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Rule 5123-9-01 | Home and community-based services waivers - enrollment, denial of enrollment, disenrollment, and reenrollment.
Effective:
January 1, 2024
(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, the person's 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" 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. (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 will
submit or assist the individual with submission of Ohio department of medicaid
form 02399, "Request for Medicaid Home and Community-Based Services
Waiver," to the county department of job and family services. The
department will 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 will 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
must: (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 the individual service plan; and (6) Be able to have
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 will
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 will 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 will 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 will 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 will 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 is eligible for home and
community-based services waiver enrollment. (d) The department will 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 will: (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 will
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 will 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 the 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 will 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 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 will 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 health and welfare assured by one or more of the measures set forth in
paragraph (F)(3) of this rule, the department will 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 will: (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 will notify the department. (a) Upon receipt of notification, the department will 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 will, 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 will 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 will 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 will 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 will provide notice of waiver capacity
to county boards. Within ninety calendar days from receipt of such notice from
the department, a county board will 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 will 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 will
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 will
include the date on which waiver services may be initiated. (2) The department will
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 will
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 will receive notice of the individual's right
to a state hearing in accordance with section 5160.31 of the Revised Code and
rules implementing that statute. (a) The department will 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 will 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.
Last updated January 2, 2024 at 9:45 AM
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Rule 5123-9-02 | Home and community-based services waivers - ensuring the suitability of services and service settings.
Effective:
January 26, 2024
(A) Purpose This rule establishes standards to ensure that
individuals receiving services through home and community-based services
waivers administered by the Ohio department of developmental disabilities
receive the services in settings that meet requirements for home and
community-based services established by the centers for medicare and medicaid
services. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (5) "Immediate
family member" means a spouse, parent or stepparent, child or stepchild,
sibling or stepsibling, grandparent, or grandchild. (6) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with section 5126.043 of
the Revised Code or other person authorized to give consent. (8) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (9) "Individual-specific expenses" means standard
monthly costs other than rent (e.g., household goods and supplies, food, minor
equipment, and medical equipment) that are not reimbursable through medicaid,
that are paid by the individual to a residential facility or provider of shared
living, and that have been identified as needed and requested by the individual
to be provided by the residential facility or provider of shared
living. (10) "Intermediate
care facility for individuals with intellectual disabilities" has the same
meaning as in section 5124.01 of the Revised Code. (11) "Landlord"
means the owner, lessor, or agent of the owner contracted by the owner to
manage the premises or to receive rent or room costs in accordance with a lease
or a residency agreement meeting the requirements set forth in paragraph (F) of
this rule. (12) "Lease"
means a written rental agreement meeting the requirements for rental agreements
set forth in Chapter 5321. of the Revised Code. (13) "Natural
supports" means the personal associations and relationships typically
developed in the community that enhance the quality of life for individuals.
Natural supports may include family members, friends, neighbors, and others in
the community or organizations that serve the general public who provide
voluntary support to help an individual achieve agreed upon outcomes through
the individual service plan development process. (14) "Provider-controlled residential setting" means a
residence where the landlord is: (a) An entity that is owned in whole or in part by the
individual's independent provider; (b) An immediate family member of the individual's
independent provider; (c) An immediate family member of an owner or a management
employee of the individual's agency provider; (d) Affiliated with the individual's agency provider,
meaning the landlord: (i) Employs a person who
is also an owner or a management employee of the agency provider;
or (ii) Has, serving as a
member of its board, a person who is also serving as a member of the board of
the agency provider; (e) An entity that is owned in whole or in part by an owner, a
management employee, or an immediate family member of the individual's
agency provider; or (f) An owner or a management employee of the individual's
agency provider. (15) "Provider-owned
residential setting" means a residence where the provider is both the
landlord and the residential home and community-based services provider. There
are only three acceptable types of provider-owned residential settings under
Ohio law: (a) A setting where shared living is provided; (b) A setting owned by an independent provider who is
living in the setting and providing services to an individual who is living in
the setting; or (c) A residential facility licensed pursuant to section
5123.19 of the Revised Code. (16) "Related to" means the
caregiver is the individual's: (a) Parent or stepparent; (b) Sibling or stepsibling; (c) Grandparent; (d) Grandchild; (e) Aunt, uncle, nephew, or niece; (f) Cousin; or (g) Child or stepchild. (17) "Rent" means the standard
charge to the individual to cover the individual's use of the property,
living space, and structure, and where applicable, the appliances, utilities,
and furniture. (18) "Residency agreement" means
a written agreement between an individual and a residential facility or
provider of shared living which establishes or modifies the terms, conditions,
rules, or any other provisions concerning the use and occupancy of a
residence. (19) "Residential facility"
means a residential facility licensed by the department in accordance with
section 5123.19 of the Revised Code other than an intermediate care facility
for individuals with intellectual disabilities. (20) "Roommate" means a person
with whom one shares a bedroom. (21) "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 5123-5-02 of the Administrative Code. (22) "Shared living" has the
same meaning as in rule 5123-9-33 of the Administrative Code. (C) Home and community-based
services (1) An individual's
private residence is presumed to be a suitable setting for home and
community-based services when it meets the requirements set forth in paragraphs
(C)(1)(a) to (C)(1)(e) of this rule. For the purposes of this rule,
provider-controlled residential settings and provider-owned residential
settings are not private residences. (a) The private residence is integrated in and supports the
individual's full access to the greater community. (b) The private residence is selected by the individual
from among setting options. (c) The private residence ensures an individual's
right to privacy, dignity, and respect as well as freedom from coercion and
restraint. (d) The private residence optimizes, but does not regiment,
individual initiative, autonomy, and independence in making life
choices. (e) The private residence facilitates individual choice
regarding services and supports, and who provides them. (2) The purpose of home and
community-based services is to support full community participation and
achievement of individual-specific outcomes. An individual receiving home and
community-based services will have opportunities to access age-appropriate
activities, engage in meaningful employment and non-work activities, and pursue
activities with persons of the individual's choosing and in settings not
created exclusively for individuals with disabilities. (3) An individual's service and
support administrator will provide the individual with a description of all
services and service setting options available through the waiver in which the
individual is enrolled. Each individual will be afforded the opportunity to
choose among services or a combination of services and settings that promote
the individual's autonomy and minimize the individual's dependency on
paid support staff. Services and service setting options (such as
technology-based supports, intermittent or drop-in staffing, shared living, and
integrated employment services) will be considered to enable the individual to
live and work in settings which promote access to and participation in the
broader community. (4) Each individual will receive home and
community-based services that: (a) Are appropriate to meet the individual's assessed needs
and desired outcomes identified in the individual service plan; (b) Supplement and not supplant existing natural
supports; (c) Support the individual in a cost-effective manner and in the
least restrictive manner available; and (d) Are not otherwise available through other resources,
including: (i) Unpaid
supports; (ii) Private
insurance; (iii) Community
resources; (iv) Special education or
related services as defined in section 602 of the Individuals with Disabilities
Education Improvement Act of 2004, 20 U.S.C. 1401, as in effect on the
effective date of this rule; (v) Vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this
rule; (vi) Medicare;
or (vii) The medicaid state
plan. (5) Home and community-based services
funds will not be used to provide modifications to the physical structure of a
residential facility unless the modifications are necessary to meet the needs
of an established resident of the residential facility or the modifications are
portable and clearly identified as the property of the individual. (D) Settings presumed unsuitable for home
and community-based services (1) Home and
community-based services will not be provided in provider-owned residential
settings that do not meet an exception set forth in paragraph (B)(15) of this
rule. (2) Except for the provision of
short-term respite services as approved by the centers for medicare and
medicaid services, home and community-based services will not be provided
in: (a) Hospitals except when: (i) Homemaker/personal
care is provided to an individual in an acute care hospital in accordance with
rule 5123-9-30 of the Administrative Code; (ii) Participant-directed
homemaker/personal care is provided to an individual in an acute care hospital
in accordance with rule 5123-9-32 of the Administrative Code; or (iii) Shared living is
provided to an individual in an acute care hospital in accordance with rule
5123-9-33 of the Administrative Code; (b) Institutions for mental diseases; (c) Intermediate care facilities for individuals with
intellectual disabilities; (d) Nursing facilities; or (e) Other locations that have been determined by the secretary of
the United States department of health and human services or the department as
having the qualities of an institution and the effect of isolating individuals
from the broader community. (3) Absent a determination by the centers
for medicare and medicaid services that the settings are suitable, home and
community-based services will not be provided in: (a) Settings located in a building that is a publicly-operated or
privately-operated facility that also provides inpatient institutional
treatment; or (b) Settings located in a building on the grounds of or
immediately adjacent to a publicly-operated facility that provides inpatient
institutional treatment. (E) Requirements for providers of home and community-based
services A provider of home and community-based services
will: (1) Meet the requirements
set forth in Chapter 5123-9 of the Administrative Code for the services
delivered; and (2) Deliver services in
accordance with each individual's choices, preferences, and needs and in a
manner that supports each individual's full participation in the community
as identified in the individual service plan. (F) Requirements for individuals enrolled in home and
community-based services waivers An individual enrolled in a home and
community-based services waiver will: (1) Communicate, as
applicable, to the independent provider and/or assigned staff of the agency
provider and the agency provider management staff, personal preferences about
the duties, tasks, and procedures to be performed; (2) Communicate to the
service and support administrator any significant change that may affect the
provision of services or result in a need for more or fewer hours of service or
different types of service; (3) Use services in
accordance with the individual service plan; and (4) Cooperate with the
county board in the county board's performance of medicaid local
administrative authority in accordance with section 5126.055 of the Revised
Code. (G) Requirement for a lease or residency agreement
(1) A lease consented to
by both the individual and the landlord is required when an individual lives in
a provider-controlled residential setting. The lease will include: (a) A statement that the residence is a provider-controlled
residential setting and an explanation of the relationship between the landlord
and the provider of home and community-based services. (b) A statement that the individual may choose any provider to
deliver home and community-based services. (2) A residency agreement
consented to by both the individual and the landlord is required when an
individual lives in a residential facility or when an individual lives in a
provider-owned residential setting as described in paragraph (B)(15)(a) or
(B)(15)(b) of this rule and the provider is not related to the individual. The
residency agreement will include: (a) Name and contact information of the landlord. (b) A statement that the residence is, as applicable, a
residential facility or a shared living setting. (c) An explanation of the relationship between the landlord and
the provider of home and community-based services and a statement regarding
whether or not the individual may choose a provider other than the residential
facility or shared living provider to deliver home and community-based
services. (d) A statement that the landlord: (i) Is responsible for
maintaining in good working order all electrical, plumbing, sanitary, heating,
ventilating, and air conditioning systems; (ii) Will ensure
barrier-free ingress and egress to and from the residence by individuals
residing in the residence; (iii) Is responsible for
keeping the residence in a safe condition that meets local health and safety
codes; and (iv) Has a right to
reasonable access to the residence in order to complete the terms of the
residency agreement. (e) Unless otherwise specified in the individual service plan and
implemented in accordance with rule 5123-2-06 of the Administrative Code, a
statement that the individual: (i) Has a right to select
the individual's roommates; (ii) Has a right to
privacy and security including locks and keys to the individual's
bedroom; (iii) Has a right to
decorate the individual's bedroom; (iv) Has a right to have
visitors of the individual's choosing at any time; (v) Has the freedom and
support to control the individual's schedule and activities;
and (vi) Has a right to
access food at any time. (f) A statement that the individual is responsible for timely
monthly payment of the rent or the individual's share of the rent, as
applicable, to the landlord. When determined to be appropriate by the
individual with the support of the team, the residency agreement may designate
a person or responsible party to ensure timely payment to the
landlord. (g) The rent amount which: (i) Will be reasonable
and comparable to community standards; (ii) Will be determined
based upon the accommodations provided and not upon an individual's
assets, resources, or ability to pay; (iii) In a residential
facility, will include the cost of providing furnishings, equipment, and
supplies required by Chapter 5123-3 of the Administrative Code;
and (iv) Will not include
items that are reimbursable under the medicaid program. (h) Individual-specific expenses: (i) Which reflect only
items that are available exclusively from the landlord and determined to be
needed by the individual with the support of the individual's
team; (ii) Which reflect only
items that the individual has been unable to access or utilize through other
available resources; and (iii) The cost of which
may be shared equally when two or more residents agree to share use of the
item. (i) A statement that the individual has a right to terminate the
residency agreement: (i) Without cause upon
thirty-day advance written notice to the landlord unless the individual and the
landlord mutually agree in writing to an alternative plan; or (ii) With cause upon
five-day advance written notice to the landlord if the landlord has breached an
obligation or failed to satisfy required conditions under the residency
agreement. (j) In a provider-owned residential setting as described in
paragraph (B)(15)(a) or (B)(15)(b) of this rule when the provider is not
related to the individual, a statement that the landlord has a right to
terminate the residency agreement: (i) Without cause upon
thirty-day advance written notice to the individual unless the individual and
the landlord mutually agree in writing to an alternative plan; or (ii) With cause upon
five-day advance written notice to the individual if the individual has
breached an obligation or failed to satisfy required conditions under the
residency agreement or chooses to leave or otherwise vacates the residence
(e.g., upon incarceration). (k) In a residential facility, a statement that the residential
facility will terminate services in accordance with rule 5123-3-05 of the
Administrative Code.
Last updated January 26, 2024 at 7:46 AM
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Rule 5123-9-03 | Home and community-based services waivers - overtime and limit on number of hours in a work week an independent provider may provide services.
(A) Purpose This rule sets forth procedures related to overtime worked by independent providers, places a limit on the number of hours in a work week an independent provider may provide services under a home and community-based services medicaid waiver component administered by the Ohio department of developmental disabilities, and establishes a process and the circumstances under which the limit may be exceeded. (B) Definitions For the purposes of this rule, the following definitions apply: (1) "Agency provider" means an entity that directly employs at least one person in addition to the director of operations for the purpose of providing services for which the entity is certified in accordance with rule 5123-2-08 of the Administrative Code. (2) "County board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of developmental disabilities. (4) "Emergency" means an unanticipated and sudden absence of an individual's provider or natural supports due to illness, incapacity, or other cause. (5) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised Code. (6) "Home and community-based services medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code. (7) "Independent provider" means a self-employed person who provides services for which the person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with section 5126.043 of the Revised Code or other person authorized to give consent. (9) "Individual service plan" means the written description of services, supports, and activities to be provided to an individual. (10) "Overtime" means hours worked in excess of forty in a work week. (11) "Provider" means an agency provider or an independent provider. (12) "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 5123-5-02 of the Administrative Code. (13) "Waiver eligibility span" means the twelve-month period beginning with the individual's initial waiver enrollment date or a subsequent eligibility re-determination date. (14) "Work week" means the seven consecutive days beginning on Sunday at twelve a.m. and ending on Saturday at eleven fifty-nine p.m. of each week. (C) Overtime The department, county boards, individuals who receive services, and independent providers will work collaboratively to efficiently use available resources and to the extent possible, reduce the need for overtime. To that end, an independent provider will inform an individual's service and support administrator of the number of persons for whom the independent provider provides any medicaid-funded services as an independent provider anywhere in the state and the number of hours of services the independent provider provides in a work week for each such person: (1) When the independent provider is selected by an individual to provide services; (2) When notifying the service and support administrator in accordance with paragraph (D)(3) of this rule; and (3) At other times upon request of the service and support administrator. (D) Limit on providing services in a work week (1) After an independent provider has worked sixty hours in a work week providing any medicaid-funded services as an independent provider, that independent provider may provide additional units of services under a home and community-based services medicaid waiver component administered by the department as an independent provider in that work week only: (a) When authorized by the service and support administrator for the individual for whom the additional services are provided in accordance with paragraph (D)(2) of this rule; or (b) Due to an emergency. (2) As part of the assessment and person-centered planning process set forth in rule 5123-4-02 of the Administrative Code, an individual and the individual's team will identify known or anticipated events or circumstances that will necessitate an individual's independent provider to exceed the limit established in paragraph (D)(1) of this rule. (a) When known or anticipated events or circumstances will necessitate an individual's independent provider to exceed the limit, the events and circumstances, including authorization for the independent provider to exceed the limit for these specific events and circumstances, will be addressed in the individual service plan. Examples of known or anticipated events or circumstances include but are not limited to: (i) Scheduled travel or surgery of the individual, the individual's family member, or the individual's provider; (ii) Holidays or scheduled breaks from school; (iii) The individual has a compromised immune system and may be put at risk by having additional providers; (iv) The independent provider is the only provider that has been trained by a nurse on delegated tasks or trained by a behavioral specialist to implement unique behavioral support strategies; and (v) A shortage of other available providers. (b) When an individual requests that an independent provider be authorized to routinely exceed the limit due to a shortage of other available providers, the individual and the service and support administrator will work together to identify additional providers. When good faith efforts to identify additional providers have not been effective, the service and support administrator may authorize the independent provider to exceed the limit as specified in the individual service plan, for the duration of the individual's waiver eligibility span. (c) When, pursuant to circumstances described in paragraph (D)(2)(a)(iv) or (D)(2)(a)(v) of this rule, the service and support administrator authorizes an independent provider to exceed the limit, the service and support administrator will work with the individual and the individual's team to develop and implement a plan to eliminate the circumstances that necessitate the independent provider to exceed the limit. (3) When an emergency necessitates an individual's independent provider to exceed the limit established in paragraph (D)(1) of this rule, the independent provider will notify the individual's service and support administrator in accordance with the county board's written procedure described in paragraph (D)(4) of this rule, within seventy-two hours of the events or circumstances creating the emergency and report the hours the independent provider worked that exceeded the limit. (4) A county board will adopt a written procedure for an individual's independent provider to notify the individual's service and support administrator when an emergency requires the independent provider to exceed the limit established in paragraph (D)(1) of this rule. The county board will notify independent providers at least thirty calendar days in advance of revising the written procedure. (E) Violations of this rule (1) 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 will not be interpreted to permit an independent provider to violate this rule. (2) An independent provider who violates the requirements of this rule may be subject to denial, suspension, or revocation of certification pursuant to rule 5123-2-09 of the Administrative Code. (F) Informal complaint process (1) If a county board receives a complaint from an individual regarding implementation of this rule, the county board will 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 will review the complaint and the response and take actions it determines necessary. (2) Initiation of a complaint in accordance with paragraph (F)(1) of this rule will not limit an individual's ability to exercise due process rights in accordance with paragraph (G) of this rule. (G) Due process rights and responsibilities (1) Applicants for and recipients of services under a home and community-based services medicaid waiver component 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, 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 5160.31 of the Revised Code is available only to applicants, recipients, and their lawfully appointed authorized representatives. Providers have no standing in an appeal under that section. (2) Applicants for and recipients of services under a home and community-based services medicaid waiver component administered by the department will 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, level, scope, or duration of services included in or excluded from an individual service plan. A county board's denial of authorization for an independent provider to exceed the limit established in paragraph (D)(1) of this rule does not necessarily result in a change in the level of services received by an individual.
Last updated June 30, 2023 at 1:52 AM
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Rule 5123-9-04 | Home and community-based services waivers - waiting list.
Effective:
November 1, 2024
(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 of developmental disabilities 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 For the purposes of this rule, the following
definitions apply: (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 that are available and
likely to meet an individual's needs in a setting other than a hospital,
an intermediate care facility for individuals with intellectual disabilities,
or a nursing facility. "Community-based alternative services"
includes, but is not limited to, services provided through a community mental
health agency or a public children services agency or services arranged by a
county family and children first council described in section 121.37 of the
Revised Code. (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 the primary caregiver's 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 care, 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 care, 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 5123-3-05 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 5123-14-01 of the Administrative
Code. (d) An adult is losing a 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 individual 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
includes 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 will 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 includes 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 will, 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 will be made available to any interested person upon
request. (D) Administration of the waiting list
assessment tool (1) A county board will
administer the initial waiting list assessment tool to an individual when the
individual, the individual's guardian, or a member of the
individual's family: (a) Requests the county board administer the waiting list
assessment tool; (b) Requests the individual be enrolled in a home and
community-based services waiver or placed on the waiting list for home and
community-based services; or (c) Identifies an unmet need. (2) A county board will
re-administer the waiting list assessment tool to an individual when the
individual, the individual's guardian, or a member of the
individual's family identifies a change in circumstance that may result in
the individual having a current need or an immediate need. (3) When cause for
administering the waiting list assessment tool is identified in accordance with
paragraph (D)(1) or (D)(2) of this rule, a county board will: (a) Explain to the individual, the individual's
guardian (which may include a public children services agency), or the
individual's family member, as applicable, the waiting list assessment
tool process and timeframes set forth in this rule. (b) Identify services available to meet the
individual's needs while the waiting list assessment tool is being
completed. (c) Assess the individual using the waiting list assessment
tool. (i) The waiting list
assessment tool will be initiated by conducting an interview with the
individual and the individual's guardian, as applicable, within fifteen
calendar days of the date that cause for administering the waiting list
assessment tool is identified in accordance with paragraph (D)(1) or (D)(2) of
this rule. The county board will document extenuating circumstances related to
the individual that delay conduct of the interview. (ii) The waiting list
assessment tool will be completed within forty-five calendar days of the date
the interview with the individual and/or the individual's guardian is
conducted in accordance with paragraph (D)(3)(c)(i) of this rule. The county
board will document extenuating circumstances related to the individual that
delay completion of the waiting list assessment tool. (4) A county board will
notify the individual or the individual's guardian, as applicable, of the
outcome of administration of the waiting list assessment tool within ten
calendar days of completion. (a) The notice will include a copy of the individual's
completed waiting list assessment tool and an explanation of the
individual's/guardian's due process rights in accordance with
paragraph (J) of this rule. (b) When the county board determines the individual does
not require waiver enrollment or placement on the waiting list for home and
community-based services because community-based alternative services are
available to meet the individual's assessed needs, the notice will
include: (i) A list of the
individual's assessed needs. (ii) Specific
community-based alternative services that address each assessed
need. (iii) The date by which
the county board will follow-up with the individual/guardian to determine if
the suggested community-based alternative services have been
accessed. (iv) Contact information
for a person at the county board who can assist in identifying and accessing
community-based alternative services. (E) Waiting list for home and community-based
services (1) The county board will 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). (2) The county board will 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 will
take action necessary to ensure the immediate need is met. The county board
will provide the individual or the individual's guardian (which may
include a public children services agency), 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 preferred setting option, the county board will 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. (3) When a county board places an
individual's name on the waiting list for home and community-based
services, the county board will: (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. (4) Annually, a county board
will: (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. (5) 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 will update the individual's
record in the department's web-based waiting list management
system. (F) Order for enrolling individuals in locally-funded home
and community-based services waivers (1) A county board will
select individuals 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 will
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 will 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 will
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 will 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 will 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. (G) Order for enrolling individuals in state-funded home
and community-based services waivers (1) The department will
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. (H) 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 will, 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 will 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 will assist the individual or the individual's guardian, as
applicable, in identifying and accessing those services. (I) Removal from waiting list for home and community-based
services A county board will 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
(E)(1)(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 from the following list to the last known
address of the individual or the individual's guardian, as
applicable: (a) Electronic mail; (b) Traceable delivery service; or (c) Personal service. (7) When the county board
determines the individual does not have a developmental disabilities level of
care in accordance with rule 5123-8-01 of the Administrative Code. (8) When the individual
is no longer a resident of Ohio. (9) Upon the
individual's death. (J) Due process (1) Due process will be
afforded to an individual when a county board takes an action related to
placement on, denial of placement on, or removal from the waiting list for home
and community-based services. (2) The county board will
issue and explain due process to the individual or the individual's
guardian, as applicable, using a form approved by the Ohio department of job
and family services (available at odjfs.state.oh.us/forms/). (3) Due process will 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
Last updated April 14, 2025 at 8:39 AM
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Rule 5123-9-05 | Home and community-based services waivers - retention payments for direct support professionals.
Effective:
March 23, 2023
(A) Purpose This rule establishes requirements and processes
for retention payments to benefit direct support professionals providing
specific home and community-based services to individuals enrolled in home and
community-based services waivers administered by the Ohio department of
developmental disabilities. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (3) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (4) "Department" means the Ohio
department of developmental disabilities. (5) "Direct support
professional" means: (a) An independent provider; (b) A person who is employed by an agency provider or a
residential facility in a "direct services position," as that term is
defined in section 5123.081 of the Revised Code, regardless of the
person's job title, and who is engaged in provision or supervision of
direct support for at least fifty per cent of the hours the person worked for
the employing agency provider or residential facility during the quarter used
by the department for determination of the amount of a retention payment;
or (c) A person who is under contract with an agency provider
to provide shared living. (6) "Good
standing" means a provider is not the subject of an action initiated by
the department to deny, suspend, or revoke the provider's certification or
license. (7) "Group
employment support" has the same meaning as in rule 5123-9-16 of the
Administrative Code. (8) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (9) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative Code and
includes on-site/on-call homemaker/personal care provided in accordance with
that rule. (10) "Homemaker/personal care daily
billing unit" has the same meaning as in rule 5123-9-31 of the
Administrative Code. (11) "Independent provider" has
the same meaning as in rule 5123-2-09 of the Administrative Code. (12) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (13) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (14) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (15) "Participant-directed
homemaker/personal care" has the same meaning as in rule 5123-9-32 of the
Administrative Code. (16) "Provider" means an
independent provider, an agency provider, or a residential facility that
provides one or more of the home and community-based services listed in
paragraphs (B)(19)(a) to (B)(19)(k) of this rule. (17) "Quarter" means one of four
three-month spans of each calendar year, that is: (a) January first through March thirty-first; (b) April first through June thirtieth; (c) July first through September thirtieth; or (d) October first through December
thirty-first. (18) "Residential facility"
means a residential facility licensed by the department pursuant to section
5123.19 of the Revised Code, other than an intermediate care facility for
individuals with intellectual disabilities. (19) "Retention
payment" means a payment intended to directly benefit direct support
professionals which the department may issue on a quarterly basis to an
eligible provider in an amount determined by the department based on a
percentage of the provider's reimbursed claims during the preceding
quarter for provision of: (a) Adult day support; (b) Career planning; (c) Group employment support; (d) Homemaker/personal care; (e) Homemaker/personal care daily billing
unit; (f) Individual employment support; (g) Non-medical transportation; (h) Participant-directed homemaker/personal
care; (i) Shared living; (j) Transportation; and (k) Vocational habilitation. (20) "Shared
living" has the same meaning as in rule 5123-9-33 of the Administrative
Code. (21) "Transportation" has the
same meaning as in rule 5123-9-24 of the Administrative Code. (22) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (C) Eligibility for retention payment -
providers (1) An independent
provider that has been reimbursed for provision of one or more of the home and
community-based services listed in paragraphs (B)(19)(a) to (B)(19)(k) of this
rule during the quarter used by the department for determination of the amount
of the retention payment and that is in good standing at the time the
department issues the retention payment, is eligible and will receive a
retention payment. The independent provider need not take any action to
participate in the retention payment program; the department will issue
retention payments to eligible independent providers in accordance with
paragraph (F)(1) of this rule. (2) An agency provider or
residential facility that has been reimbursed for provision of one or more of
the home and community-based services listed in paragraphs (B)(19)(a) to
(B)(19)(k) of this rule during the quarter used by the department for
determination of the amount of the retention payment and that is in good
standing at the time the department issues the retention payment, is eligible
to receive a retention payment when the agency provider or residential
facility: (a) Opts to participate in the retention payment program by
affirming, via the department's web-based portal for the retention payment
program, on or before the fifteenth day of the first month of the quarter
following the quarter used by the department for determination of the amount of
the retention payment, its intent to participate and assurance that it will
comply with this rule; (b) Disburses to each of its eligible direct support
professionals, the direct support professional's share of the retention
payment issued by the department in accordance with paragraph (F) of this rule;
and (c) Submits, via the department's web-based portal for
the retention payment program, on or before the fifteenth day of the first
month of the quarter following the quarter in which the department issued the
retention payment: (i) Information requested
by the department regarding the retention payment program including, but not
limited to: (a) Disbursement of the retention payment to its direct
support professionals; and (b) Any portion of a retention payment used to cover costs
associated with implementation or administration of the retention payment
program and therefore not disbursed directly to its direct support
professionals. (ii) An attestation that the retention payment was used and
disbursed to direct support professionals in accordance with this
rule. (D) Eligibility for retention payment - direct support
professionals engaged by agency providers and residential
facilities (1) A direct support
professional engaged by an agency provider or a residential facility is
eligible to receive a retention payment when the direct support
professional: (a) Provided or supervised provision of direct support
while employed by the agency provider or residential facility or was under
contract to provide shared living during the quarter used by the department for
determination of the amount of the retention payment; and (b) Is employed by the agency provider or residential
facility or under contract to provide shared living on the day the agency
provider or residential facility disburses the retention payment to its direct
support professionals. (2) Owners and management
staff of agency providers and residential facilities (e.g., directors of
operations, administrators, or operators) are not eligible to receive a
retention payment unless they meet the definition of "direct support
professional" in paragraph (B)(5) of this rule and the criteria set forth
in paragraph (D)(1) of this rule. (3) A direct support
professional who has separated from employment with the agency provider or
residential facility or is no longer under contract to provide shared living is
not eligible to receive a retention payment. (E) Use of retention
payments (1) An agency provider or
residential facility is to disburse a retention payment to its eligible direct
support professionals in accordance with one of the methods described in
paragraph (F)(3) of this rule. At least eighty-two per cent of the retention
payment is to be disbursed to direct support professionals or used to cover the
employer's share of the associated payroll taxes. (2) An agency provider or
residential facility may use up to eighteen per cent of a retention payment for
costs associated with implementation or administration of the retention payment
program, additional employee compensation, or other activities that benefit its
direct support professionals and/or improve service delivery. (3) An agency provider or
residential facility will not use a retention payment to fund a program or
incentive the agency provider or residential facility had in place prior to the
effective date of this rule unless the funding available for the program or
incentive prior to the effective date of this rule ceases to be
available. (4) An agency provider or
residential facility is to maintain records sufficient to demonstrate
compliance with this rule for a period of six years from the date of receipt of
a retention payment or until an initiated audit is resolved, whichever is
longer. (F) Disbursement of retention payments to
direct support professionals (1) The department will
issue retention payments to eligible providers via electronic funds transfer on
or before the fifteenth day of the second month of the quarter following the
quarter used by the department for determination of the amount of the retention
payment. (2) An agency provider or
residential facility will disburse to each eligible direct support
professional, on or before the fifteenth day of the third month of the quarter
following the quarter used by the department for determination of the amount of
the retention payment, the direct support professional's share of the
retention payment. (3) An agency provider or residential
facility is to choose from two methods for determining each direct support
professional's share of the retention payment: (a) Each eligible direct support professional receives the
same percentage adjustment of total wages, including standard pay and overtime
pay, or compensation for the quarter (total amount of retention payment / total
wages or compensation = percentage adjustment disbursed to each eligible direct
support professional); or (b) Each eligible direct support professional receives the
same dollar amount (total amount of retention payment / number of eligible
direct support professionals = amount disbursed to each eligible direct support
professional). (G) Recoupment of a retention payment (1) If the department
determines that a provider received a retention payment for which it was not
eligible or otherwise failed to comply with this rule, the department may
initiate recoupment. When such a determination is made, the department will
notify the provider by certified mail, return receipt requested. The notice
will explain the amount due and the basis for the recoupment and inform the
provider of the provider's right to request a hearing on the proposed
recoupment pursuant to Chapter 119. of the Revised Code. The provider will have
thirty days from the date the notice is mailed to request a hearing which, if
timely requested, will be held in accordance with Chapter 119. of the Revised
Code. (2) When a provider does not request a
hearing in accordance with paragraph (G)(1) of this rule, the amount of the
recoupment is due and payable within thirty days of the provider's receipt
of the notice. (3) At the department's discretion,
a provider may make repayment: (a) In a lump sum payment to the department;
or (b) In a single deduction from the provider's next
scheduled medicaid payment as long as the deduction will equal the total amount
due to the department. (4) The department may
charge interest on the amount of the recoupment beginning on, as
applicable: (a) The date the recoupment is due and payable in
accordance with paragraph (G)(2) of this rule; or (b) The thirtieth day following an adjudication issued by
the director of the department ordering recoupment of the retention
payment. (5) A provider that has
been subject to recoupment may be ineligible to receive future retention
payments. (H) Waiving provisions of this
rule For good cause, the director of the department
may waive a condition or specific requirement of this rule. The director's
decision to waive a condition or specific requirement is not subject to
appeal.
