must be licensed pursuant to section 5123.19 of the Revised Code.

(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 when the individual chooses services that take place outside of the shared living home and the services are provided by an approved provider of homemaker/personal care who is not the shared living caregiver.

(a) An agency provider may contract for these services. If the agency provider opts to contract, the daily rate for shared living may be billed by the shared living provider for that day.

(b) In situations where an agency provider does not contract for these services or in situations where an individual served by an independent provider seeks homemaker/personal care services outside of the shared living home, the shared living provider shall not bill for shared living on a day when homemaker/personal care is rendered. This prohibition exists regardless of whether claims for homemaker/personal care are submitted to the department for the entire twenty-four-hour period or for a lesser amount of time that day.

(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 the individual or legally responsible person in the event that substitute coverage is necessary and 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, homemaker/personal care, 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.

(H) Authority of director to suspend or modify provisions of this rule

During the COVID-19 state of emergency declared by the governor, the director of the department may suspend or modify paragraphs (D)(10), (D)(11), and/or (F)(5) of this rule to allow shared living and homemaker/personal care to be billed on the same day as long as the services are not delivered at the same time or by the same person.

View AppendixView Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 11/19/2025
Prior Effective Dates: 10/1/2007, 7/15/2011, 10/1/2017
Rule 5123-9-34 | Home and community-based services waivers - residential respite under the individual options, level one, and self-empowered life funding waivers.
 

(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" 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) "Homemaker/personal care" has the same meaning as in rule 5123-9-30 of the Administrative Code.

(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 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 5123:2-2-01 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 Chapter 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) Under the level one waiver, residential respite is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

(5) Payment for residential respite shall not include payment for room and board or transportation.

(G) Authority of director to modify or suspend provisions of this rule

During the COVID-19 state of emergency declared by the governor, the director of the department may:

(1) Modify the limitation in paragraph (D)(4) of this rule to:

(a) Extend the number of residential respite days available in a waiver eligibility span from ninety to one hundred eighty; and/or

(b) Authorize additional residential respite days beyond one hundred eighty in a waiver eligibility span for an individual based on risk to health and welfare as determined by the department.

(2) Suspend the level one waiver payment limitation in paragraph (F)(4) of this rule.

Supplemental Information

Authorized By: 5123.04, 5123.049, 5123.1611
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 7/5/2023
Prior Effective Dates: 9/1/2013
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 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) "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" 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.

(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 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 5123:2-9-33 of the Administrative Code.

(20) "Team" has the same meaning as in rule 5123:2-1-11 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 paragraph (D)(17)(g) of rule 5123:2-2-01 of the Administrative Code.

(5) Failure of a certified provider to comply with this rule and rule 5123:2-2-01 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 Chapter 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 5123:2-1-11 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.

(4) Under the level one waiver, remote support is subject to the payment limitation set forth in paragraph (D)(1) of rule 5123-9-06 of the Administrative Code.

Supplemental Information

Authorized By: 5123.1611, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024
Rule 5123-9-39 | Home and community-based services waivers - waiver nursing services under the individual options waiver.
 

(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" 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.

(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" 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.

(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) "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.

(13) "Registered nurse" has the same meaning as in section 4723.01 of the Revised Code.

(14) "Residential respite" has the same meaning as in rule 5123-9-34 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 (F) of this rule to validate payment for medicaid services.

(16) "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.

(17) "Vocational habilitation" has the same meaning as in rule 5123-9-14 of the Administrative Code.

(18) "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; or

(f) Services performed in excess of the number of hours approved pursuant to, and as specified in, the individual service plan.

(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 rule 5123:2-2-01 of the Administrative Code.

(6) Failure of a provider to comply with this rule and rule 5123:2-2-01 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; and

(b) A proposed weekly schedule with corresponding budget.

(2) Waiver nursing services shall be authorized only when an individual's needs cannot be met through medication administration and nursing delegation in accordance with Chapters 5123-6 and 5123:2-6 of the Administrative 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 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 nursing visit.

(5) 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.

(6) 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.

(7) 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.

(8) 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)(6) 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)(7) 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.

(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 paragraphs (E)(5) and (E)(7) of this rule to allow visits to be conducted by video conference or telephone.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5166.21
Five Year Review Date: 11/19/2025
Prior Effective Dates: 1/1/2017, 6/11/2020 (Emer.)
Rule 5123-9-40 | Home and community-based services waivers - administration of the self-empowered life funding waiver.
 

(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

(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 his or her 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 him or her 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 the individual has the authority and responsibility to manage his or her budget. This authority supports the individual in determining the budgeted dollar amount for each waiver service that will be provided to the individual and making decisions about the acquisition of 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 either an agency with choice or a financial management services entity under contract with the state that 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 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 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 the 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 his or her 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. 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) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised 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. 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.

