Chapter 5160-46 | Ohio Home Care Waiver

Rule 5160-46-02 | Ohio home care waiver program: eligibility and enrollment.

• Effective: September 22, 2025
• Promulgated Under: 119.03

(A) An individual is eligible for enrollment in the Ohio home care waiver program only if the individual meets all of the following criteria:

(1) The individual is between the ages of birth through age fifty-nine years.

(2) The individual is determined eligible for Ohio medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(3) The individual participates in an in-person initial comprehensive assessment to determine if the individual has needs that can be met through the Ohio home care waiver program.

(4) The individual is determined to have a nursing facility (NF) -based level of care (i.e., intermediate or skilled) in accordance with rule 5160-3-08 of the Administrative Code.

(5) The individual in the absence of the Ohio home care waiver program, would require hospitalization or institutionalization in a NF to meet the individual's needs.

(6) The individual:

(a) Has a need for and agrees to receive at least one waiver service monthly that is otherwise unavailable through another source (including, but not limited to, private pay, community resources and the medicaid state plan) in an amount sufficient to meet the individual's assessed needs; or

(b) Has a need for:

(i) Continuous nursing services for more than four hours in length,

(ii) At least one waiver service annually, and

(iii) Monthly monitoring of the individual's health and welfare through a combination of telephonic and in-person contacts with the case manager and agrees to cooperate with the monthly monitoring.

(7) The individual is able to establish residency in a place that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and that is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed or certified facility, any facility covered by section 1616(e) of the Social Security Act (42 U.S.C. 1382(e) (January 1, 2025)), residential care facility, adult foster home, or another group living arrangement subject to state licensure or certification.

(8) The individual's needs can be safely met through the Ohio home care waiver in a home or community setting as determined by the Ohio department of medicaid (ODM) or its designee.

(B) To be enrolled and maintain enrollment in the Ohio home care waiver program, the individual will meet all of the following criteria:

(1) The individual is determined eligible for the Ohio home care waiver program in accordance with paragraph (A) of this rule.

(2) The individual resides in a setting that possesses the home and community-based setting characteristics set forth in rule 5160-44-01 of the Administrative Code, and that is not a hospital, NF, intermediate care facility for individuals with an intellectual disability (ICF-IID) or another licensed or certified facility, any facility covered by section 1616(e) of the Social Security Act (42 U.S.C. 1382(e) (January 1, 2025)), residential care facility, or another group living arrangement subject to state licensure or certification.

(3) The individual's health and welfare can be ensured while enrolled on the waiver.

(4) The individual participates in the development and implementation of a person-centered services plan in accordance with the process and requirements set forth in rule 5160-44-02 of the Administrative Code.

(5) The individual agrees to and receives case management services from ODM or its designee including, but not limited to:

(a) Annual and other assessments, as needed,

(b) Home safety evaluations,

(c) Contact with the case manager including, but not limited to telephone communications and in-person visits.

(6) The individual participates in telephonic and in-person quality assurance and participant satisfaction activities during their enrollment on the Ohio home care waiver program.

(7) The individual cooperates with the in-person eligibility comprehensive assessment at least annually, and more frequently if there is a significant change in the individual's situation that may impact the individual's health and welfare.

(8) The individual signs an agreement confirming the individual has been informed of service alternatives, choice of qualified providers available in the Ohio home care waiver program, and the options of institutional and community-based care, and elects to receive Ohio home care waiver services. If the individual is unable to provide a signature at the time of enrollment, the individual is to submit an electronic signature or standard signature via regular mail, or otherwise in no instance any later than at the next in-person visit with the case manager.

(9) The individual cost limit does not exceed fourteen thousand and seven hundred dollars per month for waiver services. Waiver services excluded from the cost limit are community transition, home maintenance and chore, home modification, self-directed goods and services, supplemental adaptive and assistive device, and vehicle modification.

(a) At the time of enrollment, the initial cost of waiver services in the person-centered services plan does not exceed the cost limit.

(b) The ongoing cost of waiver services in the person-centered services plan may not exceed the cost limit unless otherwise approved by ODM.

(10) There is an available Ohio home care waiver program slot that does not exceed the centers for medicare and medicaid (CMS)-authorized limit for individuals enrolled for the waiver program year.

