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

Chapter 5160-41 | HCBS Waiver Programs for Individuals with Intellectual and Developmental Disabilities

 
 
 
Rule
Rule 5160-41-05 | Waiting lists for home and community-based services administered by the Ohio department of developmental disabilities.
 

(A) Purpose

This rule sets forth the requirements of a county board of developmental disabilities to establish and maintain a waiting list for home and community-based services.

(B) Definitions

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code with local administrative authority.

(2) "DODD" means the Ohio department of developmental disabilities established under section 121.02 of the Revised Code.

(3) "Home and community-based services" means services provided under a medicaid-funded waiver pursuant to section 5166.04 of the Revised Code.

(4) "ODM" means the Ohio department of medicaid.

(5) "Waiting lists" means a list established and maintained in accordance with rule 5123-9-04 of the Administrative Code.

(C) Requirements

(1) County boards shall establish and maintain waiting lists for home and community-based services in accordance with rule 5123-9-04 of the Administrative Code.

(2) There shall be no waiting list for the following services:

(a) Medicaid state plan services.

(b) Home and community-based services for individuals already enrolled in a home and community-based services waiver administered by DODD who are assessed and determined to have a need for the services covered by the waiver in which the individual is enrolled.

(c) Home and community-based services to children who are subject to a determination under section 121.38 of the Revised Code and require the services.

(D) DODD shall monitor compliance with this rule by the county boards and their contract agencies.

(E) Due process.

(1) Whenever an applicant for or enrollee of a waiver program administered by DODD is affected by any action proposed or taken by DODD and/or ODM, or when action is recommended by the county board, the entity recommending or taking the action will provide medicaid due process in accordance with section 5101.35 of the Revised Code through the state fair hearing process, and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. Such actions may include, but are not limited to, the approval, denial, or termination of enrollment or a denial or change in the level, and/or type of waiver services delivered to a waiver enrollee.

(2) If an applicant or enrollee requests a hearing, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code, the participation of DODD and the county board is required during the hearing proceedings to justify the decision under appeal.

Last updated April 1, 2022 at 8:26 AM

Supplemental Information

Authorized By: 5166.02, 5164.02
Amplifies: 5164.02, 5166.02, 5126.042
Five Year Review Date: 4/1/2027
Prior Effective Dates: 5/9/2002, 9/15/2011, 4/1/2017
Rule 5160-41-08 | Free choice of provider requirements for medicaid home and community-based services programs administered by the Ohio department of developmental disabilities.
 

(A) The purpose of this rule is to set forth the requirements the Ohio department of developmental disabilities (DODD) must meet to assure free choice of provider.

(B) The DODD through an interagency agreement with the Ohio department of medicaid (ODM), acts as the administrative agency for components of the medicaid home and community-based services programs in accordance with section 5162.35 of the Revised Code. In accordance with section 5166.21 of the Revised Code, the DODD, as the designated administrator, shall promulgate rule(s) to require that recipients of home and community-based services are provided choice of medicaid home and community-based providers consistent with federal free choice of provider requirements set forth in 42 C.F.R. 431.51 (October 1, 2021). Any rule(s) authorized by this rule and promulgated by the DODD are valid only to the extent they are consistent with 42 C.F.R. 431.51. If the rules promulgated by DODD are capable of more than one interpretation, they shall be applied in a manner most consistent with the letter and intent of 42 C.F.R. 431.51.

(C) Rules promulgated by DODD shall establish policies related to the provision of free choice of medicaid home and community-based service providers for each service specified in a recipient's individual service plan and shall include the following:

(1) The general roles and responsibilities of the county board of developmental disabilities as specified in rule 5123-9-11 of the Administrative Code.

(2) The roles and responsibilities of the county board of developmental disabilities for the assurance of due process and fair hearing rights regarding recipients' free choice of medicaid home and community-based service providers.

(3) The roles and responsibilities of DODD for monitoring and assuring compliance with recipients' free choice of medicaid home and community-based service provider requirements.

(D) ODM shall conduct periodic monitoring and compliance reviews related to free choice of medicaid home and community-based service providers.

Last updated April 1, 2022 at 8:26 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5166.02, 5162.35
Five Year Review Date: 4/1/2027
Prior Effective Dates: 9/15/2011
Rule 5160-41-16 | Assistance to enable a county board of developmental disabilities to pay non-federal share of medicaid expenditures for home and community-based services.
 

(A) Purpose.

This rule authorizes the provisions set forth in rule 5123-4-05 of the Administrative Code which sets forth the process a county board of developmental disabilities must follow to request assistance from the department of developmental disabilities (DODD) in the event of failure of a county property tax levy for home and community-based services (HCBS) to individuals with developmental disabilities in that county.

(B) Definitions.

(1) "County board" means a county board of developmental disabilities established under Chapter 5126. of the Revised Code.

(2) "Home and community-based services" means medicaid-funded home and community-based services provided pursuant to section 5166.20 of the Revised Code.

(3) "OBM" means the office of budget and management as established by section 121.02 of the Revised Code.

(4) "ODM" means the Ohio department of medicaid.

(5) "DODD" means the Ohio department of developmental disabilities established under section 121.02 of the Revised Code.

(C) Requirements.

(1) A county board of developmental disabilities may request assistance from the DODD to pay the non-federal share of medicaid expenditures for home and community-based services when a local county board operating levy fails in accordance with rule 5123-4-05 of the Administrative Code.

(2) Prior to a county board of developmental disabilities receiving assistance, the DODD shall notify and consult with both OBM and ODM.