(13) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(14) "Participant direction" means the individual has authority to make decisions about some or all of his or her waiver services and accepts responsibility for taking a direct role in managing the services. Participant direction includes the exercise of budget authority and employer authority as set forth in paragraph (H) of this rule.

(15) "Provider" means a person or agency certified or licensed by the department that has met the provider qualification requirements to provide the specific self-empowered life funding waiver service and holds a valid medicaid provider agreement with the Ohio department of medicaid.

(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) "Waiver eligibility span" means the twelve-month period following either an individual's initial waiver enrollment date or a subsequent eligibility redetermination date.

(C) Financial management services entity

The state shall contract with an entity to provide financial management services to individuals enrolled in the self-empowered life funding waiver.

(D) 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.

(E) Criteria for enrolling in the self-empowered life funding waiver

To be enrolled in the self-empowered life funding waiver:

(1) The individual must meet the eligibility criteria for enrollment in home and community-based services waivers set forth in rule 5123:2-9-01 of the Administrative Code;

(2) 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 (i.e., development of the individual service plan and budget, selection of residence and providers, and negotiation of payment rates for services); and

(3) 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 (H)(1) or (H)(2) of this rule, for at least one service the individual receives under the waiver.

(F) Self-empowered life funding waiver enrollment, continued enrollment, and disenrollment

An individual who meets the criteria specified in paragraph (E) 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 (G) 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.

(G) 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 5123:2-9-17 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 5123:2-9-16 of the Administrative Code;

(8) Individual employment support in accordance with rule 5123:2-9-15 of the Administrative Code;

(9) Non-medical transportation in accordance with rule 5123-9-18 of the Administrative Code;

(10) Participant-directed goods and services in accordance with rule 5123-9-45 of the Administrative Code;

(11) Participant-directed homemaker/personal care in accordance with rule 5123-9-32 of the Administrative Code;

(12) Participant/family stability assistance in accordance with rule 5123-9-46 of the Administrative Code;

(13) Remote support in accordance with rule 5123-9-35 of the Administrative Code;

(14) Residential respite in accordance with rule 5123-9-34 of the Administrative Code;

(15) Support brokerage in accordance with rule 5123-9-47 of the Administrative Code;

(16) Transportation in accordance with rule 5123-9-24 of the Administrative Code;

(17) Vocational habilitation in accordance with rule 5123:2-9-14 of the Administrative Code; and

(18) Waiver nursing delegation in accordance with rule 5123:2-9-37 of the Administrative Code.

(H) 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) Assistive technology;

(b) Clinical/therapeutic intervention;

(c) Community respite;

(d) Functional behavioral assessment;

(e) Participant-directed goods and services;

(f) Participant-directed homemaker/personal care;

(g) Participant/family stability assistance;

(h) Remote support;

(i) Residential respite; and

(j) Support brokerage.

(2) Individuals enrolled in the self-empowered life funding waiver may exercise employer authority for:

(a) Functional behavioral assessment;

(b) Participant-directed goods and services;

(c) Participant-directed homemaker/personal care;

(d) Participant/family stability assistance; and

(e) Support brokerage.

(3) Individuals enrolled in the self-empowered life funding waiver may not exercise budget authority or employment authority for:

(a) Adult day support;

(b) Career planning;

(c) Group employment support;

(d) Individual employment support;

(e) Non-medical transportation;

(f) Transportation;

(g) Vocational habilitation; or

(h) Waiver nursing delegation.

(I) Benefit limitations

(1) The cost of services available under the self-empowered life funding waiver shall not exceed the following overall benefit limitations:

(a) Adult -- forty-five thousand dollars per waiver eligibility span.

(b) Child -- thirty thousand dollars per waiver eligibility span.

(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.

(3) The benefit limitations in appendix B to rule 5123-9-19 of the Administrative Code apply to adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation provided under the self-empowered life funding waiver.

(J) 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 5123:2-1-11 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 if the Ohio department of medicaid determines that such services are medically necessary and the procedures set forth in Chapter 5160-1 of the Administrative Code would not accommodate a request for such medically necessary services.

(K) 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.

(L) 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.

(M) 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.

(N) 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.

(O) 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.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 9/23/2023
Prior Effective Dates: 7/1/2012, 4/1/2017, 9/23/2018
Rule 5123-9-41 | Home and community-based services waivers - clinical/therapeutic intervention under the self-empowered life funding waiver.
 

(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

(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) "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 his or her 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" 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.

(8) "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. 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 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.

(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 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 his or her 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 his or her 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 his or her family member.