(C) An individual is given priority for assessment to determine eligibility for enrollment in the Ohio home care waiver when ODM is made aware that the individual meets the criteria for any of the priority categories set forth in paragraphs (C)(1) to (C)(6) of this rule.

(1) The individual is under twenty-one years of age, and at the time of application:

(a) Received inpatient hospital services for at least fourteen consecutive days; or

(b) Had at least three inpatient hospital stays during the preceding twelve months.

(2) The individual is at least twenty-one but less than sixty years of age and received inpatient hospital services for at least fourteen consecutive days immediately preceding the date of application.

(3) The individual is under sixty years of age and received private duty nursing services in accordance with rule 5160-12-02 of the Administrative Code for at least twelve consecutive months immediately preceding application.

(4) The individual is under sixty years of age, lives in the community and is at imminent risk of institutionalization due to the documented loss of a primary caregiver. Written evidence is needed that substantiates the primary caregiver is unavailable to provide care and support, and the individual would need care in an inpatient hospital setting or a nursing facility (NF).

(5) The individual is under sixty years of age and resides in a medicaid-funded NF at the time of application.

(6) The individual is determined by ODM to be eligible for the HOME choice ("Helping Ohioans Move, Expanding Choice") program in accordance with Chapter 5160-51 of the Administrative Code.

(D) If at any time the individual does not meet the criteria in paragraph (A) or paragraph (B) of this rule, the individual will be denied enrollment or disenrolled from the Ohio home care waiver program. In such instances, the individual is notified of their hearing rights in accordance with division 5101:6 of the Administrative Code.

(E) Individuals will be disenrolled from the Ohio home care waiver program no later than one hundred and twenty calendar days following their sixtieth birthday. Individuals are offered the opportunity to transition to the pre-admission screening system providing options and resources today (PASSPORT) waiver if all program eligibility criteria are met in accordance with rule 5160-31-03 of the Administrative Code.

Last updated September 22, 2025 at 7:44 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5164.02, 5162.03, 5166.02, 5166.121
Five Year Review Date: 9/22/2030
Prior Effective Dates: 5/1/1987, 3/1/1992 (Emer.), 10/30/1992, 9/29/2000, 7/1/2016

Rule 5160-46-04 | Ohio home care waiver: personal care aide service.

• Effective: September 22, 2025
• Promulgated Under: 119.03

This rule sets forth the definition of personal care aide services and as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Personal care aide services" are defined as services provided pursuant to the person-centered services plan (PCSP) that assist the individual with activities of daily living (ADL) and instrumental activities of daily living (IADL) needs. If the provider cannot perform IADLs, the provider will notify the Ohio department of medicaid (ODM) or its designee, in writing, of the service limitations before inclusion on the individual's PCSP. Personal care aide services include:

(1) Bathing, dressing, grooming, nail care, hair care, oral hygiene, shaving, deodorant application, skin care, foot care, feeding, toileting, assisting with ambulation, positioning in bed, transferring, range of motion exercises, and monitoring of intake and output;

(2) General homemaking activities, including but not limited to: meal preparation and cleanup, laundry, bed-making, dusting, vacuuming, washing floors, and waste disposal;

(3) Paying bills and assisting with personal correspondence as directed by the individual; and

(4) Accompanying or transporting the individual to Ohio home care waiver services, medical appointments, other community services, and running errands on behalf of that individual.

(B) Personal care aide services do not include tasks performed, or services provided as part of the home maintenance and chore services set forth in rule 5160-44-12 of the Administrative Code.

(C) Personal care aide services do not include services performed in excess of the number of hours approved pursuant to the PCSP.

(D) Personal care aides will not administer prescribed or over-the-counter medications to the individual, but may, unless otherwise prohibited by the provider's certification or accreditation status, pursuant to paragraph (C) of rule 4723-13-02 of the Administrative Code, help the individual self-administer medications by:

(1) Reminding the individual when to take the medication, and observing to ensure the individual follows the directions on the container;

(2) Assisting the individual by taking the medication in its container from where it is stored and handing the container to the individual;

(3) Opening the container for an individual who is physically unable to open the container;

(4) Assisting an individual who is physically-impaired, but mentally alert, in removing oral or topical medication from the container and in taking or applying the medication; and

(5) Assisting an individual who is physically unable to place a dose of medication in his or her mouth without spilling or dropping it, by placing the dose in another container and placing that container to the mouth of the individual.