Last updated October 13, 2023 at 10:03 AM
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Rule 5123-9-06 | Home and community-based services waivers - administration of the individual options and level one waivers.
Effective:
January 1, 2024
(A) Purpose This rule establishes standards governing
administration of the individual options and level one waivers, components of
the medicaid home and community-based services program the Ohio department of
developmental disabilities administers pursuant to section 5166.21 of the
Revised Code. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult"
means an individual who is at least twenty-two years old or an individual who
is under twenty-two years old and no longer eligible for educational services
based on graduation, receipt of a diploma or equivalency certificate, or
permanent discontinuation of educational services within parameters established
by the Ohio department of education. (2) "Budget
authority" means an individual has the authority and responsibility to
manage the individual's budget for participant-directed services. This
authority supports the individual in determining the budgeted dollar amount for
each participant-directed waiver service that will be provided to the
individual and making decisions about the acquisition of participant-directed
waiver services that are authorized in the individual service plan (e.g.,
negotiating payment rates to providers within the applicable range as specified
in rules adopted by the department). (3) "Child"
means an individual who is under twenty-two years old and eligible for
educational services. (4) "Cost projection
and payment authorization" means the process followed and the form used by
county boards (including the payment authorization for waiver services) to
communicate the frequency, duration, scope, and amount of payment requested for
each home and community-based service that is identified in the individual
service plan. (5) "Cost projection
tool" means the web-based analytical tool that is a component of the
medicaid services system, developed and administered by the department, used to
project the cost of home and community-based services identified in an
individual service plan. (6) "County
board" means a county board of developmental disabilities. (7) "Department" means the Ohio department of
developmental disabilities. (8) "Employer
authority" means an individual has the authority to recruit, hire,
supervise, and direct the staff who furnish supports. The individual functions
as the common law employer or the co-employer of these staff. (9) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day will be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (10) "Financial
management services entity" means a governmental entity and/or another
third-party entity designated by the department to perform necessary financial
transactions on behalf of individuals who receive participant-directed
services. (11) "Funding
range" means one of the dollar ranges contained in appendix A to this rule
to which individuals enrolled in the individual options waiver have been
assigned for the purpose of funding services other than adult day support,
career planning, group employment support, individual employment support,
non-medical transportation, vocational habilitation, waiver nursing delegation,
and waiver nursing services. The funding range applicable to an individual is
determined by the score derived from the Ohio developmental disabilities
profile that has been completed by a county board employee qualified to
administer the tool. (12) "Guardian"
means a guardian appointed by the probate court under Chapter 2111. of the
Revised Code. If the individual is a minor, "guardian" means the
individual's parents. If no guardian has been appointed for a minor under
Chapter 2111. of the Revised Code and the minor is in the legal or permanent
custody of a government agency or person other than the minor's natural or
adoptive parents, "guardian" means that government agency or person.
"Guardian" includes an agency under contract with the department for
the provision of protective service in accordance with sections 5123.55 to
5123.59 of the Revised Code. (13) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (14) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (15) "Individual
funding level," as established for each individual enrolled in the
individual options waiver, means the total funds, calculated on a twelve-month
basis, that result from applying the payment rates in service-specific rules in
Chapter 5123-9 of the Administrative Code to the units of all waiver services
other than adult day support, career planning, group employment support,
individual employment support, non-medical transportation, vocational
habilitation, waiver nursing delegation, and waiver nursing services
established by the individual service plan development process to be sufficient
in frequency, duration, and scope to meet the individual's health and
welfare needs. Unless prior authorization has been obtained in accordance with
rule 5123-9-07 of the Administrative Code, the individual funding level for
services paid in accordance with this rule will be within or below the funding
range assigned to the individual as the result of administration of the Ohio
developmental disabilities profile. (16) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual developed in accordance with rule
5123-4-02 of the Administrative Code. (17) "Natural
supports" means the personal associations and relationships typically
developed in the community that enhance the quality of life for individuals.
Natural supports may include family members, friends, neighbors, and others in
the community or organizations that serve the general public who provide
voluntary support to help an individual achieve agreed upon outcomes through
the individual service plan development process. (18) "Ohio
developmental disabilities profile" means the standardized instrument used
by the department to assess the relative needs and circumstances of an
individual compared to others. The individual's responses are scored and
the individual is linked to a funding range, which enables similarly situated
individuals to access comparable waiver services paid in accordance with rules
adopted by the department. (19) "Participant
direction" means an individual has authority to make decisions about the
individual's waiver services and accepts responsibility for taking a
direct role in managing the services. Participant direction includes the
exercise of budget authority and/or employer authority as set forth in
paragraph (E) of this rule. (20) "Prior
authorization" means the process to be followed in accordance with rule
5123-9-07 of the Administrative Code to authorize an individual funding level
for an individual enrolled in the individual options waiver that exceeds the
maximum value of the funding range. (21) "Provider"
means a person or entity certified or licensed by the department that has met
the provider qualification requirements to provide specific home and
community-based services and holds a valid medicaid provider agreement with the
Ohio department of medicaid or a person or entity that has been determined by
the financial management services entity to be qualified to provide
participant-directed goods and services or self-directed
transportation. (22) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123-5-02 of the Administrative Code. (23) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in service-specific rules
in Chapter 5123-9 of the Administrative Code to validate payment for medicaid
services. (24) "Team"
means the group of persons chosen by an individual with the core responsibility
to support the individual in directing development of the individual service
plan. The team includes the individual's guardian or adult whom the
individual has identified, as applicable, the service and support
administrator, direct support professionals, providers, licensed or certified
professionals, and any other persons chosen by the individual to help the
individual consider possibilities and make decisions. (25) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
re-determination date. (C) Funding ranges and individual funding
levels for individuals enrolled in the individual options waiver (1) Individuals enrolled
in the individual options waiver will 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
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 will ensure that an Ohio developmental disabilities
profile is completed with input from the individual and the team. The service
and support administrator will 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 will 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 will be reviewed, revised, or developed
with the individual. The service and support administrator will 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 will 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 will
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 will
determine whether the individual funding level is within, exceeds, or is below
the assigned funding range for the individual. The service and support
administrator will 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 will 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 will
complete the cost projection and payment authorization and the service and
support administrator will 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
will 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 will 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 will 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
will 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 will
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
will 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 will
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 will
periodically re-examine the scoring of the Ohio developmental disabilities
profile and the linkage of the scores to the funding ranges. (D) Changes to individual funding levels
and funding ranges (1) The individual
funding level may increase or decrease based on the outcome of the individual
service plan development process. In no instance will 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 will 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 will recommend a change in individual funding
level within the funding range or assign a new funding range after notification
that the individual has requested a hearing pursuant to section 5160.31 of the
Revised Code concerning the approval, denial, reduction, or termination of
services. (E) Participant direction (1) The individual
options and level one waivers support individuals who want to direct some of
their services through participant direction. The individual or the
individual's guardian or the individual's designee must be willing
and able to perform the duties associated with participant
direction. (2) An individual
enrolled in the individual options waiver may exercise: (a) Budget authority for: (i) Participant-directed
homemaker/personal care; and (ii) Self-directed
transportation. (b) Employer authority for: (i) Participant-directed
homemaker/personal care; and (ii) Self-directed
transportation. (3) An individual
enrolled in the level one waiver may exercise: (a) Budget authority for: (i) )
Clinical/therapeutic intervention; (ii) Participant-directed
goods and services; (iii) Participant-directed homemaker/personal care;
and (iv) Self-directed
transportation. (b) Employer authority for: (i) Participant-directed
homemaker/personal care; and (ii) Self-directed
transportation. (F) Level one waiver benefit
limitations The cost of services available under the level
one waiver will not exceed: (1) Sixty-two thousand
one hundred thirty-six dollars per waiver eligibility span for an adult;
or (2) Forty-one thousand
four hundred twenty-four dollars per waiver eligibility span for a
child. (G) Staffing ratios (1) In situations where
more than one staff member serves more than one individual simultaneously, the
individuals' needs and circumstances will 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 will, as authorized in the individual service
plan, use the applicable service codes and payment rates established in
service-specific rules in Chapter 5123-9 of the Administrative Code to indicate
both staff size and group size. (2) Staffing ratios do
not change at times when one or more individuals, for whom the staff is
responsible, are not physically present, but are within verbal, visual, or
technological supervision of the staff providing the service. Technological
supervision includes staff contact with individuals through telecommunication
and/or electronic signaling devices. (H) Projection of the cost of an
individual's services (1) Prior to the
beginning of an individual's waiver eligibility span, the
individual's service and support administrator or other county board
designee will 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
will be based on staffing ratios and the total estimated number of service
units the individual is expected to receive in accordance with the individual
service plan during the waiver eligibility span. Staffing ratios contained in
the cost projection tool will be considered a part of the individual service
plan. (3) The total number of
service units will be determined with input from the individual and the
individual's team as part of the individual service plan development
process. (4) The cost projection
tool will project the cost of services based on the payment rates established
in service-specific rules in Chapter 5123-9 of the Administrative
Code. (5) Rule 5123-9-31 of the
Administrative Code will govern the circumstances when an individual receives
the homemaker/personal care daily billing unit. (6) The cost projection
tool will 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 will 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 will 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
will enter changes to the cost projection tool within ten calendar days of a
recommendation from the team to change the service authorization. These changes
will 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) A county board will
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 is the only
authorized cost projection instrument. (I) Service documentation (1) Providers will
maintain service documentation in accordance with this rule and
service-specific rules in Chapter 5123-9 of the Administrative
Code. (2) Claims for payment a
provider submits to the department for services delivered will not be
considered service documentation. Any information contained in the submitted
claim for payment may not and will 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 will
maintain all service documentation in an accessible location. The service
documentation will 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 will, within seven calendar days, notify
the county boards for the counties in which individuals for whom the provider
has provided services reside, of the location where the service documentation
will be stored, and provide the county board with the name and telephone number
of the person responsible for maintaining the service
documentation. (J) Payment for waiver
services (1) Providers will be
paid the lesser of their usual and customary rate or the payment rate for each
waiver service that is delivered. The department will maintain a mechanism
through which providers will 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 will 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 will provide notice
to the appropriate county board. (2) The billing units,
service codes, and payment rates for waiver services are contained in
service-specific rules in Chapter 5123-9 of the Administrative Code including,
but not limited to: (a) 5123-9-12 (assistive technology under the individual
options and level one waivers); (b) 5123-9-13 (career planning under the individual options
and level one waivers); (c) 5123-9-14 (vocational habilitation under the individual
options and level one waivers); (d) 5123-9-15 (individual employment support under the
individual options and level one waivers); (e) 5123-9-16 (group employment support under the
individual options and level one waivers); (f) 5123-9-17 (adult day support under the individual
options and level one waivers); (g) 5123-9-18 (non-medical transportation under the
individual options and level one waivers); (h) 5123-9-20 (money management under the individual
options and level one waivers); (i) 5123-9-21 (informal respite under the level one
waiver); (j) 5123-9-22 (community respite under the individual
options and level one waivers); (k) 5123-9-23 (environmental accessibility adaptations
under the individual options and level one waivers); (l) 5123-9-24 (transportation under the individual options
and level one waivers); (m) 5123-9-25 (specialized medical equipment and supplies
under the individual options and level one waivers); (n) 5123-9-26 (self-directed transportation under the
individual options and level one waivers); (o) 5123-9-28 (nutrition services under the individual
options waiver); (p) 5123-9-29 (home-delivered meals under the individual
options and level one waivers); (q) 5123-9-30 (homemaker/personal care under the individual
options and level one waivers); (r) 5123-9-31 (homemaker/personal care daily billing unit
under the individual options waiver); (s) 5123-9-32 (participant-directed homemaker/personal care
under the individual options and level one waivers); (t) 5123-9-33 (shared living under the individual options
waiver); (u) 5123-9-34 (residential respite under the individual
options and level one waivers); (v) 5123-9-35 (remote support under the individual options
and level one waivers); (w) 5123-9-36 (interpreter services under the individual
options waiver); (x) 5123-9-37 (waiver nursing delegation under the
individual options and level one waivers); (y) 5123-9-38 (social work under the individual options
waiver); (z) 5123-9-39 (waiver nursing services under the individual
options waiver); (aa) 5123-9-41
(clinical/therapeutic intervention under the level one waiver); (bb) 5123-9-43
(functional behavioral assessment under the level one waiver); (cc) 5123-9-45
(participant-directed goods and services under the level one
waiver); (dd) 5123-9-46
(participant/family stability assistance under the level one waiver);
and (ee) 5123-9-48 (community
transition under the individual options waiver). (3) The department will
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 will 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 will 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 will not exceed amounts authorized through the cost projection and
payment authorization for the individual's corresponding waiver
eligibility span. (K) Claims for payment for home and
community-based services (1) When home and
community-based services are also available on the medicaid state plan, state
plan services will be billed first. Only home and community-based services in
excess of those covered under the medicaid state plan will be
authorized. (2) Claims for payment
for home and community-based services will be submitted to the department in
the format prescribed by the department. The department will 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 will be submitted within three hundred
fifty calendar days after the home and community-based services are provided.
Payment will be made in accordance with the requirements of rule 5160-1-19 of
the Administrative Code. Claims for payment will include the number of units of
service. (4) All providers of home
and community-based services will 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 will be accomplished as follows: (a) The department will 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 will assign the home and
community-based services to which each individual's patient liability will
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 will notify each individual and provider, in writing, of this
assignment. (c) Upon submission of a claim for payment, the designated
provider will report the home and community-based services to which the patient
liability was assigned and the applicable patient liability amount on the claim
for payment using the format prescribed by the department. (6) The department, the
Ohio department of medicaid, the centers for medicare and medicaid services,
and/or the auditor of state may audit any funds a provider of home and
community-based services receives pursuant to this rule, including any source
documentation supporting the claiming and/or receipt of such
funds. (7) Overpayments,
duplicate payments, payments for services not rendered, payments for which
there is no documentation of services delivered or for which the documentation
does not include all of the items required in service-specific rules in Chapter
5123-9 of the Administrative Code, or payments for services not in accordance
with an approved individual service plan are recoverable by the department, the
Ohio department of medicaid, the auditor of state, or the office of the
attorney general. All recoverable amounts are subject to the application of
interest in accordance with rule 5160-1-25 of the Administrative
Code. (8) Providers of home and
community-based services will 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 will 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 are subject to denial, suspension, or revocation of certification
and/or loss of their medicaid provider agreement. (L) Due process rights and
responsibilities (1) Applicants for and
recipients of waiver services administered by the department may use the
process set forth in section 5160.31 of the Revised Code and rules implementing
that statute for any purpose authorized by that statute. The process set forth
in section 5160.31 of the Revised Code is available only to applicants,
recipients, and their lawfully appointed authorized representatives. Providers
have no standing in an appeal under that section. (2) Applicants for and
recipients of waiver services administered by the department will use the
process set forth in section 5160.31 of the Revised Code and rules implementing
that statute for any challenge related to the administration and/or scoring of
the Ohio developmental disabilities profile or to the type, amount, level,
scope, or duration of services included in or excluded from an individual
service plan. A change in staff to waiver recipient service ratios does not
necessarily result in a change in the level of services received by an
individual. (M) Ohio department of medicaid
authority The Ohio department of medicaid retains final
authority to establish funding ranges for home and community-based services; to
establish payment rates for home and community-based services; to review and
approve each service identified in an individual service plan that is funded
through a home and community-based services waiver; and to authorize the
provision of and payment for home and community-based services through the cost
projection and payment authorization.
View AppendixView Appendix
Last updated January 2, 2024 at 9:45 AM
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Rule 5123-9-07 | Home and community-based services waivers - request for prior authorization for individuals enrolled in the individual options waiver.
Effective:
January 1, 2024
(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 For the purposes of this rule, the following
definitions apply: (1) "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. (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, the person's 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 Chapter 5123-9 of the
Administrative Code to the units of all waiver services other than adult day
support, career planning, group employment support, individual employment
support, non-medical transportation, vocational habilitation, waiver nursing
delegation, and waiver nursing services established by the individual service
plan development process to be sufficient in frequency, duration, and scope to
meet the 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 5123-5-02 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 will 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 will 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 will
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 will 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 will
initiate the prior authorization process by submitting a signed and dated
request to the county board. A county board will assist in the preparation of
the request when the individual requests assistance. (3) The county board will 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 will 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 will 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 will notify the county board if additional
information is needed to make a determination. The county board will submit the
additional information to the department within five business days of receiving
notification from the department. (6) The department will
review the request and make a determination within ten business days of
receiving all necessary information. (7) When reviewing a
request, the department will determine whether the waiver services for which
prior authorization is requested meet the waiver service definition and are
medically necessary. The department will 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 will: (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
will: (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 will meet to revise the individual service plan. (12) If the individual requests a hearing
in accordance with paragraph (D)(10)(a) of this rule, the county board will
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. (13) Failure by a county board or the
department to comply with the timelines established in this rule will not
constitute approval of a request for prior authorization. (14) 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.
Last updated January 2, 2024 at 9:45 AM
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Rule 5123-9-11 | Home and community-based services waivers - free choice of providers.
Effective:
January 1, 2024
(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 directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (3) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (4) "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 5123-9-16 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 the person is
certified in accordance with rule 5123-2-09 of the Administrative Code and 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, the person's 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 5123-9-15 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 5123-5-02 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 will
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 will 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 will 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 includes 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 will 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 will
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 will
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 will 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 will 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 will
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
will: (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 will report progress on achieving benchmarks to the department
in accordance with the schedule and format established by the
department. (c) 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 November 19,
2020. (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 must cease providing home and community-based services on or before
February 28, 2024. (E) Commencement of services The county board will 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 will 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 will
periodically provide training and assistance to familiarize county boards and
individuals with the rights and responsibilities set forth in this
rule. (2) The department will investigate or
cause an investigation when an individual alleges that the individual is being
denied free choice of providers for home and community-based
services. (3) The department will 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 may not
utilize or attempt to utilize the process set forth in section 5101.35 of the
Revised Code or 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 will
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 will
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.
Last updated January 2, 2024 at 9:46 AM
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Rule 5123-9-12 | Home and community-based services waivers - assistive technology under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2025
(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 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 will
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 a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (5) "Assistive technology"
means an interactive electronic item, device, product system, or engineered
solution 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 the individual service plan. (b) "Assistive technology - equipment" means the cost
of equipment comprising the assistive technology and may include engineering,
designing, fitting, customizing, or otherwise adapting the equipment to meet an
individual's specific needs. Assistive technology - equipment may include
equipment used for remote support such as motion sensing system, radio
frequency identification, live video feed, live audio feed, web-based
monitoring, or other device that meets the requirements set forth in this rule
and rule 5123-9-35 of the Administrative Code. Assistive technology - equipment
does not include non-technical, non-electronic equipment (e.g., grab bars or
wheelchair ramps) or items otherwise available as environmental accessibility
adaptations or specialized medical equipment and supplies. (c) "Assistive technology - support" means education
and training that aids an individual in the use of assistive technology -
equipment as well as training for the individual's family members,
guardian, staff, or other persons who provide natural supports or paid
services, employ the individual, or who are otherwise substantially involved in
activities being supported by the assistive technology - equipment. Assistive
technology - support may include, when necessary, coordination with
complementary therapies or interventions and adjustments to existing assistive
technology - equipment 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 will 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) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (12) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (13) "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. (14) "Participant-directed homemaker/personal
care" has the same meaning as in rule 5123-9-32 of the Administrative
Code. (15) "Remote support" has the
same meaning as in rule 5123-9-35 of the Administrative Code. (16) "Remote support vendor" has
the same meaning as in rule 5123-9-35 of the Administrative Code. (17) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (19) "Specialized medical equipment
and supplies" has the same meaning as in rule 5123-9-25 of the
Administrative Code. (20) "Team" has the same meaning
as in rule 5123-4-02 of the Administrative Code. (21) "Useful life" means two
years. (22) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Assistive technology
will be provided only 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 approval to
provide assistive technology will complete and submit an application and adhere
to the requirements of rule 5123-2-08 of the Administrative Code. (3) An applicant seeking approval to
provide assistive technology - consultation will 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. (4) An applicant seeking approval to
provide assistive technology - equipment will 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. (5) An applicant seeking approval to
provide assistive technology - support will either: (a) Meet the requirements set forth in paragraph (C)(3) of this
rule; or (b) Meet the requirements set forth in paragraph (C)(4) of this
rule. (6) Failure to comply with this rule and
rule 5123-2-08 of the Administrative Code may result in denial, suspension, or
revocation of the provider's certification. (D) Requirements for service
delivery (1) Assistive technology
is intended to address an individual's assessed needs in a manner that
promotes autonomy and minimizes dependence on paid support staff and should be
explored prior to authorizing services that may be more intrusive, including
homemaker/personal care and participant-directed homemaker/personal
care. (2) Assistive technology
will be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (3) Prior to selecting
assistive technology - equipment, the team may access assistive technology -
consultation by a qualified provider to assess the fit between an individual
and a device or system being considered for purchase or lease. (4) In accordance with
rule 5123-9-02 of the Administrative Code, waiver funds may be used for
assistive technology only when no other funds or resources are
available. (5) Purchase or lease of
assistive technology - equipment must be the least costly alternative that
reasonably meets an individual's assessed needs. (6) Assistive technology
- equipment does not include: (a) Internet service; (b) Items or equipment that are illegal or otherwise prohibited
by federal or state statutes or regulations; (c) Items or equipment used solely for entertainment or
recreational purposes; (d) Items or equipment used solely for the purpose of general
utility; (e) New equipment or repair of previously approved equipment that
has been damaged as a result of confirmed misuse, abuse, or negligence;
or (f) Purchase or lease of a personal computing device such as a
desktop, laptop, or tablet that duplicates any similar equipment in the
possession of, or service currently used by, the individual. (7) A provider of
assistive technology - equipment is responsible for: (a) Delivery of the assistive technology - equipment to the
individual; (b) Assembly and set-up of the assistive technology - equipment,
if required; (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 will be designed so that it may be
turned off by the remote support vendor when requested by a person designated
in the individual service plan. (9) Assistive technology - support will
not exceed forty hours per waiver eligibility span. (10) A provider of assistive technology -
support will 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 will include each of the following to validate payment
for medicaid services. (a) Type of service (i.e., assistive technology - consultation,
assistive technology - equipment, or assistive technology -
support). (b) Name of individual receiving service. (c) Medicaid identification number of individual receiving
service. (d) Name of provider. (e) Provider identifier/contract number. (2) In addition to the
requirements set forth in paragraph (E)(1) of this rule, service documentation
for assistive technology - consultation will 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 will include: (a) The address where assistive technology - equipment is
installed. (b) A list of installed assistive technology - equipment
including the date each item of assistive technology - equipment is installed,
modified, repaired, or removed and the reasons therefore, and associated
adjustments in cost. (4) In addition to the
requirements set forth in paragraph (E)(1) of this rule, service documentation
for assistive technology - support will 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 will
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 will not exceed five thousand
dollars per waiver eligibility span. (4) Purchase or lease of assistive
technology - equipment will include, as appropriate, monthly fees and the
manufacturer's and seller's warranties. (5) When a provider of assistive
technology - equipment leases or manufactures assistive technology - equipment,
the cost billed to the department will be the lesser of the provider's
usual and customary charge or the manufacturer's suggested retail price
(which will be prorated over the useful life of the assistive technology -
equipment) plus a reasonable percentage adequate to cover the cost of the
provider's responsibilities as set forth in paragraph (D)(7) of this
rule. (6) When a provider of assistive
technology - equipment purchases assistive technology - equipment, the cost
billed to the department will be the lesser of the provider's usual and
customary charge or the actual price plus acquisition costs of the item plus a
reasonable percentage adequate to cover the cost of the provider's
responsibilities as set forth in paragraph (D)(7) of this rule. (7) Claims for payment for assistive
technology will be submitted to the department upon the provider's receipt
of verification from the county board that the delivered services meet the
requirements specified in the individual service plan. (8) When two or more individuals share
assistive technology - equipment, the payment rate will be divided equally
among those individuals, without regard to funding source for the
service.
View Appendix
Last updated May 19, 2025 at 2:39 PM
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Rule 5123-9-13 | Home and community-based services waivers - career planning under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines career planning and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. The expected outcome of career
planning is the individual's achievement of competitive integrated
employment and/or career advancement in competitive integrated
employment. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Acuity
assessment group" means one of four groups (i.e., group A-1, group A,
group B, or group C) to which an individual is assigned based on the
individual's score resulting from administration of the acuity assessment
instrument in accordance with rule 5123-9-19 of the Administrative
Code. (2) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code. (3) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 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 to 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 will 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 will 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 will not be provided to an individual on place
four of the path to competitive integrated employment as described in paragraph
(D)(2)(d) of rule 5123-2-05 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 will not be provided to an
individual on place four of the path to competitive integrated employment as
described in paragraph (D)(2)(d) of rule 5123-2-05 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 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 is 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 will be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (10) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (11) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (14) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (15) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of career planning. (16) "Pay stub"
means a document issued by an employer that shows, for a specified period of
time, an employee's gross earnings, deductions from those earnings, and
net pay. (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 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (19) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (20) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Career planning will
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 will complete and submit an application and
adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (3) An applicant seeking
independent provider certification to provide career planning will
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 will meet additional requirements: (a) An independent provider of the benefits education and
analysis component of career planning will have successfully completed
nationally approved or accredited training in benefits education and
analysis. (b) An independent provider of the worksite accessibility
component of career planning will 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. (5) An agency provider
will ensure that direct support professionals who provide career planning
successfully complete, no later than thirty calendar days after hire, training
in: (a) Services that comprise career planning including the
expectation that career planning will eventually lead to competitive integrated
employment; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Building/site-specific emergency response plans;
and (d) Program-specific transportation safely. (6) An agency provider will ensure
that: (a) Direct support professionals who perform the benefits
education and analysis component of career planning have successfully completed
nationally approved or accredited training in benefits education and
analysis. (b) Direct support professionals who perform the worksite
accessibility component of career planning hold an appropriate license (e.g.,
occupational therapist) or certification (e.g., certified professional
ergonomist issued by the "Board of Certification in Professional
Ergonomics"), or have successfully completed appropriate training by an
accredited college or university. (7) An agency provider will ensure that
direct support professionals who provide career planning (other than those who
have at least one year of experience providing career planning at the point of
hire), during the first year after hire, are assigned and have access to a
mentor. (8) An agency provider will ensure that
direct support professionals who provide career planning (other than those who
have at least one year of experience providing career planning at the point of
hire), no later than one year after hire, successfully complete at least eight
hours of training specific to the provision of career planning that includes,
but is not limited to: (a) Skill building in advancement of individuals on the path to
competitive integrated employment as described in rule 5123-2-05 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 civil rights, to exercise control and
responsibility over the services received, and to acquire skills that enable
becoming more independent, productive, and integrated within the
community. (9) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) The expected outcome
of career planning is the individual's achievement of competitive
integrated employment and/or career advancement in competitive integrated
employment. (2) The service and
support administrator will 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 will be provided
pursuant to a person-centered individual service plan that conforms to the
requirements of rules 5123-4-02 and 5123-2-05 of the Administrative Code and be
coordinated with other services and supports set forth in the individual
service plan. An individual will be made aware of the potential impact of
outcome-based payments described in paragraph (F)(6) of this rule before the
job development component of career planning is authorized in the individual
service plan. (4) Career planning may be provided in a
variety of settings but will 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 will be provided at a
ratio of one direct support professional to one individual. (6) Career planning services may extend
to those times when the individual is not physically present while the provider
is performing career planning activities on behalf of the
individual. (7) A provider of career planning will
complete reports and collect and submit data via the department's outcome
tracking system in accordance with rule 5123-2-05 of the Administrative
Code. (8) A provider of career planning will
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 will 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 will 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 will 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, will not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (3) The county board will
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 will 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 will 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 is
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 will 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 will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy and/or jejunostomy tube; and/or requires the administration
of insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such procedure or nursing task is
not the administration of oral prescribed medication, topical prescribed
medication, oxygen, or metered dose inhaled medication, or a health-related
activity as defined in rule 5123-6-01 of the Administrative Code. (b) The duration of the medical assistance rate modification is
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) A provider of the job
development component of career planning may be eligible for an outcome-based
payment following an individual's achievement of competitive integrated
employment. (a) A provider may obtain either or both of two possible
outcome-based payments for each individual served: (i) One payment when the
individual achieves competitive integrated employment. (ii) One payment when the
individual achieves competitive integrated employment that: (a) Pays at least twelve
dollars per hour; and/or (b) Employs the
individual for an average of at least thirty hours per week as determined over
the course of at least four weeks. (b) To obtain an outcome-based payment, a provider will
secure one or more pay stubs from the individual served sufficient to document
the competitive integrated employment and/or hourly wage or average hours
worked following provision of the job development component of career planning.