(5) Failure to comply with this rule and applicable provisions of rule 5123:2-2-01 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 5123:2-1-11 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.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 9/23/2023
Rule 5123-9-43 | Home and community-based services waivers - functional behavioral assessment under the self-empowered life funding waiver.
 

(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

(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) "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" 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.

(7) "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. 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 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) of this rule to validate payment for medicaid services.

(11) "Usual and customary charge" means the amount charged to other persons for the same service.

(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) 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 his or her family member.

(5) Failure to comply with this rule and applicable provisions of rule 5123:2-2-01 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 5123:2-1-11 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 the self-empowered life funding waiver and the medicaid state plan for the same functional behavioral assessment.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 9/23/2023
Prior Effective Dates: 7/1/2012
Rule 5123-9-45 | Home and community-based services waivers - participant-directed goods and services under the self-empowered life funding waiver.
 

(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

(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 Ohio department of medicaid to perform necessary financial transactions on behalf of individuals enrolled in the self-empowered life funding waiver.

(5) "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.

(6) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual.

(7) "Participant-directed goods and services" means services, equipment, or supplies not otherwise provided through the self-empowered life funding waiver or through the medicaid state plan that address a need identified in the individual service plan and meet all of the following requirements:

(a) The services, equipment, or supplies are required to assist the individual with achieving one of more of the following outcomes:

(i) Decrease the need for other medicaid home and community-based services;

(ii) Promote inclusion in the community;

(iii) Increase the individual's safety in his or her home;

(iv) Increase the individual's independence;

(v) Improve cognitive, social, or behavioral functions; or

(vi) 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 the least costly alternative that reasonably meets the individual's assessed need as evidenced through the county board's established cost comparison process.

(e) The services, equipment, or supplies are for the direct medical or remedial benefit of the 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)(2) of this rule to validate payment for medicaid services.

(10) "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.

(11) "Usual and customary charge" means the amount charged to other persons for the same service.

(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) Rule 5123:2-2-01 of the Administrative Code does 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 an individual service plan that conforms to the requirements of rule 5123:2-1-11 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 final.

(3) Participant-directed goods and services shall not include:

(a) Experimental treatments;

(b) Items used solely for entertainment or recreational purposes;

(c) Tobacco products or alcohol;

(d) Items considered by the federal food and drug administration as experimental or investigational or not approved to treat a specific condition;

(e) 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;

(f) 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;

(g) Home modifications that are of general utility or that add to the total square footage of the home; or

(h) 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)(7) of this rule;

(b) A person-centered assessment of the individual has been conducted and supports the medical necessity of the services, equipment, or supplies; and

(c) Documentation on hand demonstrates that no other source is available to pay for the services, equipment, or supplies.

(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) Appliances;

(b) Fences;

(c) Pools, spas, saunas, trampolines, and play sets;

(d) Home modifications exceeding ten thousand dollars;

(e) Services, equipment, or supplies that may otherwise be available to the individual through the self-empowered life funding 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 his or her 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 (K) 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 code, 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.

View Appendix

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.049, 5166.21
Five Year Review Date: 9/23/2023
Rule 5123-9-46 | Home and community-based services waivers - participant/family stability assistance under the self-empowered life funding waiver.
 

(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 these services.

(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) "Participant/family stability assistance" means training (including education and instruction) and counseling (including consultation) that enhance an individual's ability to direct his or her own services 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 his or her 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 shall be 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 he or she 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 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 (F) of this rule to validate payment for medicaid services.

(11) "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 his or her family member.

(5) Failure to comply with this rule and applicable provisions of rule 5123:2-2-01 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 his or her family member.

(5) Failure to comply with this rule and applicable provisions of rule 5123:2-2-01 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 5123:2-1-11 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.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 9/23/2023
Rule 5123-9-47 | Home and community-based services waivers - support brokerage under the self-empowered life funding waiver.
 

(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.

Supplemental Information

Authorized By: 5123.04, 5123.049
Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Five Year Review Date: 9/23/2023
Rule 5123-9-48 | Home and community-based services waivers - community transition under the under the individual options waiver.
 

(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" means an entity that 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) "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 grocery purchase which may include food, cleaning products, and household supplies.

(b) Community transition does not include:

(i) Ongoing monthly rent or mortgage expenses;

(ii) Ongoing grocery expenses;

(iii) Ongoing utility or service charges;

(iv) Ongoing cable and/or internet expenses;

(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" 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 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 5123:2-1-11 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.

Supplemental Information

Authorized By: 5123.161, 5123.049, 5123.04
Amplifies: 5123.04, 5166.21, 5123.1611, 5123.161, 5123.16, 5123.049, 5123.045
Five Year Review Date: 1/1/2024