(E) Personal care aide services will be delivered by one of the following:

(1) An employee of a medicare-certified, or otherwise-accredited home health agency; or

(2) A non-agency personal care aide.

(F) In order to be a provider and submit a claim for reimbursement, all personal care aide service providers will meet the following:

(1) Provide personal care aide services for one individual, or for up to three individuals in a group setting during a face-to-face visit.

(2) Comply with the additional applicable provider-specific criteria as specified in paragraph (G) or (H) of this rule.

(G) Medicare-certified and otherwise-accredited agencies will ensure that personal care aides meet the following criteria:

(1) Before commencing service delivery, the personal care aide will:

(a) Obtain a certificate of completion of either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health under section 3721.31 of the Revised Code, or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.80 (as in effect on October 1, 2024), and

(b) Obtain and maintain first aid certification from a program that may be from a class that is not solely internet-based, and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(2) Maintain evidence of the completion of eight hours of in-service continuing education within a twelve-month period, excluding agency and program-specific orientation. Continuing education will be initiated immediately and will be completed annually thereafter.

(3) Receive supervision from a licensed RN or a licensed LPN at the direction of a medical professional in accordance with section 4723.01 of the Revised Code. The supervising RN or LPN will:

(a) Conduct a face-to-face individual home visit at least every sixty days while the personal care aide is present and providing care to evaluate the provision of personal care aide services and the individual's satisfaction with care delivery and personal care aide's performance.

Document each visit in the individual's record.

(b) Discuss the evaluation of personal care aide services with the case manager.

(4) Parents of minor children, spouses, and relatives appointed legal decision making authority for the individual may only serve as a direct care worker in accordance with rule 5160-44-32 of the Administrative Code.

(5) This rule sets the minimum standards for Ohio home care waiver agency personal care aide providers. Medicare-certified and otherwise-accredited agencies remain responsible for ensuring the requirements of applicable medicare certification or other accreditation standards are met.

(H) Non-agency personal care aides will meet the following criteria:

(1) Before commencing service delivery personal care aides will have:

(a) Obtained a certificate of completion within the last twenty-four months for either a competency evaluation program or training and competency evaluation program approved or conducted by the Ohio department of health in accordance with section 3721.31 of the Revised Code; or the medicare competency evaluation program for home health aides as specified in 42 C.F.R. 484.80 (as in effect on October 1, 2024); or other equivalent training program. The program will include training in the following areas:

(i) Personal care aide services as defined in paragraph (A) of this rule;

(ii) Basic home safety; and

(iii) Universal precautions for the prevention of disease transmission, including hand-washing, proper disposal of bodily waste, and medical instruments that are sharp or may produce sharp pieces if broken.

(b) Obtained and maintained first aid certification from a class that is not solely internet-based and that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course.

(2) Complete six hours of in-service continuing education annually that will occur on or before the anniversary date of their enrollment as a medicaid personal care aide provider. Continuing education topics include, but are not limited to, health and welfare of the individual, cardiopulmonary resuscitation (CPR), patient rights, emergency preparedness, communication skills, aging sensitivity, developmental stages, nutrition, transfer techniques, disease-specific trainings, and mental health issues.

(3) Comply with the individual's or the individual's authorized representative's specific personal care aide service instructions, and perform a return demonstration upon request of the individual or the case manager.

(4) Comply with ODM monitoring activities in accordance with rule 5160-45-06 of the Administrative Code.

(I) All personal care aide providers will maintain a clinical record for each individual served in a manner that protects the confidentiality of these records. Medicare-certified, or otherwise-accredited agencies, will maintain the clinical records at their place of business. Non-agency personal care aides will maintain the clinical records at their place of business and maintain a copy of the records in the individual's residence. For the purposes of this rule, the place of business will be a location other than the individual's residence. At a minimum, the clinical record will contain:

(1) Identifying information of the individual including but not limited to: name, address, age, date of birth, phone number(s) and health insurance identification numbers.

(2) The medical history of the individual.

(3) The name of individual's treating physician.

(4) A copy of the initial and all subsequent PCSP.

(5) Documentation of all drug and food interactions, allergies, and dietary restrictions.

(6) A copy of any advance directives including, but not limited to, a do not resuscitate (DNR) order or medical power of attorney, if they exist.