The provider will submit the pay stub or pay stubs to the individual's
service and support administrator, who will authorize the outcome-based payment
in the individual service plan. When pay stubs cannot be secured, the provider
will instead submit an attestation in the format prescribed by the department
that the outcome has been achieved. (c) The amount of the outcome-based payment is determined
by the nature of the competitive integrated employment and the acuity
assessment group assignment of the individual at the time the individual
achieves competitive integrated employment. (d) No more than two outcome-based payments will be made
during an individual's waiver eligibility span. (e) The service codes and payment rates for outcome-based
payments are contained in the appendix to this rule.
View Appendix
Last updated July 1, 2024 at 4:34 PM
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Rule 5123-9-14 | Home and community-based services waivers - vocational habilitation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(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 competitive integrated employment in accordance with rule
5123-2-05 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 a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (3) "Career planning" has the
same meaning as in rule 5123-9-13 of the Administrative Code. (4) "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. (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 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. (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. Minutes of service delivery time
accrued throughout a day will be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (9) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (10) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (12) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (13) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (14) "Integrated community
setting" means a setting that is integrated in and supports full access of
individuals to the greater community to the same degree of access as persons
not receiving home and community-based services. (15) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of 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 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (19) "Virtual support" means the
provision of services by direct support professionals at a distant site who
engage with an individual using interactive technology that has the capability
for two-way, real time audio and video communication. (20) "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
individual's team. Activities that constitute vocational habilitation
include, but are not limited to: (a) Ongoing support, that may be provided in-person or through
virtual support, which includes direct supervision, monitoring and/or
counseling, and the provision of some or all of the following supports to
promote the development of general work skills: (i) Developing a
systematic plan of instruction and support, including task analyses to prepare
the individual for competitive integrated employment; (ii) Assisting the
individual to perform activities that result in increasing 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 the vocational
habilitation setting to competitive integrated employment emphasizing the use
of natural supports; and (viii) Providing information about or referral to career planning
services, disability benefits services, or other appropriate consultative
services. (b) Ongoing support, that may only be provided in-person,
assisting the individual with self-medication or health-related activities or
performing medication administration or health-related activities in accordance
with Chapter 5123-6 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) Vocational
habilitation will 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 will not be provided by an independent provider. (3) An applicant seeking
approval to provide vocational habilitation will complete and submit an
application and adhere to the requirements of rule 5123-2-08 of the
Administrative Code. (4) An agency provider
will ensure that direct support professionals who provide vocational
habilitation successfully complete, no later than thirty calendar days after
hire, training in: (a) Services that comprise vocational habilitation including the
expectation that vocational habilitation will eventually lead to competitive
integrated employment; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Site-specific emergency response plans; and (d) Program-specific transportation safety. (5) An agency provider
will ensure that direct support professionals who provide vocational
habilitation (other than those who have at least one year of experience
providing vocational habilitation at the point of hire), during the first year
after hire, are assigned and have access to a mentor. (6) An agency provider
will ensure that direct support professionals who provide vocational
habilitation (other than those who have at least one year of experience
providing vocational habilitation at the point of hire), no later than one year
after hire, successfully complete at least eight hours of training specific to
the provision of vocational habilitation that includes, but is not limited
to: (a) Skill building in advancement of individuals on the path to
competitive integrated employment as described in rule 5123-2-05 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 civil rights, to exercise control and
responsibility over the services received, and to acquire skills that enable
becoming more independent, productive, and integrated within the
community. (7) Failure to comply with this rule and
rule 5123-2-08 of the Administrative Code may result in denial, suspension, or
revocation of the agency provider's certification. (D) Requirements for service
delivery (1) The expected outcome
of vocational habilitation is the advancement of an individual on the path to
competitive integrated employment in accordance with rule 5123-2-05 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 will 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 will be
provided pursuant to a person-centered individual service plan that conforms to
the requirements of rules 5123-4-02 and 5123-2-05 of the Administrative Code
and coordinated with other services and supports set forth in the individual
service plan. An individual receiving vocational habilitation will have
competitive integrated employment outcomes in the individual service plan;
vocational habilitation activities will be designed to support the
individual's competitive integrated employment outcomes. (5) Vocational habilitation provided
in-person will take place in a non-residential setting separate from any
individual's home. An individual participating in vocational habilitation
provided through virtual support may do so from the individual's
home. (6) Vocational habilitation may be
provided through virtual support under the following conditions: (a) Virtual support does not have the effect of isolating an
individual from the individual's community or preventing the individual
from interacting with people with or without disabilities. (b) The use of virtual support has been agreed to by an
individual and the individual's team and is specified in the individual
service plan. (c) The use of virtual support complies with applicable laws
governing an individual's right to privacy and the individual's
protected health information. (d) Provision of vocational habilitation through virtual support
does not include assisting an individual with self-medication or health-related
activities or performing medication administration or health-related activities
in accordance with Chapter 5123-6 of the Administrative Code. (7) A provider of vocational habilitation
will notify the department within fourteen calendar days when there is a change
in the physical address (i.e., adding a new location or closing an existing
location) of any facility where vocational habilitation takes
place. (8) A provider of vocational habilitation
will complete reports and collect and submit data via the department's
outcome tracking system in accordance with rule 5123-2-05 of the Administrative
Code. (9) Individuals receiving vocational
habilitation will 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, will be based on documented evaluations and
assessments. (10) A provider of vocational habilitation
will ensure that appropriate staff are knowledgeable about the Workforce
Innovation and Opportunity Act as in effect on the effective date of this rule,
wage and hour laws, benefits, work incentives, and employer tax credits for
individuals with developmental disabilities and ensure that individuals served
receive this information. (11) A provider of vocational habilitation
will 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 will be informed of and comply with standards applicable to the
service setting. (12) A provider of vocational habilitation
will 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
will 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 provided January
1, 2024 through June 30, 2024 are contained in appendix A to this rule. The
billing units, service codes, and payment rates for vocational habilitation
provided on or after July 1, 2024 are contained in appendix B to this rule.
Payment rates, except payment rates for vocational habilitation provided
in-person in an integrated community setting for a group of four or fewer
individuals, are based on individuals' group assignments determined in
accordance with rule 5123-9-19 of the Administrative Code and the county
cost-of-doing-business category. Payment rates for vocational habilitation
provided in-person in an integrated community setting for a group of four or
fewer individuals are based on the county cost-of-doing-business category. The
cost-of-doing-business category for an individual is the category assigned to
the county in which the service is actually provided for the preponderance of
time. The cost-of-doing-business categories are contained in appendix C to this
rule. (2) A provider of vocational habilitation
may use the daily billing unit when the provider delivers between five and
seven hours of vocational habilitation in-person to the same individual during
one calendar day and: (a) The individual does not qualify for or the provider elects
not to receive the behavioral support rate modification described in paragraph
(F)(6) of this rule; (b) The individual does not qualify for or the provider elects
not to receive the medical assistance rate modification described in paragraph
(F)(7) of this rule; and (c) The provider does not provide vocational habilitation to the
individual in multiple modes on the same day (i.e., in an integrated community
setting when the individual is part of a group of four or fewer individuals and
in another setting). (3) A provider of
vocational habilitation will use the fifteen-minute billing unit
when: (a) The provider delivers less than five hours or more than seven
hours of vocational habilitation to the same individual during one calendar
day; (b) The individual being served qualifies for and the provider
elects to receive the behavioral support rate modification in accordance with
paragraph (F)(6) of this rule; (c) The individual being served qualifies for and the provider
elects to receive the medical assistance rate modification in accordance with
paragraph (F)(7) of this rule; (d) The provider provides vocational habilitation to the
individual in multiple modes on the same day (i.e., in an integrated community
setting when the individual is part of a group of four or fewer individuals and
in another setting); or (e) The provider provides vocational habilitation to the
individual through virtual support. (4) A provider of
vocational habilitation will 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, will not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (6) Payment rates for
vocational habilitation provided in-person at the fifteen-minute billing unit
are 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 as applicable, appendix A or appendix B to this rule. (a) The department will 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 is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (7) Payment rates for
vocational habilitation provided in-person at the fifteen-minute billing unit
are 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 as applicable, appendix A or appendix B to this rule. (a) The county board will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy and/or jejunostomy tube; and/or requires the administration
of insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such procedure or nursing task is
not the administration of oral prescribed medication, topical prescribed
medication, oxygen, or metered dose inhaled medication, or a health-related
activity as defined in rule 5123-6-01 of the Administrative Code. (b) The duration of the medical assistance rate modification is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually.
View AppendixView AppendixView Appendix
Last updated January 2, 2024 at 9:46 AM
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Rule 5123-9-15 | Home and community-based services waivers - individual employment support under the individual options, level one, and self-empowered life funding waivers.
(A) Purpose This rule defines individual employment support
and sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of individual employment support is competitive integrated employment
in a job well-matched to the individual's interests, strengths,
priorities, and abilities that meets the individual's personal and career
goals. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Acuity
assessment group" means one of four groups (i.e., group A-1, group A,
group B, or group C) to which an individual is assigned based on the
individual's score resulting from administration of the acuity assessment
instrument in accordance with rule 5123-9-19 of the Administrative
Code. (2) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code. (3) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 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 is 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 will be added together for the purpose of calculating
the number of fifteen-minute billing units for that day. (10) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (11) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual employment
support" means individualized support for an individual to maintain
competitive integrated employment. Activities that constitute individual
employment support include but are not limited to: (a) Job coaching, which is identification and provision of
services and supports, utilizing task analysis and systematic instruction that
assist the individual in maintaining employment and/or advancing the
individual's career. Job coaching includes supports provided to the
individual and the individual's supervisor or coworkers on behalf of the
individual, either in-person or remotely via technology. Job coaching may
include the engagement of natural supports in the workplace to provide
additional supports that allow the job coach to maximize the job coach's
ability to fade. Examples of job coaching strategies include customized
employment, job analysis, job adaptations, instructional prompts, verbal
instruction, self-management tools, physical assistance, role playing, coworker
modeling, and written instruction. Job coaching for self-employment includes
identification and provision of services and supports, including counseling and
guidance, which assist the individual in maintaining self-employment through
the operation of a business. When job coaching is provided, a plan outlining
the steps to reduce job coaching over time will be in place within thirty
calendar days. (b) Training in assistive or other technology utilized by the
individual while on the job. (c) Other workplace support services including services not
specifically related to job skill training that enable the individual to be
successful in integrating into the job setting. (d) Personal care and assistance, which may be a component of
individual employment support but will not comprise the entirety of the
service. (14) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (15) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of individual employment support. (16) "Natural supports" means
the personal associations and relationships typically developed in the
community that enhance the quality of life for individuals. Natural supports
may include family members, friends, neighbors, and others in the community or
organizations that serve the general public who provide voluntary support to
help an individual achieve agreed upon outcomes through the individual service
plan development process. (17) "Pay stub"
means a document issued by an employer that shows, for a specified period of
time, an employee's gross earnings, deductions from those earnings, and
net pay. (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 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (20) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 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) Individual employment
support will be provided by an agency provider or an independent provider that
meets the requirements of this rule and that has a medicaid provider agreement
with the Ohio department of medicaid. (2) An applicant seeking
approval to provide individual employment support will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (3) An applicant seeking
independent provider certification to provide individual employment support
must have: (a) At least one year of full-time (or part-time equivalent),
paid work experience related to supporting individuals to maintain jobs in the
general workforce; or (b) Thirty hours of formal training related to supporting
individuals to maintain jobs in the general workforce. (4) An agency provider
will ensure that direct support professionals who provide individual employment
support successfully complete, no later than thirty calendar days after hire,
training in: (a) Services that comprise individual employment
support; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Building/site-specific emergency response plans;
and (d) Program-specific transportation safety. (5) An agency provider
will ensure that direct support professionals who provide individual employment
support (other than those who have at least one year of experience providing
individual employment support at the point of hire), during the first year
after hire, are assigned and have access to a mentor. (6) An agency provider
will ensure that direct support professionals who provide individual employment
support (other than those who have at least one year of experience providing
individual employment support at the point of hire), no later than one year
after hire, successfully complete at least eight hours of training specific to
the provision of individual employment support that includes, but is not
limited to: (a) Skill-building in job training and systematic instruction
that assists an individual in maintaining employment and or advancing the
individual's career; and (b) Self-determination which includes assisting an individual to
develop self-advocacy skills, to exercise civil rights, to exercise control and
responsibility over the services received, and to acquire skills that enable
becoming more independent, productive, and integrated within the
community. (7) Failure to comply
with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) The expected outcome
of individual employment support is competitive integrated employment in a job
well-matched to the individual's interests, strengths, priorities, and
abilities that meets the individual's personal and career
goals. (2) Individual employment
support will be provided pursuant to a person-centered individual service plan
that conforms to the requirements of rules 5123-4-02 and 5123-2-05 of the
Administrative Code and coordinated with other services and supports set forth
in the individual service plan. An individual will be made aware of the
potential impact of outcome-based payments described in paragraph (F)(5) of
this rule before individual employment support is authorized in the individual
service plan. (3) The service and
support administrator will ensure that documentation is maintained to
demonstrate that the service provided as individual employment support to an
individual enrolled in a waiver is not otherwise available as vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this rule, or as
special education or related services as those terms are defined in section 602
of the Individuals with Disabilities Education Improvement Act of 2004, 20
U.S.C. 1401, as in effect on the effective date of this rule. (4) Individual employment
support, other than services and supports that assist an individual to maintain
self-employment through the operation of a business, will take place in a
setting separate from the home of the individual receiving the
services. (5) Individual employment
support will be provided at a ratio of one direct support professional to one
individual. (6) Individual employment support
services may extend to those times when an individual is not physically present
while the provider is performing individual employment support activities on
behalf of the individual (e.g., developing coworker supports or meeting with a
supervisor). (7) A provider of
individual employment support will complete reports and collect and submit data
via the department's outcome tracking system in accordance with rule
5123-2-05 of the Administrative Code. (8) A provider of
individual employment support will recognize changes in the individual's
condition and behavior, report to the service and support administrator, and
record the changes in the individual's written record. (9) A provider of
individual employment support will report identified safety and sanitation
hazards that occur at the worksite to employers having the responsibility to
remedy the condition. (E) Documentation of
services Service documentation for individual employment
support will include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (10) Times the delivered service started
and stopped. (11) Number of units of the delivered
service. (F) Payment standards (1) The billing unit,
service codes, and payment rates for individual employment support are
contained in the appendix to this rule. (2) Payment for adult day
support, career planning, group employment support, individual employment
support, and vocational habilitation, alone or in combination, will not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (3) Payment rates for
individual employment support will 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. 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 will 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 is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verity that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (4) Payment rates for
individual employment support will 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. 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 will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy and/or jejunostomy tube; and/or requires the administration
of insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such procedure or nursing task is
not the administration of oral prescribed medication, topical prescribed
medication, oxygen, or metered dose inhaled medication, or a health-related
activity as defined in rule 5123-6-01 of the Administrative Code. (b) The duration of the medical assistance rate modification is
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) A provider of
individual employment support may be eligible for an outcome-based payment
following an individual's achievement of a job retention
milestone. (a) A provider may obtain either or both of two possible
outcome-based payments for each individual served: (i) One payment when the
individual retains competitive integrated employment for ninety calendar days
following the first date the provider was authorized to deliver individual
employment support to the individual. (ii) One payment when the
individual retains competitive integrated employment for one hundred eighty
calendar days following the first date the provider was authorized to deliver
individual employment support to the individual. (b) To obtain an outcome-based payment, a provider will
secure one or more pay stubs from the individual served sufficient to document
the date span of the individual's competitive integrated employment (i.e.,
ninety or one hundred eighty calendar days, as applicable) following the first
date the provider was authorized to deliver individual employment support to
the individual. The provider will submit the pay stub or pay stubs to the
individual's service and support administrator, who will authorize the
outcome-based payment in the individual service plan. When pay stubs cannot be
secured, the provider will instead submit an attestation in the format
prescribed by the department that the outcome has been achieved. (c) The amount of an outcome-based payment is determined by
the job retention milestone and the acuity assessment group assignment of the
individual at the time the individual achieves the milestone. (d) No more than two outcome-based payments will be made
during an individual's waiver eligibility span. (e) The service codes and payment rates for outcome-based
payments are contained in the appendix to this rule.
Last updated July 1, 2024 at 4:36 PM
|
Rule 5123-9-16 | Home and community-based services waivers - group employment support under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines group employment support and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of group employment support is paid employment and work experience
leading to further career development and competitive integrated
employment. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code. (2) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (3) "Career planning" has the
same meaning as in rule 5123-9-13 of the Administrative Code. (4) "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 is 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. (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 group
employment support are delivered by the same provider to the same individual
during one calendar day in accordance with the conditions specified in
paragraph (F)(2) of this rule. (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. Minutes of service delivery time
accrued throughout a day will be added together for the purpose of calculating
the number of fifteen-minute billing units for that day. (9) "Group employment support"
means services and training activities provided in regular business, industry,
and community settings for groups of two or more workers with
disabilities. (a) Activities that constitute group employment support include
any combination of the following as necessary and appropriate to meet the
community employment goals of the individual: (i) Person-centered
employment planning; (ii) Work
adjustment; (iii) Job
analysis; (iv) Training and
systematic instruction; (v) Job coaching;
and (vi) Training in
independent planning, arranging, and using transportation. (b) Group employment support is provided in two distinct service
arrangements: (i) Dispersed enclaves in
which individuals work in a self-contained unit within a company or service
site in the community or perform multiple jobs in the company, but are not
integrated with non-disabled employees of the company; or (ii) Mobile work crews
comprised solely of individuals operating as a distinct unit and/or
self-contained business working in several locations within the
community. (10) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (12) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (13) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (14) "Mentor" means a person
employed by or under contract with the agency provider who has experience
providing direct services to persons with developmental disabilities and who is
available on a regular basis to provide guidance to new direct support
professionals regarding techniques and practices that enhance the effectiveness
of the provision of group employment support. (15) "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 5123-5-02 of the Administrative Code. (16) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (17) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (18) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Group employment
support will be provided by an agency provider that meets the requirements of
this rule and that has a medicaid provider agreement with the Ohio department
of medicaid. (2) Group employment
support will not be provided by an independent provider. (3) An applicant seeking
approval to provide group employment support will complete and submit an
application and adhere to the requirements of rule 5123-2-08 of the
Administrative Code. (4) An agency provider
will ensure that direct support professionals who provide group employment
support successfully complete, no later than thirty calendar days after hire,
training in: (a) Services that comprise group employment support; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Building/site-specific emergency response plans;
and (d) Program-specific transportation safety. (5) An agency provider
will ensure that direct support professionals who provide group employment
support (other than those who have at least one year of experience providing
group employment support at the point of hire), during the first year after
hire, are assigned and have access to a mentor. (6) An agency provider
will ensure that direct support professionals who provide group employment
support (other than those who have at least one year of experience providing
group employment support at the point of hire), no later than one year after
hire, successfully complete at least eight hours of training specific to the
provision of group employment support that includes, but is not limited
to: (a) Skill-building in advancement of individuals on the path to
competitive integrated employment as described in rule 5123-2-05 of the
Administrative Code and development of individuals' strengths and skills
necessary for competitive integrated employment; and (b) Self-determination which includes assisting an individual to
develop self-advocacy skills, to exercise civil rights, to exercise control and
responsibility over the services received, and to acquire skills that enable
becoming more independent, productive, and integrated within the
community. (7) Failure to comply
with this rule and rule 5123-2-08 of the Administrative Code may result in
denial, suspension, or revocation of the agency provider's
certification. (D) Requirements for service
delivery (1) The expected outcome
of group employment support is paid employment and work experience leading to
further career development and competitive integrated employment. (2) Group employment
support will be provided pursuant to a person-centered individual service plan
that conforms to the requirements of rules 5123-4-02 and 5123-2-05 of the
Administrative Code and coordinated with other services and supports set forth
in the individual service plan. (3) The service and
support administrator will ensure that documentation is maintained to
demonstrate that the service provided as group employment support to an
individual enrolled in a waiver is not otherwise available as vocational
rehabilitation services funded under section 110 of the Rehabilitation Act of
1973, 29 U.S.C. 730, as in effect on the effective date of this rule, or as
special education or related services as those terms are defined in section 602
of the Individuals with Disabilities Education Improvement Act of 2004, 20
U.S.C. 1401, as in effect on the effective date of this rule. (4) Group employment
support will be provided in an integrated setting and support individuals'
access to the greater community, including opportunities to seek competitive
integrated employment, to engage in community life, and to have control over
earned income. (5) Group employment
support will take place in a setting separate from the home of the individual
receiving the services. (6) Individuals receiving
group employment support will be compensated in accordance with applicable
federal and state laws and regulations. A determination that an individual
receiving group employment support is eligible to be paid at special minimum
wage rates in accordance with 29 C.F.R. Part 525, "Employment of Workers
with Disabilities Under Special Certificates," as in effect on the
effective date of this rule, will be based on documented evaluations and
assessments. (7) A provider of group
employment support will ensure that appropriate staff are knowledgeable about
the Workforce Innovation and Opportunity Act as in effect on the effective date
of this rule, wage and hour laws, benefits, work incentives, and employer tax
credits for individuals with developmental disabilities and ensure that
individuals served receive this information. (8) A provider of group
employment support will provide the service in a manner that presumes all
participants are capable of working in competitive integrated employment. The
provider will encourage individuals receiving the service, on an ongoing basis,
and as part of the annual person-centered planning process, to explore their
interests, strengths, and abilities relating to competitive integrated
employment. The provider will, as a component of the service, assist
individuals to explore, identify, and pursue opportunities that advance them
toward competitive integrated employment. (9) A provider of group
employment support will complete reports and collect and submit data via the
department's outcome tracking system in accordance with rule 5123-2-05 of
the Administrative Code. (10) A provider of group
employment support will recognize changes in the individual's condition
and behavior, report to the service and support administrator, and record the
changes in the individual's written record. (11) A provider of group
employment support will report identified safety and sanitation hazards that
occur at the work site to employers having the responsibility to remedy the
condition. (E) Documentation of
services Service documentation for group employment
support will include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (10) Times the delivered
service started and stopped. (11) Number of units of the delivered
service. (F) Payment standards (1) The billing units,
service codes, and payment rates for group employment support provided January
1, 2024 through June 30, 2024 are contained in appendix A to this rule. The
billing units, service codes, and payment rates for group employment support
provided on or after July 1, 2024 are contained in appendix B 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 C to this rule. (2) A provider of group
employment support may use the daily billing unit when the provider delivers
between five and seven hours of group employment support to the same individual
during one calendar day and: (a) The individual does not qualify for or the provider elects
not to receive the behavioral support rate modification described in paragraph
(F)(6) of this rule; and (b) The individual does not qualify for or the provider elects
not to receive the medical assistance rate modification described in paragraph
(F)(7) of this rule. (3) A provider of group
employment support will use the fifteen-minute billing unit when: (a) The provider delivers less than five hours or more than seven
hours of group employment support to the same individual during one calendar
day; (b) The individual being served qualifies for and the provider
elects to receive the behavioral support rate modification in accordance with
paragraph (F)(6) of this rule; or (c) The individual being served qualifies for and the provider
elects to receive the medical assistance rate modification in accordance with
paragraph (F)(7) of this rule. (4) A provider of group
employment will 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, will not exceed the budget
limitations contained in appendix B to rule 5123-9-19 of the Administrative
Code. (6) Payment rates for group employment
support will 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)(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 as
applicable, appendix A or appendix B to this rule. (a) The department will 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 is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (7) Payment rates for group employment
support will 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)(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 as
applicable, appendix A or appendix B to this rule. (a) The county board will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy and/or jejunostomy tube; and/or requires the administration
of insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such nursing procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually.
Last updated January 2, 2024 at 9:47 AM
|
Rule 5123-9-17 | Home and community-based services waivers - adult day support under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines adult day support and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. The expected
outcome of adult day support is development of skills that lead to greater
independence, community membership, relationship-building, self-direction, and
self-advocacy. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" means provision of regularly scheduled activities such as
assistance with acquisition, retention, or improvement of self-help,
socialization, and adaptive skills that enhance an individual's social
development and performance of daily community living. Adult day support will
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 maximum potential. Activities that constitute
adult day support include, but are not limited to: (a) Activities that may be provided in-person or through virtual
support: (i) Supports to participate in community activities and build
community membership consistent with the individual's interests,
preferences, goals, and outcomes. (ii) Supports to develop and maintain a meaningful social life,
including social skill development which offers opportunities for personal
growth, independence, and natural supports through community involvement,
participation, and relationships. (iii) Supports and opportunities that increase problem-solving
skills to maximize an individual's ability to participate in integrated
community activities independently or with natural supports. (iv) Skill reinforcement including the implementation of
behavioral support strategies, assistance in the use of communication and
mobility devices, and other activities that reinforce skills learned by the
individual that are necessary to ensure initial and continued participation in
community life. (v) Training in self-determination which includes assisting the
individual to develop self-advocacy skills; to exercise civil rights; to
exercise control and responsibility over the services received; and to acquire
skills that enable becoming more independent, productive, and integrated within
the community. (vi) Recreation and leisure including supports identified in the
person-centered individual service plan as being therapeutic in nature, rather
than merely providing a diversion, and/or as being necessary to assist the
individual to develop and/or maintain social relationships and family
contacts. (b) Activities that may only be provided in-person: (i) Personal care
including supports and supervision in the areas of personal hygiene, eating,
communication, mobility, toileting, and dressing to ensure an individual's
ability to experience and participate in community living. (ii) Assisting an
individual with self-medication or health-related activities or performing
medication administration or health-related activities in accordance with
Chapter 5123-6 of the Administrative Code. (2) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (3) "Career planning" has the
same meaning as in rule 5123-9-13 of the Administrative Code. (4) "County board" means a
county board of developmental disabilities. (5) "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. (6) "Department" means the Ohio
department of developmental disabilities. (7) "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 will be added together for the purpose of calculating
the number of fifteen-minute billing units for that day. (8) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (9) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 of the Administrative Code and 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, the person's 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 5123-9-15 of the Administrative
Code. (12) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (13) "Integrated community
setting" means a setting that is integrated in and supports full access of
individuals to the greater community to the same degree of access as persons
not receiving home and community-based services. (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 support
professionals 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 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (19) "Virtual support" means the
provision of services by direct support professionals at a distant site who
engage with an individual using interactive technology that has the capability
for two-way, real time audio and video communication. (20) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 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) Adult day support
will 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
will not be provided by an independent provider. (3) An applicant seeking
approval to provide adult day support will complete and submit an application
and adhere to the requirements of rule 5123-2-08 of the Administrative
Code. (4) An agency provider
will ensure that direct support professionals who provide adult day support
successfully complete, no later than thirty calendar days after hire, training
in: (a) Services that comprise adult day support; (b) Signs and symptoms of illness or injury and procedure for
response; (c) Site-specific emergency response plans; and (d) Program-specific transportation safety. (5) An agency provider
will ensure that direct support professionals who provide adult day support
(other than those who have at least one year of experience providing adult day
support at the point of hire), during the first year after hire, are assigned
and have access to a mentor. (6) An agency provider
will ensure that direct support professionals who provide adult day support
(other than those who have at least one year of experience providing adult day
support at the point of hire), no later than one year after hire, successfully
complete at least eight hours of training specific to the provision of adult
day support that includes, but is not limited to: (a) Skill building in the necessary activities and environments
that build on the strengths of individuals served and foster the development of
skills that lead to greater independence, community membership,
relationship-building, and self-direction; (b) Developing natural supports; and (c) Self-determination which includes assisting the individual to
develop self-advocacy skills, to exercise civil rights, to exercise control and
responsibility over the services received, and to acquire skills that enable
becoming more independent, productive, and integrated within the
community. (7) Failure to comply with this rule and
rule 5123-2-08 of the Administrative Code may result in denial, suspension, or
revocation of the agency provider's certification. (D) Requirements for service
delivery (1) The expected outcome
of adult day support is development of skills that lead to greater
independence, community membership, relationship-building, self-direction, and
self-advocacy. (2) Adult day support is
available to individuals who are no longer eligible for educational services
based on their graduation and/or receipt of a diploma or equivalency
certificate and/or their permanent discontinuation of educational services
within parameters established by the Ohio department of education. (3) Adult day support will 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 coordinated with
other services and supports set forth in the individual service
plan. (4) Adult day support provided in-person
will take place in a non-residential setting separate from any
individual's home. An individual participating in adult day support
provided through virtual support may do so from the individual's
home. (5) Adult day support may
be provided through virtual support under the following
conditions: (a) Virtual support does not have the effect of isolating an
individual from the individual's community or preventing the individual
from interacting with people with or without disabilities. (b) The use of virtual support has been agreed to by an
individual and the individual's team and is specified in the individual
service plan. (c) The use of virtual support complies with applicable laws
governing an individual's right to privacy and the individual's
protected health information. (d) Provision of adult day support through virtual support does
not include: (i) Personal care
including supports and supervision in the areas of personal hygiene, eating,
communication, mobility, toileting, and dressing to ensure an individual's
ability to experience and participate in community living; or (ii) Assisting an
individual with self-medication or health-related activities or performing
medication administration or health-related activities in accordance with
Chapter 5123-6 of the Administrative Code. (6) A provider of adult day support will
notify the department within fourteen calendar days when there is a change in
the physical address (i.e., adding a new location or closing an existing
location) of any facility where adult day support takes place. (7) A provider of adult day support will
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 will be
informed of and comply with standards applicable to the service
setting. (8) When meals are provided as part of
adult day support, they will not constitute a full nutritional regimen (i.e.,
three meals per day). (9) A provider of adult day support will
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 will
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 provided January 1, 2024
through June 30, 2024 are contained in appendix A to this rule. The billing
units, service codes, and payment rates for adult day support provided on or
after July 1, 2024 are contained in appendix B to this rule. Payment rates,
except payment rates for adult day support provided in-person in an integrated
community setting for a group of four or fewer individuals, are based on
individuals' group assignments determined in accordance with rule
5123-9-19 of the Administrative Code and the county cost-of-doing-business
category. Payment rates for adult day support provided in-person in an
integrated community setting for a group of four or fewer individuals are based
on the county cost-of-doing-business category. The cost-of-doing-business
category for an individual is the category assigned to the county in which the
service is actually provided for the preponderance of time. The
cost-of-doing-business categories are contained in appendix C to this
rule. (2) A provider of adult
day support may use the daily billing unit when the provider delivers between
five and seven hours of adult day support in-person to the same individual
during one calendar day and: (a) The individual does not qualify for or the provider elects
not to receive the behavioral support rate modification described in paragraph
(F)(6) of this rule; (b) The individual does not qualify for or the provider elects
not to receive the medical assistance rate modification described in paragraph
(F)(7) of this rule; and (c) The provider does not provide adult day support to the
individual in multiple modes on the same day (i.e., in an integrated community
setting when the individual is part of a group of four or fewer individuals and
in another setting). (3) A provider of adult
day support will use the fifteen-minute billing unit when: (a) The provider delivers less than five hours or more than seven
hours of adult day support to the same individual during one calendar
day; (b) The individual being served qualifies for and the provider
elects to receive the behavioral support rate modification in accordance with
paragraph (F)(6) of this rule; (c) The individual being served qualifies for and the provider
elects to receive the medical assistance rate modification in accordance with
paragraph (F)(7) of this rule; (d) The provider provides adult day support to the individual in
multiple modes on the same day (i.e., in an integrated community setting when
the individual is part of a group of four or fewer individuals and in another
setting); or (e) The provider provides adult day support to the individual
through virtual support. (4) A provider of adult
day support will 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, will not exceed
the budget limitations contained in appendix B to rule 5123-9-19 of the
Administrative Code. (6) Payment rates for
adult day support provided in-person at the fifteen-minute billing unit are
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 as
applicable, appendix A or appendix B to this rule. (a) The department will 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 is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (c) The purpose of the behavioral support rate modification is to
provide funding for the implementation of behavioral support strategies by
staff who have the level of training necessary to implement the strategies; the
department retains the right to verify that staff who implement behavioral
support strategies have received training (e.g., specialized training
recommended by clinicians or the team or training regarding an
individual's behavioral support strategy) that is adequate to meet the
needs of the individuals served. (7) Payment rates for
adult day support provided in-person at the fifteen-minute billing unit are
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 as
applicable, appendix A or appendix B to this rule. (a) The county board will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy and/or jejunostomy tube; and/or requires the administration
of insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires administration of medication for the treatment of metabolic glycemic
disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such procedure or nursing task is
not the administration of oral prescribed medication, topical prescribed
medication, oxygen, or metered dose inhaled medication, or a health-related
activity as defined in rule 5123-6-01 of the Administrative Code. (b) The duration of the medical assistance rate modification is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (G) Providers certified by the Ohio
department of aging (1) An agency provider
certified by the department to provide adult day support may contract with and
reimburse a provider certified by the Ohio department of aging for adult day
support provided to individuals enrolled in individual options, level one, and
self-empowered life funding waivers. (2) A provider certified
by the Ohio department of aging that is under contract with an agency provider
certified by the department to provide adult day support is not subject to the
requirements set forth in paragraph (C) of this rule. (3) A provider certified
by the Ohio department of aging that is under contract with an agency provider
certified by the department to provide adult day support will: (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) Ensure all employees and contractors who provide adult day
support 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 will 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 will
comply with the provisions of rule 173-39-02.1 of the Administrative
Code. (7) Notwithstanding the requirements of
rule 173-39-02.1 of the Administrative Code, a provider certified by the Ohio
department of aging is not required to arrange or provide non-medical
transportation for individuals, but may provide non-medical transportation
directly or through a contract, if selected by the individual. (8) Except as otherwise set forth in this
rule, all of the provisions of this rule and rule 5123-9-19 of the
Administrative Code are applicable to adult day support provided through
contract with a provider certified by the Ohio department of
aging.