(3) Documentation submitted by a county board to make a request for assistance and/or any documentation used by the department to determine a decision of approval or denial shall be made available to OBM or ODM upon request.

Last updated October 11, 2024 at 1:36 PM

Supplemental Information

Authorized By: 5162.03, 5164.02, 5166.02
Amplifies: 5162.03, 5164.02, 5166.02
Five Year Review Date: 2/8/2026
Prior Effective Dates: 2/21/2016
Rule 5160-41-17 | Medicaid home and community-based services program - self-empowered life funding waiver.
 

(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.

Last updated July 2, 2024 at 10:48 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5164.25, 5166.04, 5166.20, 5162.35
Five Year Review Date: 7/1/2029
Prior Effective Dates: 1/1/2019, 1/1/2020, 6/12/2020 (Emer.)
Rule 5160-41-18 | Individual options waiver-payment standards.
 

(A) Purpose.

The purpose of this rule is to establish the payment standards for the individual options home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the Ohio department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.

(C) Individuals enrolled in the individual options HCBS program administered by DODD are subject to payment standards set forth in this rule and the rules associated with the individual options waiver program as established in Chapter 5123-9 of the Administrative Code.

(D) Payment for individual options waiver services will not exceed the maximum rates established in Chapter 5123-9 of the Administrative Code.

(E) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-06 of the Administrative Code.

(F) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in the individual options waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the individual options waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital, unless otherwise permitted in other HCBS waiver program rules pertaining to acute care, and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services will not be considered a resident of an ICF/IID if the ICF/IID is providing the residential respite service.

(b) An ICF/IID providing respite services for any DODD administered waiver program that offers such services will not bill medicaid through the ICF/IID program. Payments for respite services will be made through the waiver program in which the individual is enrolled.

(G) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and will not be construed as a partial payment.

(H) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the individual options waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Last updated September 6, 2024 at 8:20 AM

Supplemental Information

Authorized By: 5166.02, 5166.23
Amplifies: 5166.02, 5162.35, 5166.21
Five Year Review Date: 9/6/2029
Prior Effective Dates: 3/19/2012
Rule 5160-41-19 | Level one waiver-payment standards.
 

(A) Purpose.

The purpose of this rule is to establish the payment standards for the level one home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.

(C) Individuals enrolled in the level one HCBS program administered by DODD are subject to payment standards set forth in this rule and the rules associated with the level one waiver program as established in Chapter 5123-9 of the Administrative Code.

(D) Payment for level one waiver services will not exceed the maximum rates established in Chapter 5123-9 of the Administrative Code.

(E) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-06 of the Administrative Code.

(F) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in the level one waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the level one waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital unless otherwise permitted in other HCBS waiver program rules pertaining to acute care, and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services will not be considered a resident of an ICF/IID if the ICF/IID is providing the residential respite service.

(b) An ICF/IID providing residential respite services for any DODD administered waiver program that offers such services will not bill medicaid through the ICF/IID program. Payments for residential respite services will be made through the waiver program in which the individual is enrolled.

(G) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and shall not be construed as a partial payment.

(H) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the level one waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Last updated September 6, 2024 at 8:20 AM

Supplemental Information

Authorized By: 5166.02, 5166.23
Amplifies: 5166.02, 5166.23, 5162.35, 5166.21
Five Year Review Date: 9/6/2029
Prior Effective Dates: 3/19/2012
Rule 5160-41-20 | Self-empowered life funding waiver - payment standards.
 

(A) Purpose.

The purpose of this rule is to establish the payment standards for the self-empowered life funding (SELF) home and community-based services (HCBS) waiver for services provided to individuals enrolled in a HCBS program, as a component of the medicaid program and as administered by the department of developmental disabilities (DODD) in accordance with sections 5166.02 and 5166.23 of the Revised Code.

(B) The DODD is responsible for the daily administration of certain components of the medicaid program, to include HCBS, pursuant to an interagency agreement with the Ohio department of medicaid (ODM) in accordance with sections 5162.35 and 5166.21 of the Revised Code.

(C) Payment for SELF waiver services will not exceed the maximum rates established in rule 5123-9-40 of the Administrative Code.

(D) Claims for the provision of HCBS will be submitted in accordance with the process specified in rule 5123-9-40 of the Administrative Code.

(E) Claims for the provision of HCBS will be paid as indicated in this rule when the following conditions exist:

(1) The waiver service is provided to an individual who is enrolled in the SELF waiver program at the time of service; and

(2) The waiver service is provided within the limitations specified by the SELF waiver program in which the individual is enrolled; and

(3) The waiver service is provided to an enrollee who is not an inpatient of a hospital unless otherwise permitted in other HCBS waiver program rules pertaining to acute care and is not residing in a nursing facility or an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

(a) An individual enrolled in a DODD administered waiver program which offers residential respite as one of the waiver services will not be considered a resident of an ICF/IID if the ICF/IID is providing the residential respite service.

(b) An ICF/IID providing respite services for any DODD administered waiver program that offers such services will not bill medicaid through the ICF/IID program. Payments for respite services will be made through the waiver program in which the individual is enrolled.

(F) In accordance with rule 5160-1-13.1 of the Administrative Code, payments made under authority of this rule constitute payment-in-full and will not be construed as a partial payment.

(G) ODM authority.

ODM retains the final authority to establish payment rates for waiver services approved under the SELF waiver and has final approval of any policies and rules that govern any component of the medicaid program.

Last updated September 6, 2024 at 8:20 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5166.02, 5166.23, 5162.35
Five Year Review Date: 9/6/2029
Prior Effective Dates: 7/1/2012, 5/1/2017