(7) Documentation of authorized tasks performed or not performed, arrival and departure times, and the dated signatures of the provider and individual or the individual's authorized representative, verifying the service delivery upon completion of the service delivery. The individual or the individual's authorized representative's signature of choice will be documented on the individual's PCSP and will include any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(8) Progress notes signed and dated by the personal care aide, documenting all communications with the case manager, treating physician, other members of the team, and documenting any unusual events occurring during the visit, and the general condition of the individual.

(9) A discharge summary, signed and dated by the departing non-agency personal care aide or the RN supervisor of an agency personal care aide, at the point the personal care aide is no longer going to provide services to the individual, or when the individual no longer needs personal care aide services.

(a) The summary should include documentation regarding progress made toward achievement of goals as specified on the individual's PCSP and indicate any recommended follow-ups or referrals.

(b) The discharge summary is not needed in the event the individual dies.

(J) Personal care aide services will be provided in accordance with the individual's PCSP.

Last updated September 22, 2025 at 7:44 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5162.03, 5164.02, 5166.02
Five Year Review Date: 9/22/2030
Prior Effective Dates: 3/30/1990 (Emer.), 7/1/1990, 9/1/1993, 1/1/1996, 7/1/1998, 11/3/2016, 7/1/2019, 12/10/2020

Rule 5160-46-06 | Ohio home care waiver program: reimbursement rates and billing procedures.

• Effective: September 22, 2025
• Promulgated Under: 119.03

(A) The following waiver services are covered by the Ohio home care waiver:

(1) Home delivered meals as described in rule 5160-44-11 of the Administrative Code

(2) Home maintenance and chores as described in rule 5160-44-12 of the Administrative Code

(3) Home modification as described in rule 5160-44-13 of the Administrative Code

(4) Community integration as described in rule 5160-44-14 of the Administrative Code

(5) Personal emergency response systems as described in rule 5160-44-16 of the Administrative Code

(6) Out-of-home respite as described in rule 5160-44-17 of the Administrative Code

(7) Waiver nursing as described in rule 5160-44-22 of the Administrative Code

(8) Community transition as described in rule 5160-44-26 of the Administrative Code

(9) Home care attendant as described in rule 5160-44-27 of the Administrative Code

(10) Structured family caregiving as described in rule 5160-44-33 of the Administrative Code

(11) Personal care aide as described in rule 5160-46-04 of the Administrative Code

(12) Vehicle modifications as described in rule 5160-46-09 of the Administrative Code

(13) Supplemental transportation as described in rule 5160-46-10 of the Administrative Code

(14) Supplemental adaptive and assistive devices as described in rule 5160-46-11 of the Administrative Code

(15) Adult day health center as described in rule 5160-46-12 of the Administrative Code

(B) Definitions of terms used for billing and calculating rates.

(1) "Base rate," as used in table A, column 3 of paragraph (C) of this rule, means the amount reimbursed by the Ohio department of medicaid (ODM) for the first thirty-five to sixty minutes of service delivered.

(2) "Bid rate," as used in table B, column 3 of paragraph (C) of this rule, means the per job bid rate negotiated between the provider and the individual's case manager.

(3) "Billing unit," as used in table B, column 3 of paragraph (C) of this rule, means a single fixed item, amount of time or measurement (e.g., a meal, a day, or mile, etc.).

(4) "Caretaker relative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(5) "Group rate," as used in paragraph (E)(1) of this rule, means the amount that waiver nursing and personal care aide service providers are reimbursed when the service is provided in a group setting.

(6) "Group setting" means a setting in which:

(a) A personal care aide service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(b) A waiver nursing service provider furnishes the same type of services to either:

(i) Two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(ii) Two to four individuals at the same address if all of the individuals receiving ODM-administered waiver nursing services are:

(a) Medically fragile children,

(b) Siblings, and

(c) Residing together in the home of their caretaker relative. The services provided in the group setting will be ODM-administered waiver nursing services.

(c) A structured family caregiving service provider furnishes the same type of services to two or three individuals at the same address. The services provided in the group setting can be either the same type of ODM-administered waiver service, or a combination of ODM-administered waiver services and similar non-ODM-administered waiver services.

(7) "Medicaid maximum rate" means the maximum amount that will be paid by medicaid for the service rendered.

(a) For the billing codes in table B of paragraph (C) of this rule, the medicaid maximum rate is set forth in column (4).