View AppendixView Appendix
Last updated January 2, 2024 at 9:47 AM
|
Rule 5123-9-18 | Home and community-based services waivers - non-medical transportation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 2, 2025
(A) Purpose This rule defines non-medical transportation and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (2) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (3) "Career planning" has the
same meaning as in rule 5123-9-13 of the Administrative Code. (4) "Commercial
transportation" means an entity that transports passengers in accordance
with a published usual and customary fare schedule and is either: (a) A bus or rail system owned or operated by a government
authority; or (b) An on-demand taxicab service as defined in paragraph
(B)(17) of this rule. (5) "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. (6) "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 is 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 similar tasks and who have similar training, experience,
and skills. (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 nondisabled 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. (d) That, as appropriate, presents opportunities for career
advancement that are similar to those for persons without disabilities who have
similar positions. (7) "County
board" means a county board of developmental disabilities. (8) "Department" means the Ohio department of
developmental disabilities. (9) "Group
employment support" has the same meaning as in rule 5123-9-16 of the
Administrative Code. (10) "Homemaker/personal care" has the same meaning as
in rule 5123-9-30 of the Administrative Code. (11) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with section 5126.043 of
the Revised Code or other person authorized to give consent. (13) "Individual
employment support" has the same meaning as in rule 5123-9-15 of the
Administrative Code. (14) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (15) "Modified
vehicle" means: (a) A motor vehicle to be used upon public streets and highways
that has been structurally modified in a permanent manner to meet the physical
or behavioral needs of the individual being transported; or (b) A motor vehicle that has been designed, constructed, or
fabricated and equipped to be used upon public streets and highways for
transportation of individuals who require use of a wheelchair and
that: (i) Has permanent
fasteners to secure a wheelchair to the floor or side of the vehicle to prevent
wheelchair movement; (ii) Has safety harnesses
or belts in the vehicle for the purpose of securing individuals in
wheelchairs; (iii) Is equipped with a
stable access ramp specifically designed for wheelchairs or a hydraulic lift
specifically designed for wheelchairs; and (iv) Is 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 will be documented by
the driver that conducts the inspection. (16) "Non-medical
transportation" means transportation used by an individual: (a) To get to, from, between, or among: (i) A place of employment; (ii) A location where adult day support, career planning,
group employment support, individual employment support, or vocational
habilitation is provided to the individual; (iii) A volunteer activity; (iv) A post-secondary educational program; (v) An internship or practicum; and/or (vi) 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)(i) to (B)(16)(a)(v) of this rule. (b) Via one of the following modes: (i) Transport provided by
an agency provider or an independent provider in a modified vehicle or a
non-modified vehicle at a per-trip rate or a per-mile rate; (ii) Transport provided
by an agency provider or an independent provider that is an operator of
"commercial transportation" as defined in paragraph (B)(4) of this
rule at the provider's published usual and customary fare; or (iii) Purchase by a
county board of a prepaid card, pass, token, or voucher used by an individual
to access commercial transportation. (17) "On-demand
taxicab service" means an entity that: (a) Operates one or more motor vehicles to transport
passengers between locations and at times of the day or night determined by the
passengers (i.e., not on fixed or pre-determined routes or schedules
established by the operator) and in accordance with a published usual and
customary fare schedule; (b) Is licensed or otherwise authorized to operate as a
taxicab by a municipality, county, or other local authority; and (c) Derives more than fifty per cent of its revenue from
operating in the manner described in paragraphs (B)(17)(a) and (B)(17)(b) of
this rule. (18) "Participant-directed homemaker
personal care" has the same meaning as in rule 5123-9-32 of the
Administrative Code. (19) "Passenger" means a
traveler in a vehicle who does not participate in operation of the
vehicle. (20) "Service and support
administrator" means a person, regardless of title, employed by or under
contract with a county board to perform the functions of service and support
administration and who holds the appropriate certification in accordance with
rule 5123-5-02 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
includes the items delineated in paragraph (H) of this rule to validate payment
for medicaid services. (22) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 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 will be provided by an independent provider, an agency provider,
or an operator of commercial transportation that meets the requirements of this
rule and, with the exception of a bus or rail system owned or operated by a
government authority, that has a medicaid provider agreement with the Ohio
department of medicaid. (2) An applicant seeking
approval to provide non-medical transportation will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (3) An applicant seeking
approval to provide non-medical transportation as an independent provider will
present the applicant's driving record prepared by the bureau of motor
vehicles no earlier than fourteen calendar days prior to the date of
application for initial or renewal provider certification. A person having six
or more points on the person's driving record is prohibited from providing
non-medical transportation. (4) An independent
provider of non-medical transportation will: (a) Hold a valid driver's license as specified by Ohio
law. (b) Have valid liability insurance as specified by Ohio
law. (c) Immediately notify the department, in writing, if the
independent provider accumulates six or more points on the independent
provider's driving record or has a driver's license suspended or
revoked. (d) Complete testing for controlled substances by a laboratory
certified for such testing within thirty-two hours and complete testing for
blood alcohol level by an entity certified for such testing within eight hours
of a motor vehicle accident involving the driver while the driver 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 will: (a) Ensure that each driver holds a valid driver's license
as specified by Ohio law. (b) Ensure that each driver is covered by valid liability
insurance as specified by Ohio law. (c) Obtain, for each driver, a driving record prepared by the
bureau of motor vehicles no earlier than fourteen calendar days prior to the
date of initial employment as a driver and at least once every three years
thereafter. A person having six or more points on the person's driving
record is prohibited from providing non-medical transportation. (d) Require each driver to immediately notify the agency
provider, in writing, if the driver accumulates six or more points on the
driver's driving record or has a driver's license suspended or
revoked. (e) Ensure that each driver completes testing for controlled
substances by a laboratory certified for such testing within thirty-two hours
and completes testing for blood alcohol level by an entity certified for such
testing within eight hours of a motor vehicle accident involving the driver
while the driver 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) An agency provider or
an independent provider submitting claims for payment as an operator of
commercial transportation will demonstrate ownership and operation of an
enterprise that meets the definition of "commercial transportation"
in paragraph (B)(4) of this rule. (7) Failure of a provider to comply with
this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative
Code, may result in denial, suspension, or revocation of the provider's
certification. (D) Meeting an individual's needs
for non-medical transportation (1) An individual's
non-medical transportation needs may be met through a combination of the modes
of non-medical transportation described in paragraph (B)(16)(b) of this
rule. (2) Unless otherwise
specified in an individual service plan: (a) Non-medical transportation at the per-trip rate will be
authorized for transporting an individual between the individual's
residence and a location specified in paragraphs (B)(16)(a)(i) to
(B)(16)(a)(vi) of this rule. (b) Non-medical transportation at the per-mile rate will be
authorized for transporting an individual in circumstances other than
circumstances described in paragraph (D)(2)(a) of this rule. (3) Non-medical
transportation will be provided pursuant to an individual service plan that
conforms to the requirements of rule 5123-4-02 of the Administrative Code.
Whenever possible, family, neighbors, friends, or community agencies that
transport people without charge are to be used to meet an individual's
needs. An individual's need for non-medical transportation to be provided
in a modified vehicle is to be documented in the individual service
plan. (4) The service and
support administrator will ensure that a budget limitation for non-medical
transportation is determined in accordance with rule 5123-9-19 of the
Administrative Code when the need for non-medical transportation has been
identified through development of the individual service plan for an individual
enrolled in the individual options waiver. (5) Prior to authorizing
non-medical transportation at the special per-trip payment rate to transport
one individual to or from competitive integrated employment as described in
paragraph (I)(3) of this rule, the service and support administrator
will: (a) Verify that the individual's employment meets the
definition of "competitive integrated employment" set forth in
paragraph (B)(6) of this rule. (b) Estimate the distance of a one-way trip between the
individual's residence and the individual's employer. (c) Make the individual aware of the potential impact of
the special per-trip payment rate for competitive integrated employment on the
individual's budget. (6) Nothing in this rule will be
interpreted to prevent 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 paragraphs (B)(16)(a)(i) to
(B)(16)(a)(vi) 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
will: (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 will 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 must be
in the vehicle during the times the provider bills non-medical transportation
at the per-trip rate. (2) A provider will not
bill for: (a) 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. (b) 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 must 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: (a) 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. (b) 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 will include each of the following to
validate payment for medicaid services: (a) Mode of non-medical transportation provided (i.e., per-trip
or per-mile). (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) Origination and destination points of non-medical
transportation provided. (i) Times the trip or commute started and
stopped. (j) Written or electronic signature of the driver of the
vehicle or initials of the driver of the vehicle if the signature and
corresponding initials are on file with the provider. (k) Names of all individuals who were in the vehicle during
any portion of the trip and/or commute. (2) Service documentation
for non-medical transportation at the special per-trip payment rates to
transport one individual at a time to or from competitive integrated employment
as described in paragraph (I)(3) of this rule will include, in addition to the
items required in paragraph (H)(1) of this rule: (a) The name and address of the individual's
employer. (b) The number of miles in each one-way trip, 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 at the per-mile rate will 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. (4) Service documentation for non-medical
transportation by operators of commercial transportation will include each of
the following to validate payment for medicaid services: (a) Mode of non-medical transportation provided (i.e., commercial
transportation) and specific type (i.e., bus, rail, or on-demand taxicab
service). (b) Date of service or, in the case of a purchase of prepaid
cards, passes, tokens, or 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 transportation
indicating the amount paid. (5) A county board that
purchases prepaid cards, passes, tokens, or vouchers used by an individual to
access commercial transportation in accordance with this rule will annually
submit a report of the purchases to the department in a format prescribed by
the department. (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, except the special per-trip
payment rates described in paragraph (I)(3) of this rule, 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) Special per-trip
payment rates may apply when an agency provider or an independent provider
transports one individual at a time to or from competitive integrated
employment. The special per-trip payment rates are based on the distance of the
one-way trip and whether the service is provided in a modified vehicle or a
non-modified vehicle. The modified vehicle rate will be applied only for an
individual who requires the use of a modified vehicle, as specified in the
individual service plan. (4) 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 will be applied for each
individual being transported when at least one individual requires the use of a
modified vehicle, as specified in the individual service plan. (5) An operator of commercial
transportation will be paid its published usual and customary fare which is the
same rate charged to the general public as documented by auditable records. The
published usual and customary fare will be listed as a rate for a one-way trip
or a prepaid card, pass, token, or voucher and include defined surcharges, if
applicable. (6) A county board that
purchases prepaid cards, passes, tokens, or vouchers used by an individual to
access commercial transportation in accordance with this rule will do so at the
published usual and customary fare and will not seek reimbursement for any
administrative costs associated with making the purchase on the
individual's behalf. (7) Payment for non-medical
transportation provided to individuals enrolled in the individual options
waiver will not exceed the budget limitations contained in appendix B to rule
5123-9-19 of the Administrative Code.
View Appendix
Last updated January 3, 2025 at 8:44 AM
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Rule 5123-9-19 | Home and community-based services waivers - general requirements for adult day support, career planning, group employment support, individual employment support, non-medical transportation, and vocational habilitation.
Effective:
January 1, 2024
(A) Purpose This rule establishes general requirements
governing provision of and payment for adult day support, career planning,
group employment support, individual employment support, non-medical
transportation, and vocational habilitation provided to individuals enrolled in
home and community-based services waivers administered by the
department. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Acuity
assessment instrument" means the standardized instrument utilized by the
department to assess the relative non-residential services needs and
circumstances of an adult individual compared to other adult individuals for
purposes of receiving adult day support, career planning, group employment
support, individual employment support, and vocational habilitation. Scores
resulting from administration of the acuity assessment instrument have been
grouped into ranges and subsequently linked with staffing expectations that
result in four payment rates calibrated on group size that apply to adult day
support, group employment support, and vocational habilitation. (2) "Administrative
review" means the processes internal to the department and subject to
oversight by the Ohio department of medicaid available to individuals who
believe that their acuity assessment instrument scores, their placement in
group assignment A, A-1, or B, and when applicable, the resulting budget
limitation, prevent access to or continuation in the adult day support, career
planning, group employment support, individual employment support, and/or
vocational habilitation services they have selected. Administrative review is
not applicable to individuals with placement in group assignment C or to
non-medical transportation. (3) "Adult day
services" means non-residential services including adult day support,
career planning, group employment support, individual employment support,
non-medical transportation, and vocational habilitation. (4) "Adult day
support" has the same meaning as in rule 5123-9-17 of the Administrative
Code. (5) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (6) "Budget
limitation" means the funding amount available to enable an individual
enrolled in the individual options waiver to receive adult day support, career
planning, group employment support, individual employment support, and/or
vocational habilitation within each waiver eligibility span. A separate budget
limitation enables an individual enrolled in the individual options waiver to
receive non-medical transportation within each waiver eligibility span. The
budget limitation applicable to adult day support, career planning, group
employment support, individual employment support, and vocational habilitation
and the budget limitation applicable to non-medical transportation are above
and beyond the funding range to which an individual enrolled in the individual
options waiver has been assigned. (7) "Career
planning" has the same meaning as in rule 5123-9-13 of the Administrative
Code. (8) "County
board" means a county board of developmental disabilities. (9) "Department" means the Ohio department of
developmental disabilities. (10) "Funding
range" means one of the dollar ranges contained in appendix A to rule
5123-9-06 of the Administrative Code to which individuals enrolled in the
individual options waiver have been assigned for the purpose of funding
services other than adult day support, career planning, group employment
support, individual employment support, non-medical transportation, vocational
habilitation, waiver nursing delegation, and waiver nursing
services. (11) "Group
employment support" has the same meaning as in rule 5123-9-16 of the
Administrative Code. (12) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (13) "Individual
employment support" has the same meaning as in rule 5123-9-15 of the
Administrative Code. (14) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (15) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (16) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123-5-02 of the Administrative Code. (17) "Vocational
habilitation" has the same meaning as in rule 5123-9-14 of the
Administrative Code. (18) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
re-determination date. (19) "Waiver nursing
delegation" has the same meaning as in rule 5123-9-37 of the
Administrative Code. (20) "Waiver nursing
services" has the same meaning as in rule 5123-9-39 of the Administrative
Code. (C) Acuity assessments, group
assignments, and budget limitations (1) The service and
support administrator will 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 will be provided by the individual
and informants who know the capabilities and needs of the individual outside of
the individual's residence, in the adult day services setting. Informants
may include providers, guardians, advocates, and family members. The service
and support administrator will 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 will submit
information in electronic format to the department. The information will be
automatically scored. (3) The score resulting
from administration of the acuity assessment instrument will result in
assignment of the individual by the service and support administrator to one of
four groups. These group assignments will be applied to determine the rates
paid when individuals receive adult day support, group employment support,
and/or vocational habilitation. (a) An acuity assessment instrument score of eight to
twenty-two results in assignment of the individual to group A or group A-1
based upon the staffing needs of the individual as identified in the individual
service plan development process and reflected in the individual service
plan. (b) An acuity assessment instrument score of twenty-three
to thirty-four results in assignment of the individual to group B. (c) An acuity assessment instrument score of thirty-five to
fifty-five results in assignment of the individual to group C. (4) Following assignment
of an individual enrolled in the individual options waiver to one of four
groups, the service and support administrator will 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 will 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 will 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 will inform each individual of the acuity assessment
instrument score, the resulting group assignment, and for an individual
enrolled in the individual options waiver, the individual's budget
limitations: (a) At the time the acuity assessment instrument is
initially administered; (b) At any time the acuity assessment instrument is
re-administered and results in a score that places an individual in a different
group assignment; and (c) At any time the individual receives the preponderance
of adult day services in a county with a different cost-of-doing-business
category. (6) A budget limitation
established for an individual enrolled in the individual options waiver will
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 will
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 will be provided pursuant to a person-centered individual service
plan that conforms to the requirements of rules 5123-4-02 and 5123-2-05 of the
Administrative Code. (2) Individual service
plans will 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 will 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 will
determine whether the annual cost for adult day support, career planning, group
employment support, individual employment support, and/or vocational
habilitation can be met by or exceeds the assigned budget limitation of an
individual enrolled in the individual options waiver, or the funding amount
available to meet the assessed needs of an individual enrolled in the level one
waiver or the self-empowered life funding waiver. The county board also will
determine whether the annual cost for non-medical transportation can be met by
or exceeds the assigned budget limitation of an individual enrolled in the
individual options waiver, or the funding amount available to meet the assessed
needs of an individual enrolled in the level one waiver or the self-empowered
life funding waiver. The service and support administrator will inform the
individual of these determinations in accordance with procedures developed by
the department. (4) If an individual
requests a change in the frequency and/or duration of adult day support, career
planning, group employment support, individual employment support, non-medical
transportation, and/or vocational habilitation, the request may result in an
increase or decrease in the annual cost for these services, based on the
outcome of the individual service plan development process. The county board
has the authority and responsibility to make changes which result from the
individual service plan development process when the services are within the
budget limitations of an individual enrolled in the individual options waiver,
or within the funding amount available to meet the assessed needs of an
individual enrolled in the level one waiver or the self-empowered life funding
waiver. (a) Changes in the assigned budget limitations of an
individual enrolled in the individual options waiver made by county boards are
subject to review by the department and approval by the Ohio department of
medicaid. (b) Neither the department nor the county board will
approve a change in a budget limitation or assign a new budget limitation to an
individual enrolled in the individual options waiver after notification that
the individual has requested a hearing pursuant to section 5160.31 of the
Revised Code concerning the approval, denial, reduction, or termination of
services in an individual service plan that has been developed within the
funding parameters of this rule. (E) Group assignments, billing units,
documentation, and payment conditions (1) Billing for adult day
support, group employment support, and vocational habilitation will 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 will be provided at a ratio of one staff to one
individual. (5) Agency providers will
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 will
complete a payment authorization and the service and support administrator will
ensure waiver services are initiated for an individual whose annual cost for
adult day support, career planning, group employment support, individual
employment support, and/or vocational habilitation and whose annual cost for
non-medical transportation are within the budget limitations of an individual
enrolled in the individual options waiver or within the funding amount
available to meet the assessed needs of an individual enrolled in the level one
waiver or the self-empowered life funding waiver. The service and support
administrator will inform the individual in writing in a form and manner the
individual understands, of the individual's due process rights and
responsibilities as set forth in section 5160.31 of the Revised
Code. (2) Applicants for and
recipients of waiver services who demonstrate that situational demands
associated with the adult day support, career planning, group employment
support, individual employment support, and/or vocational habilitation services
in which they desire to participate require a group assignment that is
different than the group assignment resulting from administration of the acuity
assessment instrument may submit a request for administrative review.
Administrative review requests will not be accepted for individuals having
group assignment C. (3) The department
considers the budget limitations contained in appendix B to this rule
sufficient to meet the service requirements of any adult enrolled in the
individual options waiver participating in adult day services. Therefore, in no
instance will the group assignment and resulting total budget limitation
approved through the administrative review process exceed the published amount
for group C in the cost-of-doing-business category in which the individual
receives the preponderance of the services addressed in this rule. (4) An individual or the
county board, with the consent of the individual, may submit a request for
administrative review to the department. County boards will assist an
individual to request an administrative review when asked to do so by the
individual. (5) The individual or
county board requesting administrative review will submit information requested
by the department including but not limited to: (a) The proposed group assignment for each waiver
service; (b) The duration of the proposed group assignment for each
waiver service; and (c) A statement justifying the proposed group assignment
with supporting documentation. (6) The department will
make a determination within thirty calendar days following receipt of the
information described in paragraph (F)(5) of this rule and notify the
individual and county board in writing of the determination. (7) The administrative
review approval will apply to the individual's current waiver eligibility
span. The department may extend the approval to one or more months in the
consecutive waiver eligibility span. Requests for administrative review may be
submitted on an as-needed basis and will be considered for approval if the
individual continues to meet the criteria established by the
department. (8) Following completion
of the administrative review process, the department will inform the individual
in writing in a form and manner the individual understands, of the
individual's due process rights and responsibilities as set forth in
section 5160.31 of the Revised Code. (9) If, through the
administrative review process, the department approves the request for a
different group assignment, the county board will ensure a payment
authorization is completed within fifteen calendar days following the
determination by the department and the service and support administrator will
ensure waiver services are initiated. (10) If, through the
administrative review process, the department denies the request for a
different group assignment or if the service is not subject to an
administrative review, the service and support administrator will initiate the
individual service plan development process to determine if an individual
service plan can be developed that is acceptable to the individual and is
within the assigned budget limitation or funding amount available. (a) If an individual service plan that meets these
conditions is developed, the county board will ensure a payment authorization
is completed and the service and support administrator will ensure waiver
services are initiated. (b) If an individual service plan that meets these
conditions cannot be developed, the county board will propose to deny the
initial or continuing provision of adult day support, career planning, group
employment support, individual employment support, and/or vocational
habilitation and inform the individual of the individual's due process
rights and responsibilities as set forth in section 5160.31 of the Revised
Code. (11) The department will
use the twelve-month period following either an individual's initial
individual options waiver enrollment date or the date the individual
transitions to one or more of the services addressed in this rule to verify
that cumulative payments made for adult day services remain within the approved
budget limitations specified in this rule. (12) The Ohio department
of medicaid retains the final authority, based on the recommendation of the
department, to review, revise, and approve any element of the decision process
resulting in a determination made under this rule. (G) Due process rights and
responsibilities Applicants for and recipients of waiver services
administered by the department will 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.
View Appendix
Last updated January 2, 2024 at 9:47 AM
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Rule 5123-9-20 | Home and community-based services waivers - money management under the individual options and level one waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines money management and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that employs at least one person in addition to
a director of operations for the purpose of providing services for which the
entity is certified in accordance with rule 5123-2-08 of the Administrative
Code. (2) "Authorized
representative" means a person or an organization appointed by an
individual to discuss and negotiate benefits (e.g., medicaid, social security,
or veterans' administration) on behalf of an individual who needs
assistance to manage or direct the management of benefits for which the
individual is eligible or may be eligible. (3) "County
board" means a county board of developmental disabilities. (4) "Department" means the Ohio department of
developmental disabilities. (5) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day will 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 the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (9) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (10) "Money
management" means services that provide assistance to individuals who need
support managing personal and financial affairs, including training to assist
an individual to acquire, retain, or improve related skills. The services meet
a continuum of individualized needs, from organizing and keeping track of
financial records and health insurance documentation, to assisting with
bill-paying and maintaining bank accounts. Money management does not take the
place of services provided by professionals in the accounting, investment, or
social services fields. Money management complements the work of other
professionals by facilitating the completion of the day-to-day tasks rather
than determining or executing long-term plans. Money management includes a
broad range of tasks determined necessary in the individual service plan.
Examples of supports that may be provided as a component of money management
include: (a) Bill-paying and preparing checks for individuals to
sign; (b) Balancing checkbooks, reconciling bank account
statements, and maintaining or organizing bank records; (c) Preparing and delivering bank account
deposits; (d) Assisting an individual with applying for benefits such
as medicaid buy-in for workers with disabilities and other resources as
appropriate; (e) Assisting an individual with maintaining eligibility
for benefits such as food stamps; (f) Consulting or making referrals for consultation
regarding available benefits; (g) Making referrals as appropriate for establishment of
special needs accounts (e.g., a qualified income trust or an account
established in accordance with the Achieving a Better Life Experience Act
program and section 529A of the Internal Revenue Code); (h) Organizing tax documents and other
paperwork; (i) Negotiating with creditors; (j) Deciphering medical insurance papers and verifying
proper processing of claims; (k) Providing general organization assistance; (l) Providing referrals to legal, tax, and investment
professionals; (m) Notarizing documents; (n) Providing assistance associated with financial tasks
when an individual relocates (e.g., transferring bank accounts or updating
address with creditors); and (o) Acting as power-of-attorney or authorized
representative, when so designated by the individual. (11) "Participant-directed homemaker/personal
care" has the same meaning as in rule 5123-9-32 of the Administrative
Code. (12) "Payee"
means a person, agency, organization, or institution appointed by the social
security administration to receive and manage benefits (e.g., medicaid, social
security, or supplemental security income) on behalf of an individual who needs
assistance to manage or direct the management of benefits. A payee has legal
authority to manage the benefits, uses the benefits to pay for the current and
future needs of the individual, and properly saves any benefits not needed to
meet current needs. A payee is required to keep records of expenses and provide
an accounting of how the payee used or saved the benefits. A payee will 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 5123-5-02 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 includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (15) "Shared
living" has the same meaning as in rule 5123-9-33 of the Administrative
Code. (16) "Team"
means the group of persons chosen by an individual with the core responsibility
to support the individual in directing development of the individual service
plan. The team includes the individual's guardian or adult whom the
individual has identified, as applicable, the service and support
administrator, direct support professionals, providers, licensed or certified
professionals, and any other persons chosen by the individual to help the
individual consider possibilities and make decisions. (C) Provider qualifications (1) Money management will
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 will
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 will complete and submit an application
and adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of
the Administrative Code. (4) Each person providing
money management will: (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) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) Money management will
be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. Providers of money
management will 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 will be determined by the team based on
the individual's needs. Money management will be authorized for no more
than ten hours per month. (3) Money management will
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 will
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 will: (a) Comply with rule 5123-2-07 of the Administrative
Code; (b) Act in the best interest of and take all reasonable
precautions to safeguard the interests and property of each individual the
provider serves; (c) Disclose in writing to each individual served and the
individual's service and support administrator, any affiliations,
associations, or interests that may pose a potential conflict of interest or
create the appearance of impropriety; (d) Keep current of issues related to the money management
services provided (e.g., health insurance, consumer fraud, or banking fees) and
public and private services available to individuals for use in resource
referrals; (e) Refer individuals to other service providers or consult
with other service providers when additional knowledge and expertise are
required; and (f) Maintain detailed and accurate records, documentation,
and information (e.g., bank statements, checking account transaction register,
savings account balance, spending trends, or income statements) for each
individual served which will 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 will: (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 will 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 will not also provide homemaker/personal care, participant-directed
homemaker/personal care, or shared living to the same individual. (10) Providers of money
management will not act or represent themselves as accountants, financial
advisors, attorneys, or other licensed professionals unless licensed as such by
the state of Ohio. (E) Documentation of
services Service documentation for money management will
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 money management provided January 1, 2024
through June 30, 2024 are contained in appendix A to this rule. The billing
unit, service codes, and payment rates for money management provided on or
after July 1, 2024 are contained in appendix B 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 C 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 will 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, the services will 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, the services will be authorized
and billed as participant-directed homemaker/personal care.
Last updated January 2, 2024 at 9:48 AM
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Rule 5123-9-21 | Home and community-based services waivers - informal respite under the level one waiver.
Effective:
January 1, 2024
(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 apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County board" means a
county board of developmental disabilities. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day will 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 the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (7) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (8) "Informal respite" means
care and support services furnished to an individual 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 care. Informal respite may be provided in the
individual's home or place of residence, home of a friend or family
member, or at sites of community activities. (9) "Major unusual
incident" has the same meaning as in rule 5123-17-02 of the Administrative
Code. (10) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (11) "Unusual incident" has the
same meaning as in rule 5123-17-02 of the Administrative Code. (12) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility re-determination
date. (C) Provider qualifications (1) Informal respite will
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 and adheres to the
requirements of rule 5123-2-09 of the Administrative Code. (2) Informal respite will
not be provided by an agency provider, a county board, or a regional council of
governments formed under section 5126.13 of the Revised Code by two or more
county boards. (3) Failure to comply
with this rule and rule 5123-2-09 of the Administrative Code may result in
denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) Informal respite will
be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) In order to be
eligible for informal respite, an individual or the individual's 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 the
individual's designee will 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 the individual service plan and other information related to
health and welfare needs of the individual. (b) Annual training of the provider to ensure that the provider
understands the following: (i) The requirements set
forth in rule 5123-17-02 of the Administrative Code and the reasonable steps
necessary to prevent the occurrence or recurrence of unusual incidents and
major unusual incidents; (ii) The rights of
individuals set forth in section 5123.62 of the Revised Code; and (iii) The activities
required to meet the needs and preferences of the individual, including any
training specified for the individual in the individual service plan and other
information related to health and welfare needs of the individual. (3) The individual or the
individual's designee will: (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 the individual's designee to fulfill the requirements of
this rule will 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 will be terminated. (E) Documentation of
services Service documentation for informal respite will
include each of the following to validate payment for medicaid services: (1) Type of service. (2) Date of service. (3) Place of service. (4) Name of individual receiving
service. (5) Medicaid identification number of
individual receiving service. (6) Name of provider. (7) Provider identifier/contract
number. (8) Times the delivered service started
and stopped. (9) Written or electronic signature of
the person delivering the service. (10) Description and details of the
services delivered that directly relate to the services specified in the
approved individual service plan as the services to be provided. (F) Payment standards The billing unit, service code, and payment rate
for informal respite provided January 1, 2024 through June 30, 2024 are
contained in appendix A to this rule. The billing unit, service code, and
payment rate for informal respite provided on or after July 1, 2024 are
contained in appendix B to this rule.
