(A) Purpose.
(1) The Ohio department of developmental
disabilities (DODD) is responsible for the daily operation of the
self-empowered life funding (SELF) waiver which will be administered pursuant
to sections 5166.02 and 5166.20 of the Revised Code.
(2) DODD operates the SELF waiver program
pursuant to an interagency agreement with the Ohio department of medicaid (ODM)
in accordance with section 5162.35 of the Revised Code.
(B) Definitions.
(1) "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.
(2) "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.
(3) "County board" means a
county board of developmental disabilities established under Chapter 5126. of
the Revised Code.
(4) "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.
(5) "Financial
management services" means services provided to an individual who directs
some or all of the individual's waiver services.
(6) "Financial
management services entity" means a governmental entity and another
third-party entity designated to perform necessary financial transactions on
behalf of individuals who receive participant-directed services.
(7) "Home and community-based
services (HCBS)" means any federally approved medicaid waiver service
provided to a waiver enrollee as an alternative to institutional care under
Section 1915(c) of the Social Security Act, 49 Stat. 620 (1935), 42
U.S.C.1396n, as in effect on January 1, 2024, under which federal reimbursement
is provided for designated home and community-based services to eligible
individuals.
(8) "Individual" means a person
with a developmental disability who is eligible to receive HCBS as an
alternative to placement in an intermediate care facility for individuals with
intellectual disabilities (ICF/IID) under the applicable HCBS waiver. A
guardian or authorized representative may give, refuse to give, or withdraw
consent for services and may receive notice on behalf of an individual to the
extent permitted by applicable law.
(9) "Individual Service Plan
(ISP)" means a written description of the services, supports, and
activities to be provided to an individual. The ISP is developed using a
person-centered planning process.
(10) "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 employer authority.
(11) "Person-centered planning" is a process
directed by the individual, that identifies his or her strengths, values,
capacities, preferences, needs and desired outcomes. The process includes team
members who assist and support the individual to identify and access medically
necessary services and supports needed to achieve his or her defined outcomes
in the most inclusive community setting.
(12) "Provider" means a person
or agency who is eligible per Chapter 5123-2 and rule 5160-1-17.2 of the
Administrative Code to provide the specific SELF waiver service as specified in
this rule.
(13) "SSA" means a service and
support administrator who is eligible to perform the functions of service and
support administration per rules 5123-4-02 and 5123-5-02 of the Administrative
Code.
(14) "Waiver eligibility span"
means the twelve-month period following either an individual's initial
enrollment date or a subsequent eligibility re-determination date.
(C) Eligibility.
To be eligible for the SELF waiver program:
(1) The individual's medicaid
eligibilty has been established in accordance with Chapters 5160:1-1 to
5160:1-6 of the Administrative Code;
(2) The individual
has been determined to have a developmental disabilities level of care in
accordance with rule 5123-8-01 of the Administrative Code;
(3) The
individual's health and welfare can be ensured through the utilization of
SELF waiver services at or below the federally approved cost limitation and
other formal and informal supports regardless of funding source;
(4) The individual
participates in the development of a person-centered services plan in
accordance with the process and requirements set forth in rules 5123-9-02 and
5123-4-02 of the Administrative Code; and
(5) The individual
requires the provision of at least one waiver service on a monthly basis as
documented in the individual's approved person-centered services plan.
(D) Enrollment.
(1) Requests for the SELF waiver program
are set forth in rules 5160:1-2-03 and 5123-9-01 of the Administrative Code
utilizing ODM 02399 form Request for Medicaid Home and Community Based Services
(HCBS) Waiver.
(2) Individuals who meet the eligibility
criteria in paragraph (C) of this rule will be informed of the
following:
(a) All services available on this self-empowered life
funding waiver, and any choices that the individual may make regarding those
services;
(b) Any viable alternatives to the waiver; and
(c) The right to choose either institutional or home and
community-based services.