(b) For the billing codes in table A of paragraph (C) of this rule, the medicaid maximum rate is:

(i) The base rate as defined in paragraph (C)(1) of this rule, or

(ii) The base rate as defined in paragraph (C)(1) of this rule plus the unit rate as defined in paragraph (C)(7) of this rule for each additional unit of service delivered, or

(iii) The unit rate as defined in paragraph (C)(7)(b) of this rule.

(8) "Medically fragile child" means an individual who is under eighteen years of age, has intensive health care needs, and is considered blind or disabled under section 1614(a)(2) or (3) of the "Social Security Act," (42 U.S.C. 1382c(a)(2) or (3)) (as in effect on January 1, 2024).

(9) "Modifier," as used in paragraph (E) of this rule, means the additional two-alpha-numeric-digit billing codes that providers are required to use to provide additional information regarding service delivery.

(10) "Unit rate," as used in table A, column 4 of paragraph (C) of this rule, means the amount reimbursed by ODM for each fifteen minutes of service delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. ODM will reimburse a maximum of only one unit if the service is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(C) Billing code tables.

Column1	Column 2	Column 3	Column 4
Billing code	Service	Baserate	Unitrate
T1002	Waiver nursing services provided by an agencyRN	$68.44	$9.25
T1002	Waiver nursingservices provided by a non-agency RN	$56.26	$7.46
T1002	Waiver nursingservices provided by a non-agency RN (overtime)	$84.39	$11.19
T1003	Waiver nursingservices provided by an agency LPN	$58.72	$7.82
T1003	Waiver nursingservices provided by a non-agency LPN	$48.00	$6.24
T1003	Waiver nursingservices provided by a non-agency LPN (overtime)	$72.00	$9.36
T1019	Personal careaide services provided by an agency personal care aide	$28.96	$7.24
T1019	Personal careaide services provided by a non-agency personal care aide	$22.32	$5.58
T1019	Personal care aide services provided by anon-agency personal care aide (overtime)	$33.48	$8.37

Column1	Column 2	Column 3	Column 4
Billing code	Service	Billingunit	Medicaid maximumrate
H0045	Out-of-home respite services	Per day	$199.82
S0215	Supplementaltransportation services	Permile	$0.48
S5101	Adult day health center services	Per half day	$53.11
S5102	Adult day health center services	Per day	$106.26
S5136	Structuredfamily caregiving	Perday	$102.68
S5136	Structured family caregiving	Per half day	$51.34
S5160	Personalemergency response systems	Perinstallation and testing	$32.95
S5161	Personalemergency response systems	Permonthly fee	$32.95
S5165	Homemodification services	Peritem	Amount prior-authorized on theperson-centered services plan, not to exceed $10,000 in a twelve-month calendaryear
T2029	Supplemental adaptive and assistive deviceservices	Per item	Amount prior-authorized on the person-centeredservices plan, not to exceed $10,000 in a twelve-month calendaryear
S5170	Home delivered meal services - standardmeal	Per meal	$8.80
S5170	Home deliveredmeal services - therapeutic or kosher meal	Per meal	$10.61
S5135	Communityintegration services	Perfifteen-minute unit	$3.93
T2038	Communitytransition services	Perjob	$2,000 per waiverenrollment
T2039	Vehiclemodification service	Perjob	Amount prior-authorized on theperson-centered services plan not to exceed $10,000 in a twelve-month calendaryear
S5121	Home maintenance and chore services	Per job	Amount prior-authorized on the person-centered services plan, notto exceed $10,000 in a twelve-month calendaryear

(D) The amount of reimbursement for a service will be the lesser of the provider's billed charge or the medicaid maximum rate.

(E) Required modifiers.

(1) The "HQ" modifier will be used when a provider submits a claim for billing code S5136, T1002, T1003 or T1019 if the service was delivered in a group setting. Reimbursement as a group rate will be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum.

(2) The "TU" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 and the entire claim is being billed as overtime.

(3) The "UA" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 and only a portion of the claim is being billed as overtime.

(4) The "UD" modifier will be used when a provider submits a claim for billing code S5136 for a half day of structured family caregiving.

(5) The "U1" modifier will be used when a provider submits a claim for billing code T1002 and the individual enrolled on the Ohio home care waiver is receiving infusion therapy.

(6) The "U2" modifier will be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to an individual enrolled on the Ohio home care waiver for the same date of service.