View Appendix
Last updated January 2, 2024 at 9:48 AM
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Rule 5123-9-22 | Home and community-based services waivers - community respite under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines community respite and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "Community respite" means
care and support services furnished to an individual on a short-term basis
because of the absence or need for relief of those persons routinely providing
care. Community respite is 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 will 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 will 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 will 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 the person is
certified in accordance with rule 5123-2-09 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, the person's 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
includes 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
will 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
will 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 will complete and submit an application and adhere to
the requirements of rule 5123-2-08 of the Administrative Code. (4) Failure of a certified provider to
comply with this rule and rule 5123-2-08 of the Administrative Code may result
in denial, suspension, or revocation of the provider's
certification. (5) Failure of a licensed provider to
comply with this rule and Chapter 5123-3 of the Administrative Code may result
in denial, suspension, or revocation of the provider's
license. (6) A provider of
community respite will provide written assurance and ensure that all employees,
contractors, and employees of contractors delivering community respite hold the
required certification or license (e.g., water safety instructor) and are
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 will 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 will
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
will 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
will not be provided in any residence. (6) Community respite
will not be simultaneously provided at the same location where adult day
services are being provided. (E) Documentation of services Service documentation for community respite will
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 provided January 1, 2024 through June 30,
2024 are contained in appendix A to this rule. The billing units, service
codes, and payment rates for community respite provided on or after July 1,
2024 are contained in appendix B to this rule. (a) The community respite full day billing unit will 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 will use the community respite full day
billing unit on any given day. (b) The community respite partial day billing unit will 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 will 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 will 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 C to this
rule. (3) Payment rates for
community respite will 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 will 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 is
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 will 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 will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy or jejunostomy tube; and/or requires the administration of
insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such procedure or nursing task is
not the administration of oral prescribed medication, topical prescribed
medication, oxygen, or metered dose inhaled medication, or a health-related
activity as defined in rule 5123-6-01 of the Administrative Code. (b) The duration of the medical assistance rate modification is
limited to the individual's waiver eligibility span, may be determined
needed or no longer needed within that waiver eligibility span, and may be
renewed annually. (5) Community respite provided to
individuals enrolled in the individual options waiver is subject to the funding
ranges and individual funding levels set forth in rule 5123-9-06 of the
Administrative Code. (6) Payment for community respite does
not include payment for room and board or transportation.
View AppendixView Appendix
Last updated January 2, 2024 at 9:48 AM
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Rule 5123-9-23 | Home and community-based services waivers -
environmental accessibility adaptations under the individual options and level
one waivers.
Effective:
December 1, 2024
(A) Purpose This rule defines environmental accessibility
adaptations and sets forth provider qualifications, requirements for service
delivery and documentation of services, and payment standards for the
service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Environmental
accessibility adaptations" means physical adaptations to an
individual's home (e.g., installation of ramps or grab-bars, widening of
doorways, modification of bathroom facilities, or installation of specialized
electrical systems to operate an individual's medical equipment) that
comply with the following requirements: (a) The physical adaptation to the individual's home
must be: (i) Determined by the
individual's team necessary to: (a) Support the
individual to reside in a community-based setting; and (b) Either: (i) Ensure the health,
welfare, and safety of the individual; or (ii) Enable the
individual to function with greater independence while at home. (ii) Identified in the
individual service plan. (iii) Completed in
accordance with applicable state and local building codes. (b) "Environmental accessibility adaptations"
does not include physical adaptations to the home that: (i) Add to the total
square footage of the home; (ii) Are of general
utility; or (iii) Are not of direct
medical or remedial benefit to the individual (e.g., carpeting, roof repair, or
central air conditioning). (5) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (7) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (8) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (C) Provider qualifications (1) Environmental
accessibility adaptations will 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) An applicant seeking approval to
provide environmental accessibility adaptations will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (3) An applicant seeking approval to
provide environmental accessibility adaptations will submit to the department
documentation verifying the applicant's experience in providing
environmental accessibility adaptations. (4) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) Environmental
accessibility adaptations will be provided pursuant to an individual service
plan that conforms to the requirements of rule 5123-4-02 of the Administrative
Code. (2) A provider of
environmental accessibility adaptations will comply with all applicable state
and local regulations that apply to the operation of the provider's
business or trade. (3) When an individual is
moving from an institutional setting, environmental accessibility adaptations
may be authorized for up to one hundred eighty calendar days prior to the date
on which the individual enrolls in the individual options or level one waiver.
Environmental accessibility adaptations begun while the individual is living in
the institutional setting are not considered complete and the service may not
be billed until the date the individual leaves the institution and enrolls in
the waiver. (E) Documentation of
services Service documentation for environmental
accessibility adaptations will 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 rate for environmental accessibility adaptations are
contained in the appendix to this rule. (2) Claims for payment
for environmental accessibility adaptations will 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 will
be submitted in the format prescribed by the department. (3) Payment for
environmental accessibility adaptations will not exceed ten thousand dollars
per project unless the county board documents the need for an exception in
accordance with paragraph (F)(4) of this rule. (4) When the cost of
needed environmental accessibility adaptations exceeds ten thousand dollars per
project, the department and the county board will collaborate with the
individual and the individual's team to ensure the individual's
health and welfare needs are met either through waiver funding or non-medicaid
funds. When waiver funding is necessary, the county board will submit
documentation to the department establishing how the project will ensure the
individual's health and welfare.
View Appendix
Last updated December 2, 2024 at 9:04 AM
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Rule 5123-9-24 | Home and community-based services waivers - transportation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 2, 2025
(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 apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "Department" means the Ohio
department of developmental disabilities. (3) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 of the Administrative Code and does
not employ, either directly or through contract, anyone else to provide the
services. (4) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (5) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (6) "Modified vehicle"
means: (a) A motor vehicle to be used upon public streets and highways
that has been structurally modified in a permanent manner to meet the physical
or behavioral needs of the individual being transported; or (b) A motor vehicle that has been designed, constructed, or
fabricated and equipped to be used upon public streets and highways for
transportation of individuals who require use of a wheelchair and
that: (i) Has permanent
fasteners to secure a wheelchair to the floor or side of the vehicle to prevent
wheelchair movement; (ii) Has safety harnesses
or belts in the vehicle for the purpose of securing individuals in
wheelchairs; (iii) Is equipped with a
stable access ramp specifically designed for wheelchairs or a hydraulic lift
specifically designed for wheelchairs; and (iv) Is 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 will be documented by the driver
that conducts the inspection. (7) "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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (8) "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 will not replace, medical transportation required under 42 C.F.R. 431.53 as
in effect on the effective date of this rule or 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. (C) Provider qualifications (1) Transportation will
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) An applicant seeking
approval to provide transportation will complete and submit an application and
adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (3) An applicant seeking
approval to provide transportation as an independent provider will present the
applicant's driving record prepared by the bureau of motor vehicles no
earlier than fourteen calendar days prior to the date of application for
initial or renewal provider certification. A person having six or more points
on the person's driving record is prohibited from providing
transportation. (4) An independent
provider of transportation will: (a) Hold a valid driver's license as specified by Ohio
law. (b) Have valid liability insurance as specified by Ohio
law. (c) Immediately notify the department, in writing, if the
independent provider accumulates six or more points on the independent
provider's driving record or has a driver's license suspended or
revoked. (d) Complete testing for controlled substances by a
laboratory certified for such testing within thirty-two hours and complete
testing for blood alcohol level by an entity certified for such testing within
eight hours of a motor vehicle accident involving the driver while the driver
was providing 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
transportation will: (a) Ensure that each driver holds a valid driver's license
as specified by Ohio law. (b) Ensure that each driver is covered by valid liability
insurance as specified by Ohio law. (c) Obtain, for each driver, a driving record prepared by the
bureau of motor vehicles no earlier than fourteen calendar days prior to the
date of initial employment as a driver and at least once every three years
thereafter. A person having six or more points on the person's driving
record is prohibited from providing transportation. (d) Require each driver to immediately notify the agency
provider, in writing, if the driver accumulates six or more points on the
driver's driving record or has a driver's license suspended or
revoked. (e) Ensure that each driver completes testing for
controlled substances by a laboratory certified for such testing within
thirty-two hours and completes testing for blood alcohol level by an entity
certified for such testing within eight hours of a motor vehicle accident
involving the driver while the driver was providing 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 of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in the denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Transportation will
be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. Whenever possible,
family, neighbors, friends, or community agencies that transport people without
charge are to be used to meet an individual's needs. An individual's
need for transportation to be provided in a modified vehicle is to be
documented in the individual service plan. (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 will
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) The number of miles in each trip, as indicated by
recording beginning and ending odometer readings or via tracking or mapping by
a global positioning system. (10) Names of all individuals who were in the vehicle during
any portion of the trip. (11) Written or electronic signature of
the driver of the vehicle or initials of the driver of the vehicle if a
signature and corresponding initials are on file with the
provider. (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 will be applied for each individual being transported
when at least one individual requires the use of a modified vehicle, as
specified in the individual service plan.
View Appendix
Last updated January 3, 2025 at 8:45 AM
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Rule 5123-9-25 | Home and community-based services waivers - specialized medical equipment and supplies under the individual options and level one waivers.
(A) Purpose This rule defines specialized medical equipment
and supplies and sets forth provider qualifications, requirements for service
delivery and documentation of services, and payment standards for the
service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County board" means a
county board of developmental disabilities. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (6) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (7) "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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (8) "Specialized medical equipment
and supplies" means adaptive and assistive devices, controls, or
appliances, specified in the individual service plan, which enable an
individual to increase ability to perform activities of daily living, or to
perceive, control, or communicate with the environment in which the individual
lives. Specialized medical equipment and supplies includes items necessary for
life support, ancillary supplies and equipment necessary to the proper
functioning of such items, and durable and non-durable medical equipment not
available under the medicaid state plan. Specialized medical equipment and
supplies includes repair or maintenance of a previously approved item which is
within its useful life, as well as replacement of a previously approved item
which is beyond its useful life. All items will meet applicable standards of
manufacture, design, and installation. Specialized medical equipment and
supplies does not include: (a) Repair or replacement of a previously approved item
that has been damaged as a result of confirmed misuse, abuse, or
negligence; (b) Items that are not of direct medical or remedial
benefit to the individual; (c) Items otherwise available as assistive technology
described in rule 5123-9-12 of the Administrative Code; (d) For individuals less than twenty-one years of age,
equipment or supplies that are covered under the "Early and Periodic
Screening, Diagnostic, and Treatment Program"; or (e) Equipment or supplies that are covered under the
medicaid state plan described in Chapter 5160-10 of the Administrative
Code. (9) "Useful life" means the
amount of time during which an item is expected to be in service, as determined
by the manufacturer of the item. (C) Provider qualifications (1) Specialized medical
equipment and supplies will 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) An applicant seeking approval to
provide specialized medical equipment and supplies will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (3) An applicant seeking approval to
provide specialized medical equipment and supplies will submit to the
department documentation demonstrating the applicant's qualifications and
experience in providing specialized medical equipment and
supplies. (4) An agency provider will ensure
personnel engaged in the provision of specialized medical equipment and
supplies possess appropriate knowledge, skills, and abilities relative to the
type of equipment or supplies they are providing. (5) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery (1) Specialized medical
equipment and supplies will be provided pursuant to an individual service plan
that conforms to the requirements of rule 5123-4-02 of the Administrative
Code. (2) Prior to authorizing
specialized medical equipment and supplies, an individual's service and
support administrator will document that the item is not covered under the
medicaid state plan. In accordance with rule 5160-10-01 of the Administrative
Code, only the Ohio department of medicaid can determine coverage. A provider
cannot determine whether an item or service is not covered or would not be
covered by the Ohio department of medicaid. Documentation of non-coverage will
include: (a) Notification received from the Ohio department of
medicaid or its designee that a properly submitted prior authorization request
has been processed; or (b) Guidance published by the department or the Ohio
department of medicaid specifying items not covered under the medicaid state
plan. (3) When prior
authorization is required, an individual's service and support
administrator will, upon request by the department, submit the
provider-completed certificate of medical necessity and all supporting
documentation described in rule 5160-10-01 of the Administrative
Code. (4) The provider of specialized medical
equipment and supplies will: (a) Ensure proper installation of equipment, if
required; (b) Provide training to the individual, family, and other
persons, if required; (c) Properly maintain rental equipment, if required;
and (d) Repair equipment as authorized by the county board
representative. (E) Documentation of
services Service documentation for specialized medical
equipment and supplies will 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 rate for specialized medical equipment and supplies
are contained in the appendix to this rule. (2) Payment for
specialized medical equipment and supplies will not exceed ten thousand dollars
per item. When the cost of a needed item exceeds this limit, the department and
the county board will collaborate with the individual and the individual's
team to ensure the individual's health and welfare needs are met. When
necessary: (a) Prior authorization may be requested in accordance with
rule 5123-9-07 of the Administrative Code for an individual enrolled in the
individual options waiver. (b) Non-medicaid funds available to purchase the item will
be identified for an individual enrolled in the level one waiver.
View Appendix
Last updated May 19, 2025 at 2:39 PM
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Rule 5123-9-26 | Home and community-based services waivers - self-directed transportation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines self-directed transportation
and sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "Department" means the Ohio department of
developmental disabilities. (3) "Financial
management services entity" means a governmental entity and/or another
third-party entity designated by the department to perform necessary financial
transactions on behalf of individuals who receive participant-directed
services. (4) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (6) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (7) "Modified
vehicle" means: (a) A motor vehicle to be used upon public streets and
highways that has been structurally modified in a permanent manner to meet the
physical or behavioral needs of the individual being transported;
or (b) A motor vehicle that has been designed, constructed, or
fabricated and equipped to be used upon public streets and highways for
transportation of individuals who require use of a wheelchair and
that: (i) Has permanent
fasteners to secure a wheelchair to the floor or side of the vehicle to prevent
wheelchair movement; (ii) Has safety harnesses
or belts in the vehicle for the purpose of securing individuals in
wheelchairs; (iii) Is equipped with a
stable access ramp specifically designed for wheelchairs or a hydraulic lift
specifically designed for wheelchairs; and (iv) Is inspected, on
each day the vehicle is used to provide self-directed transportation, by the
first driver of the vehicle and prior to transporting an individual in a
wheelchair, to ensure the permanent fasteners, safety harnesses or belts, and
access ramp or hydraulic lift are working. The inspection shall be documented
by the driver that conducts the inspection. (8) "Participant-directed budget" means the total
amount of annual waiver funding available for participant-directed services in
the individual service plan of an individual who chooses to receive
participant-directed services. An individual may reallocate funds among
participant-directed services as long as reallocation is preceded by a
corresponding revision to the individual service plan. (9) "Self-directed
transportation" means a service purchased through the participant-directed
budget, that enables an individual to access activities and opportunities
available in the broader community such as competitive integrated workplaces,
integrated community participation and contribution (e.g., advocacy activities
and events), community resources, and businesses consistent with the individual
service plan. Self-directed transportation enhances independence as it is
available around the clock, including on weekends and holidays, to accommodate
an individual's scheduled and spontaneous transportation
needs. (a) Self-directed transportation includes: (i) Purchase of prepaid
vouchers, cards, passes, or tokens to access modes of ground transportation
available to the general public such as modes available from regional transit
authorities and ride-hailing services (e.g., taxicab, "Lyft," or
"Uber") at the usual and customary rate or fare; and (ii) Per-mile or per-trip
reimbursement made to a person who meets the provider qualifications in
paragraph (C) of this rule and who has a written agreement for provision of
self-directed transportation with the individual being
transported. (b) An individual's self-directed transportation
budget for a waiver eligibility span is determined based on the
individual's needs and consideration of the individual's preferences
and available funds. (10) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (11) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
re-determination date. (C) Provider qualifications (1) Rules 5123-2-08 and
5123-2-09 of the Administrative Code do not apply to providers of self-directed
transportation. (2) Self-directed
transportation will be provided by: (a) A vendor of ground transportation available to the
general public; or (b) A person who receives per-mile or per-trip
reimbursement in accordance with a written agreement for provision of
self-directed transportation with the individual being transported;
or (c) An agency provider or independent provider certified by
the department to provide non-medical transportation in accordance with rule
5123-9-18 of the Administrative Code or transportation in accordance with rule
5123-9-24 of the Administrative Code that agrees to provide self-directed
transportation in accordance with this rule. (3) A person or entity
that provides self-directed transportation will: (a) Meet the requirements of this rule; and (b) Be determined qualified to provide self-directed
transportation by the financial management services entity; and (c) Hold a medicaid provider agreement with the Ohio
department of medicaid or operate under the medicaid provider agreement held by
the financial management services entity. (4) A person seeking
authorization to receive per-mile or per-trip reimbursement for self-directed
transportation will apply to the financial management services entity in the
manner prescribed by the financial management services entity. The financial
management services entity is to ensure that each person seeking
authorization: (a) Presents the person's driving record prepared by
the bureau of motor vehicles no earlier than fourteen calendar days prior to
the date of the person's application. A person having six or more points
on the person's driving record is prohibited from providing self-directed
transportation. (b) Holds a valid driver's license as specified by
Ohio law. (c) Has valid liability insurance as specified by Ohio
law. (d) Completes a background investigation in accordance with
rule 5123-2-02 of the Administrative Code and: (i) Is not included in
one or more of the databases described in paragraphs (C)(2)(a) to (C)(2)(f) of
rule 5123-2-02 of the Administrative Code; and (ii) Does not have a
conviction for, has not pleaded guilty to, or has not been found eligible for
intervention in lieu of conviction for any of the offenses listed or described
in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code if
the corresponding exclusionary period as specified in paragraph (E) of rule
5123-2-02 of the Administrative Code has not elapsed. (5) A person authorized
by the financial management services entity to receive per-mile or per-trip
reimbursement for self-directed transportation will immediately notify the
financial management services entity, in writing, if the person accumulates six
or more points on the person's driving record or if the person's
driver's license is suspended or revoked. (6) Failure to comply
with this rule may result in denial, suspension, or revocation of authorization
to provide self-directed transportation. (D) Requirements for service
delivery (1) Self-directed
transportation will be provided pursuant to an individual service plan that
conforms to the requirements of rule 5123-4-02 of the Administrative
Code. (2) An individual's
need for self-directed transportation to be provided in a modified vehicle is
to be documented in the individual service plan. (E) Documentation of
services (1) Service documentation
for self-directed transportation provided by vendors of ground transportation
available to the general public will include each of the following to validate
payment for medicaid services: (a) Mode of self-directed transportation for which voucher,
card, pass, or token may be used (e.g., bus, light rail transit, livery
vehicle, or ride-hailing service) provided. (b) Date of purchase of voucher, card, pass, or
token. (c) Name of individual receiving service. (d) Medicaid identification number of individual receiving
service. (e) Name of provider. (f) Provider identifier number or provider contract
number. (g) Receipt indicating the amount paid. (2) Service documentation
for self-directed transportation via per-mile or per-trip reimbursement made to
a person who meets the provider qualifications in paragraph (C) of this rule
and who has a written agreement for provision of self-directed transportation
with the individual being transported will include each of the following to
validate payment for medicaid services: (a) Type of motor vehicle used to provide self-directed
transportation (i.e., modified vehicle or non-modified vehicle). (b) Date of service. (c) Name of individual receiving service. (d) Medicaid identification number of individual receiving
service. (e) Name of provider. (f) Provider identifier number or provider contract
number. (g) Origination and destination points of self-directed
transportation provided. (h) Total number of miles of self-directed transportation
provided. (i) Number of individuals being transported. (j) Written or electronic signature of the person
delivering the service, or initials of the person delivering the service if a
signature and corresponding initials are on file with the financial management
services entity. (F) Payment standards (1) The billing units,
service codes, and payment rates for self-directed transportation provided
January 1, 2024 through June 30, 2024 are contained in appendix A to this rule.
The billing units, service codes, and payment rates for self-directed
transportation provided on or after July 1, 2024 are contained in appendix B to
this rule. (2) Payment rates for
vouchers, cards, passes, or tokens to access modes of ground transportation
available to the general public will be at the usual and customary rate or
fare. (3) Reimbursement made to
a person who has a written agreement for provision of self-directed
transportation with the individual being transported may be per-mile or
per-trip: (a) Per-mile reimbursement is established on a per-person
basis, depending on the number of individuals being transported, regardless of
funding source, and whether the service is provided in a modified vehicle or in
a non-modified vehicle. The modified vehicle rate will be billed for each
individual being transported when at least one individual requires the use of a
modified vehicle, as specified in the individual service plan. (b) Per-trip reimbursement may be negotiated by an
individual being transported and the person providing self-directed
transportation up to an amount not to exceed sixteen dollars and fifty-six
cents for each one-way trip.
Last updated January 2, 2024 at 9:48 AM
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Rule 5123-9-27 | Home and community-based services waivers - health care assessment under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2025
(A) Purpose This rule defines health care assessment and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. Health care
assessment is intended to provide right-on-time health assessment to determine
the best clinical course of action, often avoiding unnecessary emergency room
visits and decreasing the need for inpatient admissions; health care assessment
is not intended to replace services provided by an individual's primary
care physician. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Advanced
practice nurse" has the same meaning as in section 4723.01 of the Revised
Code. (2) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Health care assessment"
means using technology to facilitate real-time consultation and support
provided by a physician, a physician assistant, or an advanced practice nurse
to assist an individual and/or the individual's authorized caregivers to
understand the individual's presenting health symptoms and identify
appropriate next steps. Health care assessment: (a) Is consultative in nature, reflects the presentations
and treatments unique to individuals with developmental disabilities, and
provides disability-specific guidance on when best to seek additional or
in-person medical treatment. (b) Includes support and consultation, which is based on
expertise in developmental disabilities, to an individual and/or the
individual's paid and unpaid caregivers and seeks to empower the
individual and build the capacity of caregivers to better understand the best
approach for supporting the individual based on the individual's symptom
presentation. (c) Includes clinical transition of care, conducted
immediately after conclusion of the consultation, from the provider of health
care assessment to the receiving provider to help guide care and provider
coordination, when the provider of health care assessment refers the individual
to the emergency room, urgent care facility, or primary care
physician. (d) Includes follow-up and aftercare, as needed, via a
follow-up consultation with the treated individual and/or the individual's
caregiver, within eighteen hours after the initial consultation. (e) Will not duplicate or replace other home and
community-based services. (f) Is limited to additional services not otherwise covered
under the medicaid state plan (such as the "Early and Periodic Screening,
Diagnostic, and Treatment Program" or in-person medical examinations as
needed) but consistent with waiver objectives of avoiding
institutionalization. (g) Will not be used for routine, ongoing care, thus
replacing an individual's primary care physician. (5) "Individual" means a person
with a developmental disability or for the purposes of giving, refusing to
give, or withdrawing consent for services, the person's guardian in
accordance with section 5126.043 of the Revised Code or other person authorized
to give consent. (6) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (7) "Physician" means a person
authorized by Chapter 4731. of the Revised Code and rules adopted thereunder to
practice medicine and surgery or osteopathic medicine and surgery. (8) "Physician Assistant" means
a person authorized by Chapter 4730. of the Revised Code and rules adopted
thereunder to practice as a physician assistant. (9) "Plan of care" means the
medical treatment plan that is established, approved, and signed by the
treating physician, physician assistant, or advanced practice
nurse. (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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (C) Provider qualifications (1) Health care assessment will be
provided only 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
approval to provide health care assessment will complete and submit an
application and adhere to the requirements of rule 5123-2-08 of the
Administrative Code except that paragraphs (G)(3), (G)(4), (G)(7), (J)(2),
(J)(3), (K), (M), and (R) of that rule do not apply to providers of health care
assessment. The application will include documented evidence of: (a) The applicant's demonstration of at least four
years of experience providing medical care to individuals with developmental
disabilities as well as capability to address, and as necessary triage, medical
needs of individuals with developmental disabilities. (b) The applicant's achievement of positive outcomes
for individuals with developmental disabilities served (e.g., reducing
emergency room visits or individual/caregiver satisfaction with services
provided). (3) At the point of
application for certification and upon request by the department, a provider of
health care assessment will provide a certificate of a continuing policy of
professional liability insurance in an amount of at least one million
dollars. (4) A provider of health care assessment
will ensure the person providing health care assessment is a physician, a
physician assistant, or an advanced practice nurse who: (a) Is properly credentialed and in good standing in
accordance with Ohio law or laws of other states that govern the person's
practice. (b) Has successfully completed, prior to delivering health
care assessment, twenty-five hours of training specifically related to serving
individuals with developmental disabilities. (5) Failure of a provider of health care
assessment to comply with this rule and rule 5123-2-08 of the Administrative
Code may result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service delivery (1) Health care
assessment will be provided pursuant to an individual service plan that
conforms to the requirements of rule 5123-4-02 of the Administrative
Code. (2) To receive health
care assessment, an individual will: (a) Be determined by the individual's team to have a
need for health care assessment and subscribed with a certified provider of the
service. (b) Have access to a mobile smart device or webcam that has
internet service and is capable of two-way audio and video
interactions. (c) Be able to operate the mobile smart device or webcam or
be accompanied by a paid or unpaid caregiver who is able to operate the mobile
smart device or webcam. (3) A provider of health
care assessment will: (a) Be available to provide the service twenty-four hours a
day, three hundred sixty-five days per year. (b) Have capacity to participate in two-way audio and video
interactions with individuals and caregivers and provide immediate evaluations,
video-assisted examinations, and development of plans of care by professionals
with extensive specialized expertise in supporting individuals with
developmental disabilities. (c) Ensure that persons providing health care assessment
are located in a private location that guarantees the privacy of the individual
being served. (d) Ensure that communication with individuals and
caregivers is secure and compliant with state and federal regulations governing
health care assessment services, technology, and privacy, including the Health
Insurance Portability and Accountability Act. (e) Follow-up on each call that involves an individual
being attended by a physician, physician assistant, or advanced practice nurse
by contacting the individual and persons authorized by the individual within
eighteen hours of the initial call. (f) Follow-up on each call that involves an individual
being referred to an emergency room, urgent care facility, or primary care
physician, by contacting the emergency room, urgent care facility, or primary
care physician to coordinate care and ensure advance preparation. (4) Health care
assessment requires face-to-face evaluation by a treating physician, physician
assistant, or advanced practice nurse who is directly engaged with the
individual (and not merely engaged to authorize health care). (5) Health care
assessment will be provided on a one-to-one basis. (E) Documentation of services (1) Service documentation
for health care assessment will include each of the following to validate
payment for medicaid services: (a) Type of service. (b) Name of individual receiving service. (c) Medicaid identification number of individual receiving
service. (d) Name of provider. (e) Provider identifier/contract number. (f) Calendar month and year during which individual is
subscribed. (g) A documentation sheet for each calendar month during
which an individual is subscribed that includes the date, time, and description
of consultation and support provided to the individual and/or the
individual's caregiver or indicates no consultation or support were
provided during the month. The documentation sheet will include written or
electronic signature of the person delivering the service or initials of the
person delivering the service if signatures and corresponding initials are on
file with the provider. (2) Providers of health
care assessment will collect and submit service utilization data by county to
the department on a monthly basis in the format prescribed by the department,
including but not limited to: (a) Dates and times consultation and support were provided
to an individual or an individual's caregiver. (b) Reasons individuals and/or their caregivers used the
service. (c) Service outcomes. (3) Within forty-eight
hours of providing support and consultation to an individual or an
individual's caregiver, a provider of health care assessment
will: (a) Make available to the individual and persons authorized
by the individual, formal documentation of the encounter and, when appropriate,
written instructions regarding actions the individual and/or caregiver should
take post-consultation. (b) Send via secure fax or other means, documentation of
the encounter to the individual's primary care physician as a means to
coordinate care. (F) Payment standards (1) The billing unit,
service codes, and payment rate for health care assessment are contained in the
appendix to this rule. (2) Health care
assessment will be provided as a subscription service billed on a calendar
month basis. (3) Health care
assessment may be billed for an individual who is available for services at
least one day in the calendar month. (4) Health care
assessment will not be billed for an individual who is receiving services in a
hospital, nursing facility, or intermediate care facility for individuals with
intellectual disabilities.
Last updated January 2, 2025 at 8:54 AM
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Rule 5123-9-28 | Home and community-based services waivers - nutrition services under the individual options waiver.
(A) Purpose This rule defines nutrition services and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (5) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code. (6) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (7) "Nutrition
services" means a nutritional assessment and intervention for individuals
who are identified as being at nutritional risk and includes development of a
nutrition care plan, including appropriate means of nutrition intervention
(i.e., nutrition required, feeding modality, nutrition education, and nutrition
counseling). Nutrition services shall not supplant existing services provided
by the federal women, infants, and children program. (8) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that shall include the items delineated in paragraph (E) of
this rule to validate payment for medicaid services. (C) Provider qualifications (1) Nutrition services
shall be provided by a dietitian licensed by the state pursuant to section
4759.06 of the Revised Code who is either an independent provider or the
employee of an agency provider that meets the requirements of this rule and
that has a medicaid provider agreement with the Ohio department of
medicaid. (2) Nutrition services
shall not be provided by a county board or a regional council of governments
formed under section 5126.13 of the Revised Code by two or more county
boards. (3) An applicant seeking
approval to provide nutrition services shall complete and submit an application
through the department's website (http://dodd.ohio.gov/). (4) Failure to comply
with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Nutrition services
shall be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) A dietitian providing
nutrition services shall: (a) Perform nutritional assessments and evaluations in
accordance with the individual service plan; (b) Develop dietary programs, if indicated by the
nutritional assessment and the individual service plan; and (c) Train the individual, family members, professionals,
paraprofessionals, direct care workers, habilitation specialists, and
vocational/school staff regarding the dietary program. (E) Documentation of
services Service documentation for nutrition services
shall include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Group size in which
the service was provided. (10) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (11) Number of units of
the delivered service. (12) Times the delivered
service started and stopped. (F) Payment standards (1) The billing unit,
service codes, and payment rates for nutrition services are contained in
appendix A to this rule. (2) Payment rates for
nutrition services are based on the county cost-of-doing-business category. The
cost-of-doing-business categories are contained in appendix B to this
rule. (3) Payment rates for
nutrition services are established separately for services provided by
independent providers and services provided through agency
providers. (4) Payment rates for
nutrition services are based on the number of individuals receiving
services.