(3) DODD allocates waivers to the county
board in accordance with section 5166.22 of the Revised Code.
(4) The county board
offers an available SELF waiver to eligible individuals in accordance with
applicable waiting list category requirements set forth in rules 5160-41-05 and
5123-9-04 of the Administrative Code.
(5) An individual's
continued enrollment in the SELF waiver program is redetermined no less
frequently than every twelve months beginning with the individual's
initial enrollment date or subsequent redetermination date. Individuals will
continue to meet the eligibility criteria specified in paragraph (C) of this
rule to continue enrollment in the waiver program.
(6) The maximum number of
individuals that can be enrolled in the SELF waiver program statewide will not
exceed the allowable number specified in the federally approved waiver
document.
(E) Benefit Package
(1) The SELF waiver program provides
necessary home and community-based services to individuals of any age as an
alternative to institutional care in an intermediate care facility for
individuals with intellectual disabilities (ICF/IID).
(a) The SELF benefit package, as indicated in the federally
approved waiver application, is limited to the services specified in Chapter
5123-9 of Administrative Code.
(b) The SELF waiver program is a participant directed
program as described in rule 5123-9-40 of the Administrative Code.
(c) Financial management services provided by a financial
management services entity are included in the benefit package.
(d) The individual or the individual's guardian or the
individual's designee perform the duties associated with participant
direction including budget authority and employer authority in accordance with
rule 5123-9-40 of the Administrative Code.
(2) All services will be provided to an
individual enrolled in the SELF waiver program pursuant to a written
person-centered Individual Service Plan (ISP).
(a) The ISP will be developed by qualified persons with
input from the individual in accordance with rule 5123-4-02 of the
Administrative Code.
(b) The ISP will be developed to include only waiver
services which are consistent with efficiency, economy, and quality of care and
identify non-waiver services, regardless of funding source.
(3) The ISP is subject to approval by ODM
and DODD pursuant to section 5166.05 of the Revised Code. Notwithstanding the
procedures set forth in this rule, ODM may in its sole discretion, and in
accordance with section 5166.05 of the Revised Code direct the county board or
DODD to amend ISPs for individuals.
(4) When DODD, ODM, or the county board
acts to, deny, or terminate enrollment in the SELF waiver program, or to deny
or reduce the level of waiver services delivered to an enrollee, the individual
will be notified of his or her hearing rights in accordance with division
5101:6 of the Administrative Code.
(F) Service Provisions
(1) Authorized SELF waiver services will
be provided by persons or agencies who:
(a) Are eligible per rule 5160-1-17.2 of the Administrative
Code and
(b) Are eligible in accordance with Chapter 5123-2 and if
applicable 5123-3 of the Administrative Code.
(2) Services will be
provided utilizing person-centered practices and in settings in accordance with
42 C.F.R. 441.530 (as in effect January 1, 2024).
(3) Individuals enrolled,
or their legal representative will be informed of freedom of choice in
qualified providers in accordance with rule 5160-41-08 of the Administrative
Code and 42 C.F.R. 431.51 (as in effect on January 1, 2024).
(4) SELF waiver program
payment standards are operated in accordance with rules 5160-41-20 and
5123-9-40 of the Administrative Code.
The maximum allowable payment rates of the SELF waiver program
services are provided in Chapter 5123-9 of the Administrative Code.
(5) ODM may conduct
periodic monitoring and compliance reviews in accordance with section 5162.10
of the Revised Code.
Reviews may consist of, but are not limited to, physical
inspections of records and sites where services are provided, interviews of
providers, recipients, and administrators of waiver services.
(6) Records related to
the administration and provision of SELF waiver services may be reviewed by
ODM, the auditor of the state, the attorney general, and the medicaid fraud
control unit or their designees per sections 5162.10 and 5160.22 of the Revised
Code.
(7) Individuals enrolled
in the SELF waiver program are responsible for the provision of information to
administering agencies as set forth in Chapter 5160:1-2 of the Administrative
Code.