(7) The "U3" modifier will be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for three or more visits to an individual enrolled on the Ohio home care waiver for the same date of service.

(8) The "U4" modifier will be used when a provider submits a claim for billing code T1002, T1003 or T1019 for a single visit that was more than twelve hours in length but did not exceed sixteen hours.

(9) The "U6" modifier will be used when a provider submits a claim for billing code S5170 for a therapeutic or kosher home delivered meal.

(F) Claims will be submitted to, and reimbursement will be provided by, ODM in accordance with Chapter 5160-1 of the Administrative Code.

Last updated September 22, 2025 at 7:45 AM

Supplemental Information

Authorized By: 5162.03, 5166.02
Amplifies: 5166.02, 5166.041
Five Year Review Date: 10/1/2029
Prior Effective Dates: 10/1/2024

Rule 5160-46-06.1 | Ohio home care waiver program: home care attendant services reimbursement rates and billing procedures.

• Effective: January 1, 2024
• Promulgated Under: 119.03

(A) Definitions of terms used for billing and calculating home care attendant services (HCAS) rates.

(1) "Base rate," as set forth in column 3 of tables A and B of this rule, means the amount reimbursed by Ohio medicaid for the first thirty-five to sixty minutes of assistance with self-administration of medications and the performance of nursing tasks provided during a single visit.

(2) "Continuous nursing" means nursing services (waiver nursing and/or private duty nursing) that are more than four hours in length and during which personal care aide service tasks as described in paragraph (A)(1) of rule 5160-46-04 of the Administrative Code may be provided incidental to nursing services.

(3) "Group rate" means the amount that HCAS providers will be reimbursed when the service is provided in a group setting.

(4) "Group setting" means a situation in which an HCAS provider furnishes HCAS in accordance with rule 5160-44-27 of the Administrative Code, and as authorized by the Ohio department of medicaid (ODM), to two or three individuals who reside at the same address.

(5) "HCAS visit" is a visit during which HCAS is provided in accordance with rule 5160-44-27 of the Administrative Code. An HCAS visit will not exceed twelve hours or forty-eight units in duration.

(6) "Intermittent nursing" means nursing services (waiver nursing and/or home health nursing) that are four hours or less in length.

(7) "Medicaid maximum rate" means the maximum amount that will be paid by the Ohio medicaid program for the service rendered. The base rate in column 3 and the unit rate in column 4 of table A of this rule, and the base rate in column 3 and the unit rates in column 5 of table B of this rule represent the medicaid maximum rates for HCAS.

(8) "Modifier", as set forth in column 4 of table A of this rule and column 4 of table B of this rule, means the additional two-alpha-numeric-digit billing code as set forth in paragraph (G) of this rule that HCAS providers will use to provide additional information regarding service delivery.

(9) "Unit rate," as set forth in column 5 of table A of this rule and column 5 of table B of this rule, means the amount reimbursed by Ohio medicaid for each fifteen minutes of HCAS delivered when the visit is:

(a) Greater than sixty minutes in length.

(b) Less than or equal to thirty-four minutes in length. Ohio medicaid will reimburse a maximum of only one unit if HCAS is equal to or less than fifteen minutes in length, and a maximum of two units if the service is sixteen through thirty-four minutes in length.

(B) Providers will bill for reimbursement using table A when HCAS is provided in lieu of continuous nursing as described in paragraph (A)(2) of this rule. Personal care aide tasks are included in the unit rate.

Column 1	Column 2	Column 3	Column 4	Column 5
Billing code	Home care attendant service description	Base rate	Modifier	Unit rate
S5125	Assistance with self-administration of medications and/or the performance of nursing tasks (HCAS/N)	$27.53	N/A	$6.39 per fifteen minute unit of HCAS/N delivered during visit
S5125	HCAS/N (overtime)	$35.11	TU or UA	$9.81

(C) Providers will bill for reimbursement using table B when HCAS is provided in lieu of intermittent nursing as described in paragraph (A)(6) of this rule. The first four units of HCAS will be billed for at the base rate. Beginning with the fifth unit of HCAS, assistance with self-administration of medications and the performance of nursing tasks (HCAS/N) will be billed at the HCAS/N unit rate; and personal care aide service tasks (HCAS/PC) will be billed at the HCAS/PC unit rate using the U8 modifier. There is no base rate for HCAS/PC. The HCAS/PC service can only be rendered in conjunction with an HCAS/N service.