View Appendix
Last updated March 25, 2024 at 9:51 AM
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Rule 5123-9-29 | Home and community-based services waivers - home-delivered meals under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines home-delivered meals and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Home-delivered
meals" means meals delivered to an individual who is otherwise unable to
prepare or obtain nourishing meals. Meals may be ready-to-eat, frozen,
vacuum-packed, modified-atmosphere-packed, or shelf-stable. (a) A maximum of two meals per day may be provided under a home
and community-based services waiver. (b) There are three types of home-delivered meals: (i) Kosher meal, meaning
a meal certified as kosher by a recognized kosher certification or a kosher
establishment under orthodox rabbinic supervision. (ii) Therapeutic meal,
meaning a meal that is part of a therapeutic diet ordered by a licensed
healthcare professional whose scope of practice includes ordering therapeutic
diets: (a) As part of the treatment for a disease or clinical
condition; (b) To modify, eliminate, decrease, or increase certain
substances in the diet; or (c) To provide mechanically altered food (i.e., the texture of
food is altered by chopping, grinding, mashing, or pureeing so that it can be
successfully chewed and safely swallowed) when indicated. (iii) Standard meal,
meaning a meal that is not a kosher meal or a therapeutic meal. (c) "Home-delivered meals" do not include meals that
are processed, frozen, or pre-packaged and commercially available to the
general public. (5) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with section 5126.043 of
the Revised Code or other person authorized to give consent. (7) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (8) "Modified-atmosphere-packed" means the atmosphere
of a package of food is modified so that its composition is different from air
but the atmosphere may change over time due to the permeability of the
packaging material or the respiration of the food and includes reduction in the
proportion of oxygen, total replacement of oxygen, or an increase in the
proportion of other gases such as carbon dioxide or nitrogen. (9) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (10) "Shelf-stable" means non-perishable foods that can
be safely stored at room temperature. (11) "Vacuum-packed" means air is removed from a package
of food and the package is hermetically sealed so that a vacuum remains inside
the package. (C) Provider qualifications (1) Home-delivered meals
will be provided by an independent provider or an agency provider that meets
the requirements of this rule and that has a medicaid provider agreement with
the Ohio department of medicaid. (2) Home-delivered meals
will 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 will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (4) Failure of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Home-delivered meals
will be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. The individual
service plan will specify: (a) The type of home-delivered meals (i.e., kosher meals,
therapeutic meals, or standard meals) to be provided. (b) The number of noontime and/or evening meals to be
provided. (c) The location for meal delivery, which will be the
individual's residence or an alternative location chosen by the
individual. (d) The range of time in which the meals are to be
delivered. (2) A provider of
home-delivered meals will: (a) Be able to provide two meals per day, seven days per
week. (b) Ensure that each meal: (i) Contains at least
one-third of the daily recommended dietary allowances in accordance with the
"Dietary Guidelines for Americans" published by the United States
department of health and human services and the United States department of
agriculture (available at https://health.gov/our-work/nutrition-
physical-activity/dietary-guidelines); and (ii) Includes clear
instructions on how to safely maintain, heat, reheat, and/or assemble the
meal. (c) Ensure that a licensed dietitian approves and signs all menus
and develops all therapeutic meal menus in accordance with the individual
service plan. (d) Ensure handling and delivery of meals meet applicable
federal, state, and local food safety, storage, and sanitation
requirements. (e) Unless the provider uses a common carrier for meal delivery,
maintain a roster of delivery drivers who are trained and have available backup
staff for scheduled meal deliveries. (f) Initiate new orders for home-delivered meals within
seventy-two hours of referral or as otherwise specified in the individual
service plan. (g) Ensure delivery of home-delivered meals is verified
by: (i) Signature of the
individual or the individual's representative upon delivery; (ii) Attestation by the
delivery driver, which may be made via an electronic system, that delivery
occurred; or (iii) Retaining the
common carrier's tracking statement or returned postage-paid delivery
invoice. (h) Replace any home-delivered meal or portion thereof that is
lost or stolen between the time of delivery and intended receipt by the
individual at no cost to the individual, the Ohio department of medicaid, or
the department. (3) On condition that
appropriate methods exist to ensure proper and safe handling by the provider of
home-delivered meals and safe consumption by the individual, the provider
may: (a) Deliver the evening meal with the noontime meal. (b) Deliver all meals for a week at one time during the week when
frozen, vacuum-packed, modified-atmosphere-packed, or shelf-stable meals are
provided. Each frozen, vacuum-packed, modified-atmosphere-packed, or
shelf-stable meal will be individually packaged and labeled with the words,
"use before" or "use by," followed by the month, day, and
year by which the meal is to be used. (E) Documentation of
services Service documentation for home-delivered meals
will include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Type of meals
provided (i.e., kosher meals, therapeutic meals, or standard
meals). (3) Date of
service. (4) Place of
service. (5) Name of individual
receiving service. (6) Medicaid
identification number of individual receiving service. (7) Name of
provider. (8) Provider
identifier/contract number. (9) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. When a provider uses a common carrier for meal delivery, the
provider will verify the success of the delivery by retaining the common
carrier's tracking statement or returned postage-paid delivery invoice. A
provider may use an electronic system to verify delivery. (10) Number of meals
delivered. (11) Time that meals were
delivered. (12) Name of person
accepting delivery of meals, name of delivery driver who attested that delivery
occurred, or the common carrier's tracking statement or returned
postage-paid delivery invoice. (F) Payment standards (1) The billing unit,
service codes, and payment rates for home-delivered meals are contained in the
appendix to this rule. (2) Payment rates for
home-delivered meals are based on the type of meal provided (i.e., kosher meal,
therapeutic meal, or standard meal).
Last updated January 2, 2024 at 9:49 AM
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Rule 5123-9-30 | Home and community-based services waivers - homemaker/ personal care under the individual options and level one waivers.
Effective:
January 1, 2024
(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 apply: (1) "Acute care
hospital" means a hospital that provides inpatient medical care and other
related services for surgery, acute medical conditions, or injuries (usually
for a short-term illness or condition). (2) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code. (3) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (4) "County board" means a
county board of developmental disabilities. (5) "Department" means the Ohio
department of developmental disabilities. (6) "Developmental center"
means a department-operated intermediate care facility for individuals with
intellectual disabilities. (7) "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 will be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (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) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (10) "Group size" means the
number of individuals who are sharing services, regardless of the funding
source for those services. (11) "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 the individual's 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) Implementation of 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. (12) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 of the Administrative Code and does
not employ, either directly or through contract, anyone else to provide the
services. (13) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (14) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (15) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (16) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (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
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. (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
homemaker/personal care if an unanticipated need arises but is not required to
remain awake. This rate and service may only be authorized in the residence of
the individual or at another location in the community selected by the
individual other than the residence of the provider of the
service. (21) "Residential respite" has
the same meaning as in rule 5123-9-34 of the Administrative Code. (22) "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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (23) "Shared living" has the
same meaning as in rule 5123-9-33 of the Administrative Code. (24) "Team" means the group of
persons chosen by an individual with the core responsibility to support the
individual in directing development of the individual service plan. The team
includes the individual's guardian or adult whom the individual has
identified, as applicable, the service and support administrator, direct
support professionals, providers, licensed or certified professionals, and any
other persons chosen by the individual to help the individual consider
possibilities and make decisions. (25) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (26) "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 will 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 will 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 will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (4) Providers licensed
under section 5123.19 of the Revised Code seeking to provide homemaker/personal
care will: (a) Meet all of the requirements set forth in and maintain a
license issued under section 5123.19 of the Revised Code. (b) Maintain a current medicaid provider agreement with the Ohio
department of medicaid. (5) Failure of a certified provider to
comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (6) Failure of a licensed provider to
comply with this rule and Chapter 5123-3 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 will be provided pursuant to an individual service plan that conforms to
the requirements of rule 5123-4-02 of the Administrative Code. Providers will
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 will not also provide money management or shared living
to the same individual. (3) Homemaker/personal care will 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 will 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 will 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) Homemaker/personal
care may be provided to an individual in an acute care hospital to address the
individual's intensive personal care, behavioral support/stabilization, or
communication needs when the following conditions are met: (a) Homemaker/personal care is necessary to ensure smooth
transition between the acute care hospital and the individual's home and
to preserve the individual's functional abilities; (b) Homemaker/personal care is not a substitute for
services the acute care hospital provides or is obligated to provide (e.g.,
attendant care) through its conditions of participation, federal law, state
law, or other applicable requirement; (c) The person providing homemaker/personal care is
awake; (d) A maximum of sixteen hours of homemaker/personal care
per day may be provided to an individual in an acute care
hospital; (e) An individual may receive homemaker/personal care in an
acute care hospital on no more than thirty calendar days per waiver eligibility
span; and (f) The cost of homemaker/personal care provided to an
individual in an acute care hospital can be accommodated by the
individual's budget authorized in the medicaid services
system. (8) A provider of homemaker/personal care
will arrange for substitute coverage, when necessary, only from a provider
certified or approved by the department and as identified in the individual
service plan; notify as applicable, the individual or legally responsible
person in the event that substitute coverage is necessary; and notify the
person identified in the individual service plan when substitute coverage is
not available to allow such person to make other arrangements. (9) A provider delivering
homemaker/personal care in fifteen-minute billing units in accordance with this
rule, excluding on-site/on-call, will utilize electronic visit verification in
accordance with rule 5160-1-40 of the Administrative Code. (10) An agency provider will 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
will 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 provided January
1, 2024 through June 30, 2024 are contained in appendix A to this rule. The
billing units, service codes, and payment rates for homemaker/personal care
provided on or after July 1, 2024 are contained in appendix B 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 C to this
rule. The department may cause independent providers to be paid a rate that
exceeds the payment rates contained in appendix A or appendix B 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 independent providers
and agency providers. (3) Payment rates for
homemaker/personal care will 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 is 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 is 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 is 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, as applicable, the "Application of Appendix A
to Rule 5123-9-30" or the "Application of Appendix B to Rule
5123-9-30" available at https://dodd.ohio.gov. (4) Payment rates for
routine homemaker/personal care will 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 as applicable, appendix A or appendix B to this rule. (a) The department will 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 is
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 will 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 as applicable, appendix A or appendix B to this
rule. (a) The county board will 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 self 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 is 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 will 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 as applicable, appendix A or appendix B to this
rule. (a) The county board will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy or jejunostomy tube; and/or requires the administration of
insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such nursing procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification is
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 will 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 as applicable, appendix A or appendix B to this
rule. (a) An independent provider or a staff member of an agency
provider will be determined eligible for the staff competency rate modification
when the independent provider or staff member: (i) Has successfully
completed at least two years of full-time (or equivalent part-time) paid work
experience providing direct services to individuals; and (ii) Either: (a) Holds a "Professional Advancement Through Training and
Education in Human Services" or "DSPaths" certificate of initial
proficiency or certificate of advanced proficiency; or (b) Within the past five years has successfully completed at
least sixty hours of competency-based training with proof of successful
completion that is available for print, download, or issued to the learner that
includes the name of the learner, the course title, the completion date, and
the number of hours of training completed. For purposes of this paragraph,
"competency-based training" means online or in-person training in
topics not otherwise required by rule 5123-2-08, rule 5123-2-09, rule
5123-17-02, Chapter 5123-3, 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 will be determined by the department when documentation
submitted by the independent provider 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 will be determined by the employing agency
provider. The employing agency provider will 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 is 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 will 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 will
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;
(vi) Emergency action
needed to keep the individual safe; and (vii) On-site/on-call
will be delivered in the residence of the individual or at another location in
the community selected by the individual other than the residence of the
provider of the service. (b) A provider will be paid at the on-site/on-call rate for
homemaker/personal care contained in as applicable, appendix A or appendix B 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 will
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 will 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
does not include room and board, items of comfort and convenience, or costs for
the maintenance, upkeep, and improvement of the home in which
homemaker/personal care is provided.
View AppendixView AppendixView Appendix
Last updated January 2, 2024 at 9:57 AM
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Rule 5123-9-31 | Home and community-based services waivers - homemaker/ personal care daily billing unit for sites where individuals enrolled in the individual options waiver share services.
Effective:
January 1, 2024
(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 will 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 apply: (1) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which entity is certified
in accordance with rule 5123-2-08 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 the person is
certified in accordance with rule 5123-2-09 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, the person's 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
includes 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 will 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
will use 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 will use 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 will 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 will
use 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 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 will 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, will be followed. (2) The process for
establishing applicable rate modifications, set forth in paragraph (F) of rule
5123-9-30 of the Administrative Code, will 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, will 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 will 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 will use that
information to prepare a claim for payment. (7) Within thirty
calendar days of the end of each calendar month, an agency provider will 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 will 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 will 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
does not include room and board, items of comfort or convenience, or costs for
the maintenance, upkeep, and improvement of the home in which
homemaker/personal care is provided. (G) Monitoring (1) Agency providers,
county boards, and the department will 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 will be made available to the Ohio department of medicaid upon
request. (2) The department will
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.
View Appendix
Last updated January 2, 2024 at 9:58 AM
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Rule 5123-9-32 | Home and community-based services waivers - participant-directed homemaker/personal care under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(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 apply: (1) "Acute care
hospital" means a hospital that provides inpatient medical care and other
related services for surgery, acute medical conditions, or injuries (usually
for a short-term illness or condition). (2) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code. (3) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (4) "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. (5) "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. (6) "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 will not employ, either directly or through contract,
anyone else to provide participant-directed homemaker/personal
care. (7) "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. (8) "County board" means a
county board of developmental disabilities. (9) "Department" means the Ohio
department of developmental disabilities. (10) "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. (11) "Family" means a person who
is related to the individual by blood, marriage, or adoption. (12) "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 will be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (13) "Financial management
services" means services provided to an individual who directs some or all
of the individual's waiver services. When used in conjunction with
employer authority, financial management services includes, but is not limited
to, operating a payroll service for individual-employed staff and making
required payroll withholdings. (14) "Group employment support"
has the same meaning as in rule 5123-9-16 of the Administrative
Code. (15) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (16) "Individual employment
support" has the same meaning as in rule 5123-9-15 of the Administrative
Code. (17) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (18) "Money management" has the
same meaning as in rule 5123-9-20 of the Administrative Code. (19) "Non-medical
transportation" has the same meaning as in rule 5123-9-18 of the
Administrative Code. (20) "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. (21) "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. This rate and service may only be
authorized in the residence of the individual or at another location in the
community selected by the individual other than the residence of the provider
of the service. (22) "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 the individual's 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) Implementation of 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. (23) "Provider" means an agency
with choice or a common law employee. (24) "Residential respite" has
the same meaning as in rule 5123-9-34 of the Administrative Code. (25) "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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (26) "Shared living" has the
same meaning as in rule 5123-9-33 of the Administrative Code. (27) "Team" means the group of
persons chosen by an individual with the core responsibility to support the
individual in directing development of the individual service plan. The team
includes the individual's guardian or adult whom the individual has
identified, as applicable, the service and support administrator, direct
support professionals, providers, licensed or certified professionals, and any
other persons chosen by the individual to help the individual consider
possibilities and make decisions. (28) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (29) "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 will 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 will be provided by a common law employee or
an agency with choice. (3) A provider of
participant-directed homemaker/personal care will 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 will provide participant-directed
homemaker/personal care. (5) A provider of
participant-directed homemaker/personal care is subject to the requirements of
rule 5123-2-08 or 5123-2-09 of the Administrative Code, as applicable, except
that: (a) A common law employee need not hold a high school diploma or
certificate of high school equivalence, "American Red Cross" or
equivalent certification in first aid, or "American Red Cross" or
equivalent certification in cardiopulmonary resuscitation unless specifically
required to do so by the individual receiving services; and (b) A common law employee need not complete the eight hours of
annual training described in appendix A to rule 5123-2-09 of the Administrative
Code unless specifically required to do so by the individual receiving
services, but in any case will annually complete training in accordance with
standards established by the department in: (i) The rights of
individuals set forth in section 5123.62 of the Revised Code; and (ii) Rule 5123-17-02 of
the Administrative Code including a review of health and welfare alerts issued
by the department since the previous year's training. (6) A provider of
participant-directed homemaker/personal care will 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 will
complete and submit an application and adhere to the requirements of as
applicable, rule 5123-2-08 or 5123-2-09 of the Administrative
Code. (8) The individual
receiving participant-directed homemaker/personal care will determine training
to be completed by the common law employee or staff of the agency with choice
as necessary to meet the individual's unique needs. (9) Failure of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) The individual
receiving participant-directed homemaker/personal care or the individual's
guardian or the individual's designee must be willing and able to perform
the duties associated with participant direction. (2) Participant-directed
homemaker/personal care will 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 will not also provide money
management or shared living to the same individual. (5) Participant-directed
homemaker/personal care will 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 will 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) Participant-directed
homemaker/personal care may be provided to an individual in an acute care
hospital to address the individual's intensive personal care, behavioral
support/stabilization, or communication needs when the following conditions are
met: (a) Participant-directed homemaker/personal care is
necessary to ensure smooth transition between the acute care hospital and the
individual's home and to preserve the individual's functional
abilities; (b) Participant-directed homemaker/personal care is not a
substitute for services the acute care hospital provides or is obligated to
provide (e.g., attendant care) through its conditions of participation, federal
law, state law, or other applicable requirement; (c) The person providing participant-directed
homemaker/personal care is awake; (d) A maximum of sixteen hours of participant-directed
homemaker/personal care per day may be provided to an individual in an acute
care hospital; (e) An individual may receive participant-directed
homemaker/personal care in an acute care hospital on no more than thirty
calendar days per waiver eligibility span; and (f) The cost of participant-directed homemaker/personal
care provided to an individual in an acute care hospital can be accommodated by
the individual's budget authorized in the medicaid services
system. (9) A provider will 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. (10) The ratio of persons providing
participant-directed homemaker/personal care to the individuals being served
will not exceed one to three. (11) A provider of participant-directed
homemaker/personal care will arrange for substitute coverage, when necessary,
only from a provider certified or approved by the department and as identified
in the individual service plan; notify as applicable, the individual or legally
responsible person in the event that substitute coverage is necessary; and
notify the person identified in the individual service plan when substitute
coverage is not available to allow such person to make other
arrangements. (12) A provider delivering
participant-directed homemaker/personal care in accordance with this rule,
excluding on-site/on-call, will 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 will 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
will 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 provided January 1, 2024 through June 30, 2024 are contained in appendix A
to this rule. The billing unit, service codes, and payment rates for
participant-directed homemaker/personal care provided on or after July 1, 2024
are contained in appendix B to this rule. (2) The payment rates for
participant-directed homemaker/personal care provided by a common law employee
are negotiated by the individual and the common law employee subject to the
minimum and maximum payment rates contained in as applicable, appendix A or
appendix B to this rule and will 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 are 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 as applicable, appendix
A or appendix B to this rule. (a) The department will 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 is
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 as applicable, appendix
A or appendix B to this rule. (a) The county board will determine that an individual meets the
criteria for the medical assistance rate modification when: (i) The individual
requires the administration of fluid, nutrition, and/or prescribed medication
through gastrostomy or jejunostomy tube; and/or requires the administration of
insulin through subcutaneous injection, inhalation, or insulin pump; and/or
requires the administration of medication for the treatment of metabolic
glycemic disorder by subcutaneous injection; or (ii) The individual requires a nursing procedure or nursing task
that a licensed nurse agrees to delegate in accordance with rules in Chapter
4723-13 of the Administrative Code, which is provided in accordance with
section 5123.42 of the Revised Code, and when such nursing procedure or nursing
task is not the administration of oral prescribed medication, topical
prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule 5123-6-01 of the Administrative
Code. (b) The duration of the medical assistance rate modification is
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 as applicable, appendix A or appendix B to this
rule. (a) The county board will 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 self 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 is 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 will 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 will
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;
(vi) Emergency action
needed to keep the individual safe; and (vii) On-site/on-call will be delivered in the residence of
the individual or at another location in the community selected by the
individual other than the residence of the provider of the
service. (b) A provider will be paid at the on-site/on-call rate for
participant-directed homemaker/personal care contained in as applicable,
appendix A or appendix B 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 will
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 will 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 does not include room and board,
items of comfort and convenience, or costs for the maintenance, upkeep, and
improvement of the home in which participant-directed homemaker/personal care
is provided.
View AppendixView Appendix
Last updated January 2, 2024 at 9:58 AM
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Rule 5123-9-33 | Home and community-based services waivers - shared living under the individual options waiver.
Effective:
January 1, 2024
(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) "Acute care
hospital" means a hospital that provides inpatient medical care and other
related services for surgery, acute medical conditions, or injuries (usually
for a short-term illness or condition). (2) "Adult" means a person
eighteen years of age or older. (3) "Agency provider" means an
entity that directly employs at least one person in addition to a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (4) "Community respite" has the
same meaning as in rule 5123-9-22 of the Administrative Code. (5) "County board" means a
county board of developmental disabilities. (6) "Department" means the Ohio
department of developmental disabilities. (7) "Group size" means the
number of individuals who are sharing services, regardless of the funding
source for those services. (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 the person is
certified in accordance with rule 5123-2-09 of the Administrative Code and 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (11) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (12) "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. (13) "Primary legal
residence" means the residence where a shared living caregiver has a
permanent and principal establishment, where that person has a right to reside,
and to where, whenever that person is absent, that person intends to return. A
person has one, and only one, primary legal residence at a time. (14) "Related to" means the
caregiver is the individual's: (a) Parent or stepparent; (b) Sibling or stepsibling; (c) Grandparent; (d) Grandchild; (e) Aunt, uncle, nephew, or niece; (f) Cousin; or (g) Child or stepchild. (15) "Residential respite" has
the same meaning as in rule 5123-9-34 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 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (18) "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, when twenty per
cent or more of the personal care and support is provided by one or more adult
caregivers who reside 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 the
individual's 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, 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 the 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 the individual's 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. (19) "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 will 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 will
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 and has been approved by the probate
court to provide the services. (4) An applicant seeking approval to
provide shared living will complete and submit an application and adhere to the
requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (5) Failure of an agency provider or an
independent provider to comply with this rule and as applicable, rule 5123-2-08
or 5123-2-09 of the Administrative Code, may result in denial, suspension, or
revocation of the provider's certification. (6) Failure of a licensed residential
facility to comply with this rule and Chapter 5123-3 of the Administrative Code
may result in denial, suspension, or revocation of the residential
facility's license. (D) Requirements for service
delivery (1) Except as provided in
paragraph (G) of this rule, residential supports will be authorized as shared
living for an individual enrolled in the individual options waiver who receives
services meeting the definition of shared living as set forth in this
rule. (2) Shared living will 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 will not exceed four. (4) An independent provider will reside
in the home where shared living is provided and that home must be the
independent provider's primary legal residence. (5) An agency provider will employ or
contract with a person to be the caregiver who will reside in the home where
shared living is provided and that home must be the person's primary legal
residence. (6) Shared living will 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. (7) An independent provider of shared
living will not bill homemaker/personal care or deliver state plan home health
aide services as an employee of an agency to an individual for whom the
independent provider provides shared living. (8) An individual who resides in a shared
living setting may receive community respite at the full day billing unit or
residential respite at the daily billing unit during a short-term absence or
need for relief of the shared living caregiver on a day the shared living
caregiver does not bill for provision of shared living. (9) An individual who
resides in a shared living setting may receive residential respite at the
fifteen-minute billing unit for the temporary relief of the shared living
caregiver on a day the shared living caregiver bills for provision of shared
living as long as: (a) Residential respite and shared living services are not
delivered at the same time; (b) Residential respite is not provided by the shared
living caregiver or any other person who resides in the shared living
setting; (c) No more than twelve hours of residential respite are
provided to the individual on that day; and (d) No more than two hundred eight fifteen-minute billing
units of residential respite are provided per calendar month. (10) An individual who
resides in a shared living setting may receive homemaker/personal care on a day
the shared living caregiver does not bill for provision of shared living when
the services are provided by an approved provider of homemaker/personal care
who is not the shared living caregiver or any other person who resides in the
shared living setting. (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, the shared living
provider will 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) Shared living may be
provided to an individual in an acute care hospital to address the
individual's intensive personal care, behavioral support/stabilization, or
communication needs when the following conditions are met: (a) Shared living is necessary to ensure smooth transition
between the acute care hospital and the individual's home and to preserve
the individual's functional abilities; (b) Shared living is not a substitute for services the
acute care hospital provides or is obligated to provide (e.g., attendant care)
through its conditions of participation, federal law, state law, or other
applicable requirement; and (c) An individual may receive shared living in an acute
care hospital on no more than thirty calendar days per waiver eligibility
span. (12) A provider of shared
living will 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 will include contact
information for and a requirement to notify: (a) As applicable, the individual or legally responsible person
in the event that substitute coverage is necessary; and (b) The person identified in the individual service plan when
substitute coverage is not available to allow such person to make other
arrangements. (E) Documentation of
services Service documentation for shared living will
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 provided January 1, 2024
through June 30, 2024 are contained in appendix A to this rule. The billing
unit, service codes, and payment rates for shared living provided on or after
July 1, 2024 are contained in appendix B to this rule. (2) Payment for shared
living will be at a daily billing unit. Payment rates are adjusted based on the
county cost-of-doing-business category. The cost-of-doing-business categories
are contained in appendix C 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 is adjusted to reflect the group size: (a) Payment for one individual is 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 is 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 is 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 is sixty-five per cent of
the daily rate for the Ohio developmental disabilities profile range for each
individual. (5) Shared living will not be billed on
the same day as community respite at the full day billing unit or residential
respite at the daily billing unit. (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 will
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 as
applicable, appendix A or appendix B 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) Exemptions from shared
living (1) 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 choose to continue to receive
homemaker/personal care from that caregiver as an alternative to shared living,
unless the individual experiences a significant change. (2) An individual
enrolled in the individual options waiver who receives services meeting the
definition of shared living as set forth in this rule may choose to receive
homemaker/personal care from that caregiver as an alternative to shared living
when the individual: (a) Has been assessed to need two-to-one staffing;
or (b) Has been assessed to need awake staff present around
the clock; or (c) Meets the criteria for the behavioral support rate
modification described in paragraph (F)(4) of rule 5123-9-30 of the
Administrative Code; or (d) Meets the criteria for the complex care rate
modification described in paragraph (F)(5) of rule 5123-9-30 of the
Administrative Code.
View AppendixView AppendixView Appendix
Last updated January 2, 2024 at 9:58 AM
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Rule 5123-9-34 | Home and community-based services waivers - residential respite under the individual options, level one, and self-empowered life funding waivers.
(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 apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County board" means a
county board of developmental disabilities. (3) "Department" means the Ohio
department of developmental disabilities. (4) "Group
size" means the number of individuals who are sharing services, regardless
of the funding source for those services. (5) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (6) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (8) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (9) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (10) "Participant-directed
homemaker/personal care" has the same meaning as in rule 5123-9-32 of the
Administrative Code. (11) "Residential facility"
means a home or facility, including an intermediate care facility for
individuals with intellectual disabilities, in which an individual with a
developmental disability resides, that is licensed by the department pursuant
to section 5123.19 of the Revised Code. (12) "Residential respite" means
care and support services furnished to an individual on a short-term basis
because of the absence or need for relief of those persons routinely providing
care. Depending on the circumstances of service provision, residential respite
is billed at a daily billing unit or at a fifteen-minute billing
unit: (a) Residential respite at the daily billing unit (i) Residential respite
at the daily billing unit will be used when: (a) Residential respite is provided to an individual for more
than seven hours during a twenty-four hour period and the individual stays
overnight at the residential respite service delivery location;
and (b) A shared living caregiver does not bill for provision of
shared living to the individual on that day. (ii) Residential respite
at the daily billing unit will be provided by: (a) A residential facility; (b) An agency provider; or (c) An independent provider. (iii) Residential respite
at the daily billing unit may be provided at: (a) A residential facility; (b) The individual's home; (c) The home of the employee of an agency provider who is
providing the service; or (d) The home of the independent provider who is providing the
service. (b) Residential respite at the fifteen-minute billing
unit (i) Residential respite
at the fifteen-minute billing unit is available only to an individual who
resides in a shared living setting and will be used when residential respite is
provided to the individual on the same day the shared living caregiver bills
for provision of shared living. (ii) Residential respite
at the fifteen-minute billing unit may be provided by: (a) A residential facility other than an intermediate care
facility for individuals with intellectual disabilities; (b) An agency provider; or (c) An independent provider. (iii) Residential respite
at the fifteen-minute billing unit will be provided at: (a) A residential facility other than an intermediate care
facility for individuals with intellectual disabilities; (b) The individual's home; (c) The home of the employee of an agency provider who is
providing the service; (d) The home of the independent provider who is providing the
service; or (e) Another location chosen by the individual. (iv) The residential
respite fifteen-minute billing unit 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 will be added together for the purpose of calculating
the number of fifteen-minute billing units for the day. (13) "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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (14) "Shared living" has the
same meaning as in rule 5123-9-33 of the Administrative Code. (15) "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
will be provided by a residential facility, 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 residential respite will complete and submit an application and adhere
to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (3) Failure of a certified provider to
comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (4) Failure of a licensed provider to
comply with this rule and Chapter 5123-3 of the Administrative Code may result
in denial, suspension, or revocation of the provider's
license. (D) Requirements for service delivery (1) Residential respite will 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 will
address emergency and replacement coverage should the individual unexpectedly
need to leave the residential respite service delivery location. (3) Residential respite
at the daily billing unit may be provided at a residence other than a
residential facility 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 at the daily
billing unit is limited to ninety calendar days of service per waiver
eligibility span. (5) Residential respite
at the fifteen-minute billing unit is limited to two hundred eight units per
calendar month. (6) Residential respite will not be
provided to an individual at the same time as homemaker/personal care,
participant-directed homemaker/personal care, or shared living. (7) An individual who
resides in a shared living setting may receive residential respite at the daily
billing unit during a short-term absence or need for relief of the shared
living caregiver on a day the shared living caregiver does not bill for
provision of shared living. (8) An individual who
resides in a shared living setting may receive residential respite at the
fifteen-minute billing unit for the temporary relief of the shared living
caregiver on a day the shared living caregiver bills for provision of shared
living as long as: (a) Residential respite and shared living services are not
delivered at the same time; (b) Residential respite is not provided by the shared living
caregiver or any other person who resides in the shared living setting;
and (c) No more than twelve hours of residential respite are provided
to the individual on that day. (9) A provider delivering
residential respite in fifteen-minute billing units will utilize electronic
visit verification in accordance with rule 5160-32-01 of the Administrative
Code. (E) Documentation of services Service documentation for residential respite
will include each of the following to validate payment for medicaid
services: (1) Type of service (i.e., residential
respite daily billing unit or residential respite fifteen-minute billing
unit). (2) Date of service. (3) Times the delivered
service started and stopped. (4) Place of service. (5) Name of individual receiving
service. (6) Medicaid identification number of
individual receiving service. (7) Name of provider. (8) Provider identifier/contract
number. (9) Written or electronic signature of
the person delivering the service, or initials of the person delivering the
service if a signature and corresponding initials are on file with the
provider. (10) 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) The payment rates for
residential respite vary by type of provider. (3) The rate paid to a
provider delivering residential respite in fifteen-minute billing units is
adjusted to reflect the group size: (a) Payment for serving an individual in a group size of
two is eighty-five per cent of the rate for serving one
individual. (b) Payment for serving an individual in a group size of
three is seventy-five per cent of the rate for serving one
individual. (c) Payment for serving an individual in a group size of
four is sixty-five per cent of the rate for serving one
individual. (4) Only one provider may bill a daily
billing unit for provision of residential respite for the same individual on
any given day. (5) 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. (6) Payment for residential respite does
not include payment for room and board or transportation.
View Appendix
Last updated July 1, 2024 at 4:37 PM
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Rule 5123-9-35 | Home and community-based services waivers - remote support under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines remote support and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "Backup support
person" means the person who is responsible for responding in the event of
an emergency or when an individual receiving remote support otherwise needs
assistance or the equipment used for delivery of remote support stops working
for any reason. Backup support may be provided on an unpaid basis by a family
member, friend, or other person selected by the individual or on a paid basis
by an agency provider of homemaker/personal care for an individual enrolled in
the individual options waiver or level one waiver or in an agency-with-choice
arrangement for participant-directed homemaker/personal care provided to an
individual enrolled in the self-empowered life funding waiver, as applicable.
When backup support is provided on a paid basis by an agency provider or in an
agency-with-choice arrangement, the agency provider will 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 will 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 the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (10) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (11) "Monitoring
base" means the off-site location from which the remote support staff
monitor an individual. (12) "Participant-directed homemaker/personal
care" has the same meaning as in rule 5123-9-32 of the Administrative
Code. (13) "Remote
support" means the provision of supports by staff of an agency provider at
a remote location who are engaged with an individual through equipment with the
capability for live two-way communication. Equipment used to meet this
requirement will 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 5123-5-02 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 includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (19) "Shared
living" has the same meaning as in rule 5123-9-33 of the Administrative
Code. (20) "Team"
means the group of persons chosen by an individual with the core responsibility
to support the individual in directing development of the individual service
plan. The team includes the individual's guardian or adult whom the
individual has identified, as applicable, the service and support
administrator, direct support professionals, providers, licensed or certified
professionals, and any other persons chosen by the individual to help the
individual consider possibilities and make decisions. (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 will
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 will
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 will complete and submit an application and
adhere to the requirements of rule 5123-2-08 of the Administrative
Code. (4) Staff of agency
providers and entities under contract with agency providers who monitor
individuals from the monitoring base will complete the training specified in
appendix C to rule 5123-2-08 of the Administrative Code. (5) Failure of a
certified provider to comply with this rule and rule 5123-2-08 of the
Administrative Code may result in denial, suspension, or revocation of the
provider's certification. (6) Failure of a licensed
provider to comply with this rule and Chapter 5123-3 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, will assess whether remote support is sufficient to
ensure the individual's health and welfare. (3) Remote support will
be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (4) Remote support will
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 will not have duties other than remote
support. (5) Remote support will
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 will 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 will consent in writing. The
individual's service and support administrator will keep a copy of each
signed consent form with the individual service plan. (7) The remote support
vendor will provide initial and ongoing training to its staff to ensure they
know how to use the monitoring base system. (8) The remote support
vendor will 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 will have other backup systems and additional safeguards in
place including but 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 will 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 will 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 will 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
will 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 will stay engaged with the individual during an emergency
until emergency personnel or the backup support person arrives. (a) The backup support person will verbally acknowledge
receipt of a request for assistance from the remote support staff. (b) The backup support person will 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 will: (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 will 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 will 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
will 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 will 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 will 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 will
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 provided January 1, 2024
through June 30, 2024 are contained in appendix A to this rule. The billing
units, service codes, and payment rates for remote support provided on or after
July 1, 2024 are contained in appendix B 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 will bill for the remote
support. (b) When an individual receives remote support with paid
backup support, the remote support provider will 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 will 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 is divided equally among the individuals concurrently
receiving remote support.
Last updated January 2, 2024 at 9:58 AM
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Rule 5123-9-36 | Home and community-based services waivers - interpreter services under the individual options waiver.
(A) Purpose This rule defines interpreter services and sets
forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (5) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code. (6) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (7) "Interpreter
services" means the process by which one person's message is conveyed
to another in a manner that incorporates both the message and attitude of the
communicator. (8) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that shall include the items delineated in paragraph (E) of
this rule to validate payment for medicaid services. (C) Provider qualifications (1) Interpreter services
shall be provided by a person who: (a) Holds a certification recognized by the registry of
interpreters for the deaf; (b) Is either an independent provider or the employee of an
agency provider that meets the requirements of this rule and that has a
medicaid provider agreement with the Ohio department of medicaid;
and (c) Meets one of the following standards: (i) Has graduated from an
interpreter training program (of a minimum of two-years) and has at least one
year of documented experience providing interpreter services; (ii) Has successfully
completed a written test administered by the registry of interpreters for the
deaf and has at least one year of documented experience providing interpreter
services; or (iii) Has at least two
years of documented experience interpreting for persons who are deaf or hard of
hearing. (2) An applicant seeking
approval to provide interpreter services shall complete and submit an
application through the department's website
(http://dodd.ohio.gov/). (3) Failure to comply
with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Interpreter services
shall be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) A person providing
interpreter services shall: (a) Maintain a role of facilitator of communication rather
than the initiator of communication; and (b) Render the message faithfully, always conveying the
content and spirit of the individual being served, using language most readily
understood by the individual. (3) A person providing
interpreter services shall not counsel, advise, or interject personal
opinions. (E) Documentation of
services Service documentation for interpreter services
shall include each of the following to validate payment for medicaid
services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service, or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Group size in which
the service was provided. (10) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (11) Number of units of
the delivered service. (12) Times the delivered
service started and stopped. (F) Payment standards (1) The billing unit,
service code, and payment rates for interpreter services are contained in
appendix A to this rule. (2) Payment rates for
interpreter services are based on the county cost-of-doing-business category.
The cost-of-doing-business categories are contained in appendix B to this
rule. (3) Payment rates for
interpreter services are established separately for services provided by
independent providers and services provided through agency
providers. (4) Payment rates for
interpreter services are based on the number of individuals receiving
services.
View AppendixView Appendix
Last updated March 25, 2024 at 9:52 AM
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Rule 5123-9-37 | Home and community-based services waivers - waiver nursing delegation under the individual options, level one, and self-empowered life funding waivers.
Effective:
January 1, 2024
(A) Purpose This rule defines waiver nursing delegation and
sets forth provider qualifications, requirements for service delivery and
documentation of services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult day
services" means adult day support, career planning, group employment
support, individual employment support, and vocational habilitation as those
services are defined in Chapter 5123-9 of the Administrative Code. (2) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (3) "County
board" means a county board of developmental disabilities. (4) "Delegating
nurse" means the nurse who delegates a nursing task or assumes
responsibility for individuals who are receiving delegated nursing care in
accordance with Chapter 4723-13 or 5123-6 of the Administrative
Code. (5) "Department" means the Ohio department of
developmental disabilities. (6) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day will be added together for the purpose of calculating
the number of fifteen-minute billing units for that day. (7) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (9) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (10) "Licensed
nurse" means a registered nurse or a licensed practical
nurse. (11) "Licensed
practical nurse" has the same meaning as in section 4723.01 of the Revised
Code and for purposes of this rule, may practice waiver nursing delegation only
at the direction of a registered nurse. (12) "Provider"
means an agency provider or an independent provider. (13) "Registered
nurse" has the same meaning as in section 4723.01 of the Revised
Code. (14) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (15) "Significant
change" means a decline or improvement in an individual's medical
condition or a change in location of service delivery. (16) "Team"
means the group of persons chosen by an individual with the core responsibility
to support the individual in directing development of the individual service
plan. The team includes the individual's guardian or adult whom the
individual has identified, as applicable, the service and support
administrator, direct support professionals, providers, licensed or certified
professionals, and any other persons chosen by the individual to help the
individual consider possibilities and make decisions. (17) "Unlicensed
personnel" means a person not currently licensed by the board of nursing
as a registered nurse or licensed practical nurse, or a person who does not
hold a current valid certificate to practice as a dialysis technician or
administer medications as a medication aide. (18) "Waiver nursing
delegation" means activities related to the transfer of responsibility for
performance of a specific nursing task from a licensed nurse authorized to
perform the task to unlicensed personnel. Waiver nursing delegation has two
distinct components: (a) Waiver nursing delegation/assessment, when the
delegating nurse who is a registered nurse, conducts a comprehensive assessment
of an individual's health for the purpose of determining the
appropriateness of delegating nursing tasks to be performed for the
individual. (b) Waiver nursing delegation/consultation, when the
delegating nurse who is either a registered nurse or a licensed practical nurse
at the direction of a registered nurse in accordance with rule 4723-13-05 of
the Administrative Code, consults with an individual, a physician who ordered a
delegated nursing task, or unlicensed personnel to whom the delegating nurse
has delegated responsibility for a nursing task. Waiver nursing
delegation/consultation includes: (i) Evaluation of the
ability of unlicensed personnel to perform the delegated task such
as: (a) Verifying that unlicensed personnel have successfully
completed prerequisite training; or (b) Observing a return demonstration of a delegated task
performed by unlicensed personnel. (ii) Development and
implementation of a delegation plan such as: (a) Verifying medications and treatments ordered by
physicians; (b) Creating or modifying individual-specific instructions
for performing delegated nursing tasks; (c) Identifying expected outcomes of delegated nursing
tasks; (d) Identifying possible side effects of prescribed
medication being administered under nursing delegation; (e) Providing instructions for documenting when a delegated
task is completed or omitted; (f) Confirming medications/supplies necessary for the
delegated tasks are available in the service setting; or (g) Completing delegation-related documentation such as
medication administration records. (iii) Evaluation of
progress of nursing delegation such as: (a) Consulting with the individual receiving services,
physicians, or unlicensed personnel performing delegated nursing tasks via
in-person contact, telephone calls, teleconferencing, videoconferencing, or
other means; or (b) Reviewing delegation-related documentation such as
medication administration records, progress notes, physician's orders, or
hospital discharge records. (C) Provider qualifications (1) Waiver nursing
delegation will be provided by an agency provider or an independent provider
that meets the requirements of this rule and that has a medicaid provider
agreement with the Ohio department of medicaid. (2) The person providing
waiver nursing delegation will: (a) Be a registered nurse or a licensed practical nurse
with current valid licensure in good standing to practice nursing in Ohio
pursuant to Chapter 4723. of the Revised Code; and (b) Be working within the scope of practice as set forth in
Chapter 4723. of the Revised Code and administrative rules adopted
thereunder. (3) A county board or a
regional council of governments formed under section 5126.13 of the Revised
Code by two or more county boards may provide waiver nursing delegation only
when no other certified provider is willing and able. (4) A family member who
lives with an individual is not eligible to be paid for waiver nursing
delegation provided to that individual. (5) An applicant seeking
approval to provide waiver nursing delegation will complete and submit an
application and adhere to the requirements of as applicable, rule 5123-2-08 or
5123-2-09 of the Administrative Code. (6) Failure of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Waiver nursing
delegation will be provided pursuant to a person-centered individual service
plan that conforms to the requirements of rule 5123-4-02 of the Administrative
Code. The individual service plan will identify the providers that may provide
waiver nursing delegation. When an individual receives waiver nursing
delegation in multiple settings and/or from multiple providers, the team will
determine and specify in the individual service plan, the allocation of waiver
nursing delegation/assessment and/or waiver nursing delegation/consultation
services to each provider. (2) An individual may
receive up to: (a) One waiver nursing delegation/assessment every sixty
days in the individual's residential setting; and (b) One waiver nursing delegation/assessment every sixty
days in the individual's adult day services setting. (3) An individual may
receive up to ten hours of waiver nursing delegation/consultation each month,
regardless of the number of providers delivering the service. (4) Waiver nursing
delegation/assessment may be billed sequentially to, but not concurrently with,
waiver nursing delegation/consultation. (5) Waiver nursing
delegation does not include time spent by a licensed nurse: (a) Participating in individual service plan development
meetings; (b) Consulting with an individual's team on matters
not specifically related to waiver nursing delegation for that
individual; (c) Directly providing nursing services; (d) Coordinating an individual's health
care; (e) Conducting general health-related training for
unlicensed personnel; or (f) Conducting training described in Chapter 5123-6 of the
Administrative Code. (6) A provider of waiver
nursing delegation will utilize electronic visit verification in accordance
with rule 5160-1-40 of the Administrative Code. (E) Documentation of
services (1) Service documentation
for waiver nursing delegation/assessment and waiver nursing
delegation/consultation will include each of the following to validate payment
for medicaid services: (a) Type of service (i.e., waiver nursing
delegation/assessment or waiver nursing delegation/consultation). (b) Date of service. (c) Place of service. (d) Name of individual receiving service. (e) Medicaid identification number of individual receiving
service. (f) Name of provider. (g) Provider identifier/contract number. (h) Written or electronic signature of the person
delivering the service or initials of the person delivering the service if a
signature and corresponding initials are on file with the
provider. (i) Description and details of the service delivered that
directly relate to the services specified in the approved individual service
plan as the services to be provided, including the name of the unlicensed
person for whom a supervisory visit was performed. (j) Number of units of the delivered service or continuous
amount of uninterrupted time during which the service was
provided. (k) Beginning and ending times of the delivered
service. (2) In addition to
service documentation specified in paragraph (E)(1) of this rule, service
documentation for waiver nursing delegation/assessment will include the
precipitating factor indicating why an assessment was needed, that
is: (a) The individual was discharged from
hospital; (b) The individual has experienced a significant change;
or (c) Initiation of waiver nursing delegation for an
individual who has not previously received waiver nursing
delegation. (3) In addition to
service documentation specified in paragraph (E)(1) of this rule, service
documentation for waiver nursing delegation/consultation will include a
description and details of the consultation purpose and outcomes, including the
name of the person with whom the delegating nurse was consulting. (F) Payment standards The billing units, procedure codes, and payment
rates for waiver nursing delegation are contained in the appendix to this
rule.
Last updated January 2, 2024 at 9:59 AM
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Rule 5123-9-38 | Home and community-based services waivers - social work under the individual options waiver.
(A) Purpose This rule defines social work and sets forth
provider qualifications, requirements for service delivery and documentation of
services, and payment standards for the service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" has the same meaning as in rule 5123-2-08 of the Administrative
Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Family
member" means a person who is related to the individual by blood,
marriage, or adoption. (5) "Independent
provider" has the same meaning as in rule 5123-2-09 of the Administrative
Code. (6) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code. (7) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (8) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123:2-5-02 of the Administrative Code. (9) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that shall include the items delineated in paragraph (E) of
this rule to validate payment for medicaid services. (10) "Social
work" means the application of specialized knowledge of human development
and behavior as well as social, economic, and cultural systems. This knowledge
is used to assist individuals and their families to improve and/or restore
their capacity for social functioning. Social work includes the provision of
counseling and active participation in problem-solving with individuals and
family members; counseling to meet the psychosocial needs of individuals;
collaboration with healthcare professionals and other providers to assist them
to understand and support the social and emotional needs and problems
experienced by individuals and their families; advocacy; referral to
community-based and specialized services; development of social work/counseling
plans of treatment; and assisting providers of services and family members to
understand and implement activities related to implementation of the plan of
treatment. Social work is not intended to duplicate the efforts of the service
and support administrator. (C) Provider qualifications (1) Social work shall be
provided by one of the following persons who is either an independent provider
or the employee of an agency provider that meets the requirements of this rule
and that has a medicaid provider agreement with the Ohio department of
medicaid: (a) An independent social worker licensed by the state
pursuant to section 4757.27 of the Revised Code; (b) A social worker licensed by the state pursuant to
section 4757.28 of the Revised Code; (c) A professional clinical counselor licensed by the state
pursuant to section 4757.22 of the Revised Code; or (d) A professional counselor licensed by the state pursuant
to section 4757.23 of the Revised Code. (2) Social work shall not
be provided by a county board or a regional council of governments formed under
section 5126.13 of the Revised Code by two or more county boards. (3) Social work shall not
be provided to an individual by the individual's family
member. (4) An applicant seeking
approval to provide social work shall complete and submit an application
through the department's website (http://dodd.ohio.gov/). (5) Failure to comply
with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Requirements for service
delivery (1) Social work shall be
provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) A person providing
social work shall: (a) Document the individual's social needs and develop
a social work/counseling plan of treatment; (b) Provide direct service in the form of counseling and
actively participate in resolving problems; (c) Counsel the individual and involved family members with
regard to the individual's psychosocial needs; (d) Collaborate with the individual's physician and
assist various providers of services in understanding emotional and social
needs of the individual being served; (e) Recognize the social needs of the individual and
caregiver and take appropriate therapeutic intervention; (f) Act as an advocate for the individual's social
needs; (g) Assist the individual, staff, and family to resolve
challenges which prevent the individual's adjustment or any other
challenges which affect the individual's ability to benefit from medical
treatment; (h) Assist the individual to develop self-help, social, and
adaptive skills that enable the individual to remain functional within the
community; (i) Arrange individual and caregiver counseling and other
supportive services to alleviate the pressures of estrangement from social
support systems such as family, employment, and residential placement;
and (j) Refer individuals/families to the service and support
administrator for financial matters or interagency collaboration and
follow-up. (E) Documentation of
services Service documentation for social work shall
include each of the following to validate payment for medicaid services: (1) Type of
service. (2) Date of
service. (3) Place of
service. (4) Name of individual
receiving service. (5) Medicaid
identification number of individual receiving service. (6) Name of
provider. (7) Provider
identifier/contract number. (8) Written or electronic
signature of the person delivering the service or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider. (9) Group size in which
the service was provided. (10) Description and
details of the services delivered that directly relate to the services
specified in the approved individual service plan as the services to be
provided. (11) Number of units of
the delivered service. (12) Times the delivered
service started and stopped. (F) Payment standards (1) The billing unit,
service codes, and payment rates for social work are contained in appendix A to
this rule. (2) Payment rates for
social work are based on the county cost-of-doing-business category. The
cost-of-doing-business categories are contained in appendix B to this
rule. (3) Payment rates for
social work are established separately for services provided by independent
providers and services provided through agency providers. (4) Payment rates for
social work are based on the number of individuals receiving
services.
Last updated March 25, 2024 at 9:52 AM
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Rule 5123-9-39 | Home and community-based services waivers - waiver nursing services under the individual options waiver.
Effective:
January 1, 2024
(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 a director of
operations for the purpose of providing services for which the entity is
certified in accordance with rule 5123-2-08 of the Administrative
Code. (3) "Community
respite" has the same meaning as in rule 5123-9-22 of the Administrative
Code. (4) "County board" means a
county board of developmental disabilities. (5) "Department" means the Ohio
department of developmental disabilities. (6) "Homemaker/personal care"
has the same meaning as in rule 5123-9-30 of the Administrative
Code. (7) "Independent provider"
means a self-employed person who provides services for which the person is
certified in accordance with rule 5123-2-09 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, the person's guardian in
accordance with section 5126.043 of the Revised Code or other person authorized
to give consent. (9) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (10) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (11) "Licensed practical nurse"
has the same meaning as in section 4723.01 of the Revised Code. (12) "Medically
necessary" has the same meaning as "medical necessity" described
in rule 5160-1-01 of the Administrative Code. (13) "Plan of care" means the
medical treatment plan that is established, approved, and signed by the
treating physician, physician's assistant, or advanced practice nurse. The
plan of care must be signed and dated by the treating physician,
physician's assistant, or advanced practice nurse prior to requesting
payment for a service. The plan of care is not the same as the individual
service plan. (14) "Registered nurse" has the
same meaning as in section 4723.01 of the Revised Code. (15) "Residential respite" has
the same meaning as in rule 5123-9-34 of the Administrative Code. (16) "Service documentation"
means all records and information on one or more documents, including documents
that may be created or maintained in electronic software programs, created and
maintained contemporaneously with the delivery of services, and kept in a
manner as to fully disclose the nature and extent of services delivered that
includes the items delineated in paragraph (F) of this rule to validate payment
for medicaid services. (17) "Significant change" means
a change experienced by an individual including but not limited to, a change in
health status, caregiver status, or location/residence; referral to or active
involvement on the part of a protective services agency; or
institutionalization. (18) "Vocational habilitation"
has the same meaning as in rule 5123-9-14 of the Administrative
Code. (19) "Waiver nursing services"
means services provided to an individual who requires the skills of a
registered nurse or licensed practical nurse working at the direction of a
registered nurse. Waiver nursing services does not include: (a) Services delegated in accordance with Chapter 4723. of the
Revised Code and rules adopted thereunder, and performed by persons who are not
licensed nurses in accordance with Chapter 4723. of the Revised
Code; (b) Services that require the skills of a psychiatric
nurse; (c) Visits performed for the purpose of conducting a registered
nurse assessment as set forth in rule 5160-12-08 of the Administrative Code
including but not limited to, an outcome and assessment information set or any
other assessment; (d) Registered nurse consultations as set forth in rule
5160-12-08 of the Administrative Code including but not limited to, those
performed by registered nurses for the sole purpose of directing licensed
practical nurses in the performance of waiver nursing services or directing
personal care aides or home health aides employed by a medicare-certified home
health agency or otherwise-accredited agency; (e) Visits performed for the sole purpose of meeting the home
care attendant service registered nurse visit requirements set forth in rules
173-39-02.24 and 5160-46-04.1 of the Administrative Code; (f) Services performed in excess of the number of hours approved
pursuant to, and as specified in, the individual service plan; or (g) Services performed that meet the definition of waiver nursing
delegation/assessment or waiver nursing delegation/consultation set forth in
rule 5123-9-37 of the Administrative Code. (C) Provider qualifications (1) Waiver nursing services will 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 will be provided by a registered nurse or by a licensed practical
nurse working at the direction of a registered nurse who: (a) Possesses current valid licensure in good standing to
practice nursing in Ohio pursuant to Chapter 4723. of the Revised Code;
and (b) Is working within the scope of practice as set forth in
Chapter 4723. of the Revised Code and rules adopted thereunder. (3) Nursing tasks and
activities that must 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 will 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 will complete and submit an application and
adhere to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (6) Failure of a provider
to comply with this rule and as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code, may result in denial, suspension, or revocation of the
provider's certification. (D) Service authorization (1) A county board or its
contracted agent will 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 will include: (a) An assessment of resources available to address each skilled
nursing task ordered by a physician, physician's assistant, or advanced
practice nurse; (b) A proposed weekly schedule with corresponding budget;
and (c) A nursing task inventory that identifies the nursing tasks to
be performed, the frequency and duration of each nursing task to be performed,
and the current method by which each nursing task is performed. (2) Waiver nursing
services will be authorized only when an individual's needs cannot be met
by developmental disabilities personnel holding certification issued in
accordance with rule 5123-6-06 of the Administrative Code and when applicable,
through nursing delegation in accordance with rules adopted by the Ohio board
of nursing pursuant to Chapter 4723. of the Revised Code, and/or state plan
nursing services as defined in Chapter 5160-12 of the Administrative
Code. (3) The department will
review a service authorization request to determine whether the requested
services are medically necessary. When the department or the Ohio department of
medicaid has determined within the previous twelve months that the requested
services are not medically necessary, the department may without further review
accept the Ohio department of medicaid determination. The department will
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 will not be denied without
review by a registered nurse. (5) The individual will
be afforded notice and hearing rights regarding service authorizations in
accordance with section 5101.35 of the Revised Code. Providers 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 will 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 will 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
will be identified as the provider and have specified in the individual service
plan the number of hours for which the provider is authorized to furnish waiver
nursing services. (4) A registered nurse or licensed
practical nurse working at the direction of a registered nurse may provide
services for no more than three individuals in a group setting during a
face-to-face waiver nursing services visit. (5) A waiver nursing
services visit by a registered nurse or a licensed practical nurse working at
the direction of a registered nurse will not exceed twelve hours in length
during a twenty-four hour period unless an unforeseen event causes a medically
necessary scheduled visit to extend beyond twelve hours, in which case the
visit will not exceed sixteen hours. (6) Individuals who
receive waiver nursing services must be under the supervision of a treating
physician, physician's assistant, or advanced practice nurse who is
directly providing care and treatment to the individual (and not merely engaged
to authorize plans of care for waiver nursing services). (7) A provider of waiver nursing services
who is a licensed practical nurse working at the direction of a registered
nurse will conduct a face-to-face visit with the individual and the directing
registered nurse prior to initiating services and at least once every one
hundred twenty days for the purpose of evaluating the provision of waiver
nursing services, the individual's satisfaction with care delivery and
performance of the licensed practical nurse, and to ensure that waiver nursing
services are being provided in accordance with the approved plan of
care. (8) In all instances, when a treating
physician, physician's assistant, or advanced practice nurse gives verbal
orders to the registered nurse or licensed practical nurse working at the
direction of a registered nurse, the nurse will record in writing, the orders,
the date and time the orders were given, and sign the entry in the service
documentation. The nurse will subsequently secure documentation of the verbal
orders signed and dated by the treating physician, physician's assistant,
or advanced practice nurse. (9) In all instances, when an independent
provider who is a licensed practical nurse working at the direction of a
registered nurse is providing waiver nursing services, the licensed practical
nurse will provide clinical notes, signed and dated by the licensed practical
nurse, documenting all consultations between the licensed practical nurse and
the directing registered nurse, documenting the face-to-face visits between the
licensed practical nurse and the directing registered nurse, and documenting
the face-to-face visits between the licensed practical nurse, the individual
receiving waiver nursing services, and the directing registered nurse. The
clinical notes may be collected and maintained in electronic software
programs. (10) Waiver nursing services may be
provided on the same day as, but not concurrently with, a registered nurse
assessment and/or registered nurse consultation as set forth in rule 5160-12-08
of the Administrative Code. (F) Documentation of services (1) Service documentation
for waiver nursing services will 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
orders issued by the treating physician, physician's assistant, or
advanced practice nurse or the 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 will 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, physician's assistant, or advanced
practice nurse. (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 will include documentation that the registered nurse has reviewed the
plan of care with the licensed practical nurse. The plan of care will be
certified by the treating physician, physician's assistant, or advanced
practice nurse 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,
physician's assistant, or advanced practice nurse in accordance with
paragraph (E)(8) of this rule. (f) The clinical notes of an independent provider who is a
licensed practical nurse working at the direction of a registered nurse in
accordance with paragraph (E)(9) of this rule. (g) A copy of any advance directives including but not limited
to, a "do not resuscitate" order or medical power of attorney, if
they exist. (h) Documentation of drug and food interactions, allergies, and
dietary restrictions. (i) Clinical notes signed and dated by the registered nurse or
licensed practical nurse working at the direction of a registered nurse,
documenting all communications with the treating physician, physician's
assistant, or advanced practice nurse and other members of the
multidisciplinary team. (3) Providers of waiver
nursing services will maintain, in a confidential manner for at least thirty
days at the individual's residence, medication and/or treatment records
which indicate the person who prescribed the medication and/or treatment and
the date, time, and person who administered the medication and/or
treatment. (G) Payment standards (1) The billing units,
service codes, and payment rates for waiver nursing services are contained in
the appendix to this rule. (2) Services meeting the definition of
"homemaker/personal care" may be reimbursed as waiver nursing
services when provided incidental to waiver nursing services performed during
an authorized waiver nursing services visit.
View Appendix
Last updated April 14, 2025 at 8:39 AM
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Rule 5123-9-40 | Home and community-based services waivers - administration of the self-empowered life funding waiver.
Effective:
January 1, 2024
(A) Purpose This rule implements the self-empowered life
funding waiver, a component of the medicaid home and community-based services
program administered by the department pursuant to section 5166.21 of the
Revised Code. Individuals enrolled in the self-empowered life funding waiver
exercise participant direction through budget authority and/or employer
authority. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult"
means an individual who is at least twenty-two years old or an individual who
is under twenty-two years old and no longer eligible for educational services
based on graduation, receipt of a diploma or equivalency certificate, or
permanent discontinuation of educational services within parameters established
by the Ohio department of education. (2) "Agency with
choice" means a service arrangement in which an agency provider acts as a
co-employer with an individual. Under this arrangement, the individual is
responsible for hiring, managing, and dismissing staff. The agency with choice
enables the individual to exercise choice and control over services while
relieving the individual of the burden of carrying out financial matters and
other legal responsibilities associated with the employment of workers. The
agency with choice is considered the employer of staff who are selected, hired,
and trained by the individual and assumes responsibility for: (a) Employing and paying staff who have been selected by the
individual; (b) Reimbursing allowable services; (c) Withholding, filing, and paying federal, state, and local
income and employment taxes; and (d) Providing other supports to the individual as described in
the individual service plan. (3) "Budget
authority" means an individual has the authority and responsibility to
manage the individual's budget for participant-directed services. This
authority supports the individual in determining the budgeted dollar amount for
each participant-directed waiver service that will be provided to the
individual and making decisions about the acquisition of participant-directed
waiver services that are authorized in the individual service plan (e.g.,
negotiating payment rates to providers within the applicable range as specified
in rules adopted by the department). (4) "Child"
means an individual who is under twenty-two years old and eligible for
educational services. (5) "Co-employer" means an individual who recruits and
directs staff providing services to the individual and either an agency with
choice or a financial management services entity under contract with the state
that functions as the employer of the staff recruited and directed by the
individual. The agency with choice or a financial management services entity
conducts all necessary payroll functions and is legally responsible for the
employment-related functions and duties for individual-selected staff with the
individual based on the roles and responsibilities identified in the individual
service plan for the two co-employers. The agency with choice or financial
management services entity serving as co-employer may function solely to
support the individual's employment of workers or it may provide other
employer-related supports to the individual, including providing traditional
agency-based staff. (6) "Common law
employer" means the individual is the legally responsible and liable
employer of staff selected by the individual. The individual hires, supervises,
and discharges staff. The individual is liable for the performance of necessary
employment-related tasks and uses a financial management services entity under
contract with the state to perform necessary payroll and other
employment-related functions as the individual's agent in order to ensure
that the employer-related legal obligations are fulfilled. (7) "County
board" means a county board of developmental disabilities. (8) "Department" means the Ohio department of
developmental disabilities. (9) "Employer
authority" means an individual has the authority to recruit, hire,
supervise, and direct the staff who furnish supports. The individual functions
as the common law employer or the co-employer of these staff. (10) "Financial
management services" means services provided to an individual who directs
some or all of the individual's waiver services. When used in conjunction
with budget authority, financial management services includes, but is not
limited to, paying invoices for waiver goods and services and tracking
expenditures against the individual's budget for participant-directed
services. When used in conjunction with employer authority, financial
management services includes, but is not limited to, operating a payroll
service for individual-employed staff and making required payroll withholdings.