Column 1	Column 2	Column 3	Column 4	Column 5
Billing code	Home care attendant service description	Base rate	Modifier	Unit rate
S5125	HCAS/N	$27.53	N/A	$6.39 per fifteen minute unit of HCAS/N delivered during the visit
S5125	HCAS/PC	N/A	U8	$4.70 per fifteen minute unit of HCAS/PC delivered during the visit
S5125	HCAS/N (overtime)	$35.11	TU or UA	$9.81
S5125	HCAS/PC (overtime)	N/A	either TU or UA, and U8	$7.05

(D) The amount of reimbursement for a service will be the lesser of the provider's billed charge or the medicaid maximum rate.

(E) When HCAS/N and HCAS/PC are provided during an uninterrupted period of time, the visit will be considered a single HCAS visit. An HCAS provider is entitled to only one base rate during an HCAS visit.

(F) HCAS providers will be limited to a maximum of twelve hours or forty-eight units of HCAS during a twenty-four-hour period, regardless of the number of individuals enrolled on an ODM-administered waiver who are served.

(G) Required modifiers.

(1) The "HQ" modifier will be used when a provider submits a claim if HCAS was delivered in a group setting. Reimbursement at a group rate will be the lesser of the provider's billed charge or seventy-five per cent of the medicaid maximum rate.

(2) The "TU" modifier will be used when a provider submits a claim for billing code S5125 and the entire visit is being billed as overtime.

(3) The "UA" modifier will be used when a provider submits a claim for billing code S5125 and only a portion of the visit is being billed as overtime.

(4) The "U2" modifier will be used when a provider submits a claim for a second HCAS visit to an individual enrolled on the Ohio home care waiver for the same date of service.

(5) The "U3" modifier will be used when the same provider submits a claim for three or more HCAS visits to an individual enrolled on the Ohio home care waiver for the same date of service.

(6) The "U8" modifier will be used when a provider submits a claim for an HCAS visit that is in lieu of intermittent nursing as described in paragraph (A)(6) of this rule, and for units of service that are HCAS/PC.

(H) Claims will be submitted to, and reimbursement will be provided by, the ODM in accordance with Chapter 5160-1 of the Administrative Code.

Last updated September 12, 2025 at 8:35 AM

Supplemental Information

Authorized By: 5166.02, 5166.30
Amplifies: 5162.03, 5164.02, 5166.30, 5166.301, 5166.302, 5166.303, 5166.304, 5166.305, 5166.306, 5166.307, 5166.308, 5166.309, 5166.3010
Five Year Review Date: 1/1/2029
Prior Effective Dates: 10/1/2011, 8/1/2015, 1/1/2017

Rule 5160-46-09 | Ohio home care waiver: vehicle modification service.

• Effective: September 22, 2025
• Promulgated Under: 119.03

This rule sets forth the definition of the vehicle modification service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Vehicle modifications" are adaptations or alterations to an automobile that is identified as the individual's primary means of transportation, that are needed in order to accommodate the needs of the individual. Vehicle modifications are authorized when necessary to enable the individual to function with greater independence, integrate more fully into the community, and to ensure the health, welfare, and safety of the individual.

(B) Vehicle modifications include but are not limited to:

(1) External handling devices and carriers.

(2) Operating aids, such as assistive equipment and technologies.

(3) Raised or lowered floors or roofs.

(4) Raised doors.

(5) Scooter/wheelchair hoists, hitches, and tie downs.

(6) Lifts.

(7) Maintenance, repair, or replacement of a previous vehicle modification funded by the individual's waiver that does not meet reimbursement criteria through another source.

(8) Transfers of adaptable equipment from one vehicle to another for use by the same individual in accordance with this rule.

(9) Factory-installed adaptations when documented on a separate, itemized invoice associated with the purchase of a new vehicle that is not pre-owned or pre-leased. Such modifications are payable upon proof of transfer of vehicle ownership from the dealer into the name of the allowable owner of the vehicle as described in this rule.

(C) Vehicle modifications do not include:

(1) Modifications that are available through another funding source.

(2) Routine auto care and maintenance of general utility unrelated to the vehicle's modification.

(3) Replacement or repair of previously approved vehicle modifications damaged because of apparent misuse, abuse, or negligence.