Financial management services also includes acting as the employer of staff on
behalf of an individual under the co-employer model of employer
authority. (11) "Financial
management services entity" means a governmental entity and/or another
third-party entity designated by the department to perform necessary financial
transactions on behalf of individuals who receive participant-directed
services. (12) "Home and
community-based services" has the same meaning as in section 5123.01 of
the Revised Code. (13) "Individual" means a person with a developmental
disability or for purposes of giving, refusing to give, or withdrawing consent
for services, the person's guardian in accordance with section 5126.043 of
the Revised Code or other person authorized to give consent. An individual may
designate another person to assist with development of the individual service
plan and budget, selection of residence and providers, and negotiation of
payment rates for services; the individual's designee will not be employed
by a county board or a provider, or a contractor of either. (14) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (15) "Participant
direction" means an individual has authority to make decisions about the
individual's waiver services and accepts responsibility for taking a
direct role in managing the services. Participant direction includes the
exercise of budget authority and/or employer authority as set forth in
paragraph (G) of this rule. (16) "Provider"
means a person or entity certified or licensed by the department that has met
the provider qualification requirements to provide specific home and
community-based services and holds a valid medicaid provider agreement with the
Ohio department of medicaid or a person or entity that has been determined by
the financial management services entity to be qualified to provide
participant-directed goods and services or self-directed
transportation. (17) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123-5-02 of the Administrative Code. (18) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
redetermination date. (C) Application for the self-empowered
life funding waiver The county board is responsible for explaining to
individuals requesting home and community-based services the services available
through the self-empowered life funding waiver benefit package including the
type, amount, scope, and duration of services and any applicable benefit
package limitations. (D) Criteria for enrolling in the
self-empowered life funding waiver To be enrolled in the self-empowered life funding
waiver: (1) The individual or the
individual's guardian or the individual's designee must be willing
and able to perform the duties associated with participant direction;
and (2) The individual or the
individual's guardian or the individual's designee is required to
exercise budget authority or employer authority, in accordance with paragraph
(G)(1) or (G)(2) of this rule, for at least one service the individual receives
under the waiver. (E) Self-empowered life funding waiver
enrollment, continued enrollment, and disenrollment A county board will inform an individual who
meets the criteria specified in paragraph (D) of this rule or the
individual's guardian or the individual's designee, as applicable,
of: (1) All services
available under the self-empowered life funding waiver, as delineated in
paragraph (F) of this rule, and any choices that the individual may make
regarding those services; (2) Any feasible
alternative to the waiver; and (3) The right to choose
either institutional care or home and community-based services. (F) Self-empowered life funding waiver
benefit package The self-empowered life funding waiver benefit
package is comprised of: (1) Adult day support in
accordance with rule 5123-9-17 of the Administrative Code; (2) Assistive technology
in accordance with rule 5123-9-12 of the Administrative Code; (3) Career planning in
accordance with rule 5123-9-13 of the Administrative Code; (4) Clinical/therapeutic
intervention in accordance with rule 5123-9-41 of the Administrative
Code; (5) Community respite in
accordance with rule 5123-9-22 of the Administrative Code; (6) Functional behavioral
assessment in accordance with rule 5123-9-43 of the Administrative
Code; (7) Group employment
support in accordance with rule 5123-9-16 of the Administrative
Code; (8) Home-delivered meals
in accordance with rule 5123-9-29 of the Administrative Code; (9) Individual employment
support in accordance with rule 5123-9-15 of the Administrative
Code; (10) Non-medical
transportation in accordance with rule 5123-9-18 of the Administrative
Code; (11) Participant-directed
goods and services in accordance with rule 5123-9-45 of the Administrative
Code; (12) Participant-directed
homemaker/personal care in accordance with rule 5123-9-32 of the Administrative
Code; (13) Participant/family
stability assistance in accordance with rule 5123-9-46 of the Administrative
Code; (14) Remote support in
accordance with rule 5123-9-35 of the Administrative Code; (15) Residential respite
in accordance with rule 5123-9-34 of the Administrative Code; (16) Self-directed
transportation in accordance with rule 5123-9-26 of the Administrative
Code; (17) Support brokerage in
accordance with rule 5123-9-47 of the Administrative Code; (18) Transportation in
accordance with rule 5123-9-24 of the Administrative Code; (19) Vocational
habilitation in accordance with rule 5123-9-14 of the Administrative Code;
and (20) Waiver nursing
delegation in accordance with rule 5123-9-37 of the Administrative
Code. (G) Participant direction The self-empowered life funding waiver is
designed to support individuals who want to direct their services through
exercise of budget authority and/or employer authority. (1) Individuals enrolled
in the self-empowered life funding waiver may exercise budget authority
for: (a) Clinical/therapeutic intervention; (b) Participant-directed goods and services; (c) Participant-directed homemaker/personal care; (d) Self-directed transportation; and (e) Support brokerage. (2) Individuals enrolled
in the self-empowered life funding waiver may exercise employer authority
for: (a) Participant-directed homemaker/personal care; (b) Self-directed transportation; and (c) Support brokerage. (H) Benefit limitations (1) The cost of services
available under the self-empowered life funding waiver will not
exceed: (a) Sixty-two thousand one hundred thirty-six dollars per waiver
eligibility span for an adult; or (b) Forty-one thousand four hundred twenty-four dollars per
waiver eligibility span for a child. (2) The following
services are subject to specific benefit limitations: (a) Payment for support brokerage will 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 will not exceed one
thousand five hundred dollars. (I) Individual service plan
requirements (1) All services will be
provided to an individual enrolled in the self-empowered life funding waiver
pursuant to a written individual service plan that meets the requirements set
forth in rule 5123-4-02 of the Administrative Code. (2) The individual
service plan is subject to approval by the department and the Ohio department
of medicaid pursuant to section 5166.21 of the Revised Code. Notwithstanding
the procedures set forth in this rule, the Ohio department of medicaid may in
its sole discretion, and in accordance with section 5166.05 of the Revised
Code, direct the department or a county board to amend the individual service
plan for an individual. (J) Service documentation (1) Services under the
self-empowered life funding waiver will not be considered delivered unless the
provider maintains service documentation. (2) A provider will
maintain all service documentation in an accessible location. The service
documentation will 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 will
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 will, 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 will not be considered service
documentation. Any information contained on the submitted claim will not be
substituted for any required service documentation information that the
provider is required to maintain to validate payment for medicaid
services. (K) Payment standards (1) Services provided
under the self-empowered life funding waiver are 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 will 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
will 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 will be billed first.
Only services in excess of what is covered under the state plan will be
authorized. (6) Claims for payment
will 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, will 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
will be submitted within three hundred thirty calendar days after the service
is provided. Payment will be made in accordance with the requirements of rule
5160-1-19 of the Administrative Code. Claims for payment will include the
number of units of service. (8) Providers will 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 will be accomplished as follows: (a) The department will 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 will assign the home and community-based
services to which each individual's patient liability will 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 will notify each individual and provider, in writing, of this
assignment. (c) Upon submission of a claim for payment, the designated
provider will report the home and community-based services to which the patient
liability was assigned and the applicable patient liability amount on the claim
for payment using the format prescribed by the department. (10) The department, the
Ohio department of medicaid, the centers for medicare and medicaid services,
and/or the auditor of state may audit any funds a provider of home and
community-based services receives pursuant to this rule, including any source
documentation supporting the claiming and/or receipt of such
funds. (11) Overpayments,
duplicate payments, payments for services not rendered, payments for which
there is no documentation of services delivered or the documentation does not
include all required items as set forth in rules adopted by the department, or
payments for services not in accordance with an approved individual service
plan are recoverable by the department, the Ohio department of medicaid, the
auditor of state, or the office of the attorney general. All recoverable
amounts are subject to the application of interest in accordance with rule
5160-1-25 of the Administrative Code. (L) Due process rights and
responsibilities (1) An applicant for or
recipient of self-empowered life funding waiver services may use the process
set forth in section 5160.31 of the Revised Code and rules implementing that
statute, for any purpose authorized by that statute. The process set forth in
section 5160.31 of the Revised Code is available only to applicants,
recipients, and their lawfully appointed authorized representatives. Providers
have no standing in an appeal under that section. (2) An applicant for or
recipient of self-empowered life funding waiver services will use the process
set forth in section 5160.31 of the Revised Code and rules implementing that
statute for any challenge related to the type, amount, scope, or duration of
services included in or excluded from an individual service plan. (M) Ohio department of medicaid
authority The Ohio department of medicaid retains final
authority to establish payment rates for self-empowered life funding waiver
services; to review and approve each service identified in an individual
service plan that is funded through the self-empowered life funding waiver and
the payment rate for the service; and to authorize the provision of and payment
for waiver services through the payment authorization process. (N) Monitoring, compliance, and quality
assurance The Ohio department of medicaid will 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 will 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 will cooperate with all
monitoring, compliance, and quality assurance reviews conducted by the Ohio
department of medicaid, the department, a county board, the centers for
medicare and medicaid services, and the medicaid fraud control unit or their
designees.
Last updated January 2, 2024 at 9:59 AM
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Rule 5123-9-41 | Home and community-based services waivers - clinical/therapeutic intervention under the level one and self-empowered life funding waivers.
Effective:
December 1, 2024
(A) Purpose This rule defines clinical/therapeutic
intervention and sets forth provider qualifications, requirements for service
delivery and documentation of services, and payment standards for the
service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "Clinical/therapeutic intervention" means
services that are necessary to reduce an individual's intensive behaviors
and to improve the individual's independence and inclusion in the
community and that are not otherwise available under the medicaid state plan.
Clinical/therapeutic intervention includes consultation activities that are
provided by professionals in psychology, counseling, special education, and
behavior management. The service includes the development of a
treatment/support plan, training and technical assistance to assist unpaid
caregivers and/or paid support staff in carrying out the plan, delivery of the
services described in the plan, and monitoring of the individual and the
provider in the implementation of the plan. Clinical/therapeutic intervention
may be delivered in the individual's home or in the community as described
in the individual service plan. Clinical/therapeutic intervention may be
determined necessary to reduce an individual's intensive behaviors only 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 the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. An individual may designate another person to assist with development
of the individual service plan and budget, selection of residence and
providers, and negotiation of payment rates for services; the individual's
designee shall not be employed by a county board or a provider, or a contractor
of either. (9) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (10) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (C) Provider qualifications (1) Clinical/therapeutic
intervention will 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 and adheres
to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (2) Clinical/therapeutic
intervention will 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 will have a doctoral degree in psychology, special education,
medicine, or a related discipline; be licensed or certified under the laws of
the state to practice in that field; and have at least three months of
experience and/or training in the implementation and oversight of comprehensive
interventions for individuals with developmental disabilities who need
significant behaviorally-focused interventions. (b) A specialized clinical/therapeutic interventionist
will: (i) Have a master's
degree in psychology, special education, or a related discipline and be
licensed or certified under the laws of the state to practice in that field or
be registered with the state board of psychology as an aide or a psychology
aide working under psychological work supervision in accordance with rule
4732-13-03 of the Administrative Code; and (ii) Have at least three
months of experience and/or training in the implementation and oversight of
comprehensive interventions for individuals with developmental disabilities who
need significant behaviorally-focused interventions. (c) A clinical/therapeutic interventionist will work under
the supervision of a senior level specialized clinical/therapeutic
interventionist or a specialized clinical/therapeutic interventionist
and: (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) Clinical/therapeutic intervention
shall not be provided to an individual by the individual's family
member. (4) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery Clinical/therapeutic intervention will be
provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (E) Documentation of
services Service documentation for clinical/therapeutic
intervention will 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 will 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
identified in the individual service plan. (3) The payment rate for
clinical/therapeutic intervention provided by an agency provider will be the
lesser of the agency provider's usual and customary charge or the
statewide payment rate contained in the appendix to this rule.
Last updated December 2, 2024 at 9:09 AM
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Rule 5123-9-43 | Home and community-based services waivers - functional behavioral assessment under the level one and self-empowered life funding waivers.
Effective:
December 1, 2024
(A) Purpose This rule defines functional behavioral
assessment and sets forth provider qualifications, requirements for service
delivery and documentation of services, and payment standards for the
service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Family
member" means a person who is related to the individual by blood,
marriage, or adoption. (5) "Functional
behavioral assessment" means an assessment, not otherwise available under
the medicaid state plan, to determine why an individual engages in intensive
behaviors and how the individual's behaviors relate to the environment. A
functional behavioral assessment describes the relationship between a skill or
performance problem and the variables that contribute to its occurrence. A
functional behavioral assessment may provide information to develop a
hypothesis as to why an individual engages in a behavior, when the individual
is most likely to demonstrate the behavior, and situations in which the
behavior is least likely to occur. (6) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. An individual may designate another person to assist with development
of the individual service plan and budget, selection of residence and
providers, and negotiation of payment rates for services; the individual's
designee shall not be employed by a county board or a provider, or a contractor
of either. (8) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (9) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (E) of this
rule to validate payment for medicaid services. (10) "Usual and
customary charge" means the amount charged to other persons for the same
service. (11) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
redetermination date. (C) Provider qualifications (1) Functional behavioral
assessment will 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 and adheres
to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (2) Functional behavioral
assessment will 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 pursuant to Chapter 4732. of the
Revised Code; (b) Professional clinical counselor licensed pursuant to
section 4757.22 of the Revised Code; (c) Professional counselor licensed pursuant to section
4757.23 of the Revised Code; (d) Independent social worker licensed pursuant to section
4757.27 of the Revised Code; (e) Social worker licensed 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 pursuant to
section 4783.04 of the Revised Code. (3) Functional behavioral assessment
shall not be provided to an individual by the individual's family
member. (4) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery Functional behavioral assessment will be provided
pursuant to an individual service plan that conforms to the requirements of
rule 5123-4-02 of the Administrative Code. (E) Documentation of
services Service documentation for functional behavioral
assessment will 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 rate for functional behavioral assessment are
contained in the appendix to this rule. (2) Providers of
functional behavioral assessment will 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 will not exceed one thousand five hundred
dollars. (4) Providers of
functional behavioral assessment are prohibited from submitting claims under
both a home and community-based services waiver and the medicaid state plan for
the same functional behavioral assessment.
Last updated December 2, 2024 at 9:09 AM
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Rule 5123-9-45 | Home and community-based services waivers - participant-directed goods and services under the level one and self-empowered life funding waivers.
Effective:
December 1, 2024
(A) Purpose This rule defines participant-directed goods and
services and sets forth provider qualifications, requirements for service
delivery and documentation of services, and payment standards for the
service. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Community
respite" has the same meaning as in rule 5123-9-22 of the Administrative
Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Financial
management services entity" means a governmental entity and/or another
third-party entity designated by the department to perform necessary financial
transactions on behalf of individuals who receive participant-directed
services. (5) "Individual" means a person with a
developmental disability or for the purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. An individual may designate another person to assist with development
of the individual service plan and budget, selection of residence and
providers, and negotiation of payment rates for services; the individual's
designee shall not be employed by a county board or a provider, or a contractor
of either. (6) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (7) "Participant-directed budget" means the total
amount of annual waiver funding available for participant-directed services in
the individual service plan of an individual who chooses to receive
participant-directed services. An individual may reallocate funds among
participant-directed services as long as reallocation is preceded by a
corresponding revision to the individual service plan. (8) "Participant-directed goods and services"
means services, equipment, or supplies not otherwise provided through the
individual's waiver or through the medicaid state plan that are purchased
through the participant-directed budget, address a need clearly identified
through assessment of the individual, are specified in the individual service
plan, and meet all of the following requirements: (a) The services, equipment, or supplies are required to
achieve at least one of the following objectives: (i) Decrease the
individual's need for other medicaid home and community-based
services; (ii) Advance the
individual's participation in the community; (iii) Increase the
individual's safety in the home; (iv) Increase the
individual's independence; (v) Improve or maintain
the individual's cognitive, social, or behavioral functions;
or (vi) Assist the
individual to develop or maintain personal, social, or physical
skills. (b) The individual does not have funds to purchase the
services, equipment, or supplies, and they are not available through another
source. (c) The services, equipment, or supplies support the health
and welfare of the individual. (d) The services, equipment, or supplies are directly
linked in the individual service plan as addressing a need clearly identified
through assessment of the individual. (e) The services, equipment, or supplies are for the direct
medical or remedial benefit of the individual. (9) "Service and
support administrator" means a person, regardless of title, employed by or
under contract with a county board to perform the functions of service and
support administration and who holds the appropriate certification in
accordance with rule 5123-5-02 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 includes the items delineated in paragraph (E)(2) of
this rule to validate payment for medicaid services. (11) "Specialized
services" means any program or service designed and operated to serve
primarily a person with a developmental disability, including a program or
service provided by an entity licensed or certified by the department. Programs
or services available to the general public are not specialized
services. (12) "Usual and
customary charge" means the amount charged to other persons for the same
service. (13) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
redetermination date. (C) Provider qualifications (1) Rules 5123-2-08 and
5123-2-09 of the Administrative Code do not apply to providers of
participant-directed goods and services. (2) Provision of
participant-directed goods and services will be coordinated by a financial
management services entity. (D) Requirements for service
delivery (1) Participant-directed
goods and services will be provided pursuant to the assessed needs of an
individual and an individual service plan that conforms to the requirements of
rule 5123-4-02 of the Administrative Code. (2) Participant-directed
goods and services will not be specialized services. If there is a question as
to whether participant-directed goods and services are specialized services,
the director of the department may make a determination. The director's
determination is not subject to appeal. (3) Participant-directed
goods and services will not include: (a) Experimental treatments, including items considered by
the federal food and drug administration as experimental or investigational or
not approved to treat a specific condition; (b) Items used solely for entertainment or recreational
purposes; (c) Pools, spas, or saunas; (d) Tobacco products or alcohol; (e) Food; (f) Internet service; (g) Items of general utility; (h) New equipment or supplies or repair of previously
approved equipment or supplies that have been damaged as a result of confirmed
misuse, abuse, or negligence; (i) Equipment, supplies, and devices of the same type for
the same individual, unless there is a documented change in the
individual's condition that warrants the replacement; (j) Home modifications that are of general utility or that
add to the total square footage of the home; or (k) Items that are illegal or otherwise prohibited through
federal or state regulations. (4) Prior to authorizing
services, equipment, or supplies as participant-directed goods and services in
the individual service plan or submitting a request for processing to the
financial management services entity, an individual's service and support
administrator will ensure that: (a) The services, equipment, or supplies meet the
definition of participant-directed goods and services set forth in paragraph
(B)(8) of this rule; (b) A person-centered assessment of the individual has been
conducted and supports the need for the services, equipment, or supplies for
one or more of the reasons delineated in paragraph (B)(8)(a) of this
rule; (c) The individual does not have funds to purchase the
services, equipment, or supplies; and (d) Documentation on hand demonstrates that the
requirements of paragraphs (D)(4)(a) to (D)(4)(c) of this rule are
met. (5) A county board will
submit requests for the following services, equipment, or supplies to the
department for review prior to authorizing them as participant-directed goods
and services in the individual service plan: (a) Generators; (b) Fences; (c) Play sets or other generic equipment typically for the
purpose of recreation or entertainment requested for the therapeutic or
habilitative benefit of the individual; (d) Home modifications exceeding ten thousand
dollars; (e) Services, equipment, or supplies that may otherwise be
available to the individual through the individual's waiver (e.g., as
community respite) or the medicaid state plan; and (f) Services, equipment, or supplies that may otherwise be
available to the individual through Ohio's early and periodic screening,
diagnostic, and treatment (i.e., "Healthchek") program or pursuant to
the Individuals with Disabilities Education Act. (6) The department will
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 denies a request, the department will notify
the county board and the individual in writing. The notice will advise the
individual of the individual's right to due process. (7) Requests submitted to
the department in accordance with paragraph (D)(5) of this rule less than
forty-five days in advance of the last day of an individual's waiver
eligibility span may not be resolved with sufficient time to purchase the
services, equipment, or supplies within that waiver eligibility
span. (E) Documentation of
services (1) Paragraph (J) of rule
5123-9-40 of the Administrative Code does not apply to participant-directed
goods and services. (2) Service documentation
for participant-directed goods and services will 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 will maintain all service documentation for a period
of six years from the date of receipt of payment for the service or until an
initiated audit is resolved, whichever is longer. (F) Payment standards (1) The billing unit,
service codes, and payment rate for participant-directed goods and services are
contained in the appendix to this rule. (2) Providers of
participant-directed goods and services will be paid no more than their usual
and customary charge for the services, equipment, or supplies
provided. (3) Under the level one
waiver, participant-directed goods and services will not exceed two thousand
five hundred dollars during a waiver eligibility span.
Last updated May 19, 2025 at 2:39 PM
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Rule 5123-9-46 | Home and community-based services waivers - participant/family stability assistance under the level one and self-empowered life funding waivers.
Effective:
December 1, 2024
(A) Purpose This rule defines participant/family stability
assistance and sets forth provider qualifications, requirements for service
delivery and documentation of services, and payment standards for the
service. (B) Definitions (1) "Agency
provider" means an entity that directly employs at least one person in
addition to a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Family
member" means a person who is related to the individual by blood,
marriage, or adoption. (5) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. An individual may designate another person to assist with development
of the individual service plan and budget, selection of residence and
providers, and negotiation of payment rates for services; the individual's
designee shall not be employed by a county board or a provider, or a contractor
of either. (7) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (8) "Participant/family stability assistance"
means training (including education and instruction) and counseling (including
consultation) that enhance an individual's ability to direct services
received and/or enable an individual and/or family members who reside with the
individual to understand how best to support the individual in order that the
individual and the individual's family members may live as much like other
families as possible and to prevent or delay unwanted out-of-home
placement. (a) Participant/family stability assistance may be
utilized only by the individual and family members who reside with the
individual and will be outcome-based, meaning that there is a specific goal for
the service which is recorded in the individual service plan. (b) Participant/family stability assistance includes
training and counseling related to accommodating the individual's
disability in the home, accessing supports offered in the community,
effectively supporting the individual so that the individual may be fully
engaged in the life of the family, and supporting the unique needs of the
individual. (c) Participant/family stability assistance includes the
cost of enrollment fees and materials, but does not cover travel expenses or
experimental and prohibited treatments. (9) "Service
documentation" means all records and information on one or more documents,
including documents that may be created or maintained in electronic software
programs, created and maintained contemporaneously with the delivery of
services, and kept in a manner as to fully disclose the nature and extent of
services delivered that includes the items delineated in paragraph (F) of this
rule to validate payment for medicaid services. (10) "Usual and
customary charge" means the amount charged to other persons for the same
service. (C) Provider qualifications for
participant/family stability assistance-training (1) Participant/family
stability assistance-training will 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 and adheres
to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (2) An individual may
determine additional qualifications for a provider of participant/family
stability assistance-training; additional qualifications determined by the
individual will be recorded in the individual service plan. (3) Participant/family stability
assistance-training shall not be provided to an individual by the
individual's family member. (4) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (D) Provider qualifications for
participant/family stability assistance-counseling (1) Participant/family
stability assistance-counseling will 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 and adheres
to the requirements of as applicable, rule 5123-2-08 or 5123-2-09 of the
Administrative Code. (2) Participant/family
stability assistance-counseling will be provided by a person who is
a: (a) Psychologist licensed pursuant to Chapter 4732. of the
Revised Code; (b) Professional clinical counselor licensed pursuant to
section 4757.22 of the Revised Code; (c) Professional counselor licensed pursuant to section
4757.23 of the Revised Code; (d) Independent social worker licensed pursuant to section
4757.27 of the Revised Code; (e) Social worker licensed 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 pursuant to
section 4757.30 of the Revised Code. (3) Participant/family stability
assistance-counseling shall not be provided to an individual by the
individual's family member. (4) Failure to comply with this rule and
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in denial, suspension, or revocation of the provider's
certification. (E) Requirements for service
delivery Participant/family stability assistance will be
provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (F) Documentation of
services Service documentation for participant/family
stability assistance will 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 will be paid no more than their usual
and customary charge for the service.
Last updated December 2, 2024 at 9:10 AM
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Rule 5123-9-47 | Home and community-based services waivers - support brokerage under the self-empowered life funding waiver.
Effective:
December 1, 2024
(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 a director of operations for the purpose of providing services for
which the entity is certified in accordance with rule 5123-2-08 of the
Administrative Code. (2) "County
board" means a county board of developmental disabilities. (3) "Department" means the Ohio department of
developmental disabilities. (4) "Family
member" means a person who is related to the individual by blood,
marriage, or adoption. (5) "Independent
provider" means a self-employed person who provides services for which the
person is certified in accordance with rule 5123-2-09 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, the person's guardian in accordance with section
5126.043 of the Revised Code or other person authorized to give consent. An
individual may designate another person to assist with development of the
individual service plan and budget, selection of residence and providers, and
negotiation of payment rates for services; the individual's designee shall
not be employed by a county board or a provider, or a contractor of
either. (7) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual. (8) "Participant
direction" means an individual has authority to make decisions about the
individual's waiver services and accepts responsibility for taking a
direct role in managing the services. Participant direction includes the
exercise of budget authority and/or employer authority as set forth in rule
5123-9-40 of the Administrative Code. (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 5123-5-02 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (11) "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
the individual's 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. (12) "Support brokerage" means
the services of a support broker. (13) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
waiver enrollment date or a subsequent eligibility redetermination
date. (C) Provider qualifications (1) Support brokerage
will 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 and adheres to the requirements of as applicable, rule
5123-2-08 or 5123-2-09 of the Administrative Code. (b) An unpaid volunteer who has the qualifications specified in
paragraph (C)(2) of this rule. (2) Support brokerage
will 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 will 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
as applicable, rule 5123-2-08 or 5123-2-09 of the Administrative Code, may
result in the denial, suspension, or revocation of the provider's
certification. (D) Requirements for service
delivery Support brokerage will be provided pursuant to an
individual service plan that conforms to the requirements of rule 5123-4-02 of
the Administrative Code. (E) Documentation of
services Service documentation for support brokerage will
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 will
not exceed eight thousand dollars per waiver eligibility span.
View Appendix
Last updated December 2, 2024 at 9:10 AM
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Rule 5123-9-48 | Home and community-based services waivers - community transition under the under the individual options waiver.
Effective:
December 1, 2024
(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 apply: (1) "Agency
provider" means an entity that employs at least one person in addition to
a director of operations for the purpose of providing services for which the
entity is certified in accordance with rule 5123-2-08 of the Administrative
Code. (2) "Community
transition" means reimbursement for non-recurring household start-up
expenses for which an individual who previously resided in an intermediate care
facility for individuals with intellectual disabilities or a nursing facility
for at least ninety days and is transitioning to enrollment in the individual
options waiver is directly responsible. (a) Community transition includes expenses that do not constitute
room and board, necessary to enable an individual to establish a basic
household. Community transition includes, but is not limited to: (i) Security deposits and
rental start-up expenses required to obtain a lease on an apartment or
house; (ii) Essential household
furnishings required to occupy and use a community domicile such as furniture,
window coverings, food preparation items, and bed or bath linens; (iii) Start-up fees or
deposits for utility or service access such as telephone, electricity, heating,
and water; (iv) Moving
expenses; (v) Pre-transition
transportation services necessary to secure housing and benefits;
and (vi) Initial cleaning
products and household supplies. (b) Community transition does not include: (i) Grocery
expenses; (ii) Internet
expenses; (iii) Ongoing monthly rent or mortgage expenses; (iv) Ongoing utility or service charges; (v) Items intended for
entertainment or recreational purposes; or (vi) Tobacco products or
alcohol. (3) "County
board" means a county board of developmental disabilities. (4) "Department" means the Ohio
department of developmental disabilities. (5) "Individual" means a person
with a developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, the person's guardian in accordance with
section 5126.043 of the Revised Code or other person authorized to give
consent. (6) "Individual service plan"
means the written description of services, supports, and activities to be
provided to an individual. (7) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section 5124.01 of the Revised Code. (8) "Nursing facility" has the
same meaning as in section 5165.01 of the Revised 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
includes the items delineated in paragraph (E) of this rule to validate payment
for medicaid services. (C) Provider qualifications (1) Community transition
will be provided only 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 will complete and submit an application and
adhere to the requirements of rule 5123-2-09 of the Administrative
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 community transition only when no
other qualified provider is available. (D) Requirements for service
delivery (1) Community transition
will be provided pursuant to an individual service plan that conforms to the
requirements of rule 5123-4-02 of the Administrative Code. (2) Community transition may be
authorized for up to one hundred eighty calendar days prior to the date on
which an individual enrolls in the individual options waiver. (3) Community transition
may be authorized for up to thirty calendar days after the date on which an
individual enrolls in the individual options waiver. (4) Expenses are reimbursable as
community transition only to the extent: (a) No other person, including a landlord, has a legal or
contractual responsibility to provide the item or service or pay the
expense; (b) They are reasonable and necessary as determined through the
person-centered planning process and clearly identified in the individual
service plan; (c) The individual is unable to pay such expenses and the item or
service cannot be obtained from other sources such as family, friends,
neighbors, or community agencies; and (d) They take into consideration the appropriateness and
availability of a lower cost alternative for comparable services that meet the
individual's needs. (5) An individual will be involved in
selection of any item or service authorized as community transition and
purchased on the individual's behalf. (E) Documentation of
services Service documentation for community transition
will 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 the individual's
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 will not exceed
two thousand dollars per individual. (3) Pre-transition transportation
services covered as community transition will not exceed five hundred
dollars. (4) The date of service
for purposes of reimbursement is 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 will submit the individual's
expenses to the department within one year. Expenses incurred in these
circumstances are reimbursable to the county board by the department and to the
department by the Ohio department of medicaid.
Last updated December 2, 2024 at 9:10 AM
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