(4) Payment for purchase of a vehicle except as set forth in paragraph (B)(9) of this rule.

(5) Permanent modifications to leased vehicles.

(6) Vehicle insurance costs.

(7) Services performed which exceed what is specified on the individual's person-centered services plan.

(8) Removal of a modification except set forth in paragraph (B)(8) of this rule.

(9) Repairs needed to a vehicle before a modification can be installed.

(D) Limitations:

(1) Service authorization is limited to ten thousand dollars per calendar year per individual.

(2) Vehicle modifications will only be made to a vehicle owned by one of the following:

(a) The individual,

(b) A relative of the individual who provides primary long-term support, whether paid or non-paid, or

(c) A non-relative who provides primary long-term support to the individual and is not a paid provider.

(3) Vehicle modifications are not allowed for vehicles owned by business entities or provider agencies.

(E) Service authorization process

(1) Prior to the service being authorized, the individual, and if applicable any person(s) who will operate the vehicle will provide the Ohio department of medicaid (ODM) or its designee with the following documentation:

(a) The valid driver's license for the person(s) who will be operating the vehicle, with appropriate endorsements;

(b) Proof of ownership and current title or registration of the vehicle to be modified;

(c) Written consent from the vehicle owner to modify the vehicle, including acknowledgment that the vehicle owner understands that ODM is not responsible for returning the vehicle to its prior condition;

(d) Written attestation from the individual or the individual's parent or guardian, as applicable, that identifies the vehicle to be modified as the individual's primary means of transportation; and

(e) Proof of active collision and liability insurance for the vehicle being modified.

(2) ODM or its designee may require the completion of an evaluation by an occupational therapist (OT) or physical therapist (PT). The evaluation will determine the appropriate vehicle modification and the individual's capacity to utilize the vehicle modification.

(3) In consultation with the individual and any person(s) who will be operating the vehicle, ODM or its designee, or the OT or PT will develop a vehicle modification referral that is intended to address the individuals needs.

(4) All submitted proposals will be reviewed by the individual, the individual's parent or guardian, as applicable, the owner of the vehicle if other than the individual, and ODM or its designee.

(5) The service will be awarded to the provider who proposes the lowest cost alternative that meets the individual's assessed need.

(F) Vehicle modification provider:

(1) Vehicle modification providers will submit a fixed cost proposal to ODM or its designee.

(a) The proposal is developed to meet the individual's needs as identified in the evaluation and includes the following:

(i) A description of the work to be performed;

(ii) A drawing or diagram of the modification(s);

(iii) Itemized materials and associated costs;

(iv) Year, make, and model of the vehicle being modified;

(v) Documentation from an automotive service excellence-certified professional stating the vehicle is in good operating condition including that it is structurally sound;

(vi) Estimated time needed to complete the modification;

(vii) A written statement of warranties provided, including a warranty lasting at least one year from date of final acceptance of work against defective workmanship; and

(viii) A written guarantee that all materials furnished and modifications installed perform their intended function.

(b) A fixed proposal may be adjusted with good cause only if the job specifications are modified in writing, and the adjustment is approved by ODM or its designee.

(2) Upon completion of a vehicle modification, but before submitting a claim, the vehicle modification provider will:

(a) Perform all necessary inspections and submit documentation to verify the repair, modification, or installation was completed in accordance with applicable federal, state, and local laws;

(b) Document that the vehicle modification was tested, is in proper working order, and is safe to be operated by the individual or his or her caregiver;

(c) Attest that the individual and if applicable, any other person(s) who will operate the vehicle modification, was instructed on the usage of the modification;

(d) Attest the vehicle modification was completed in accordance with the agreed upon specifications using all the materials and equipment described in the proposal; and

(e) Obtain final written confirmation from the individual, the individual's parent or guardian as applicable, and the owner of the vehicle if other than the individual, that the vehicle modification has been completed to their satisfaction.

(3) Request for reimbursements include:

(a) Itemized cost of material and labor as identified in the approved proposal and

(b) Any approved adjustments made per paragraph (F)(2)(b) of this rule.

(G) The authorization of vehicle modifications may be combined with other waiver services to meet the assessed needs of the individual. In such instances, individual waiver service limits as described in paragraph (D)(1) of this rule still apply.

Last updated September 22, 2025 at 7:45 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5162.03, 5164.02, 5166.02
Five Year Review Date: 9/22/2030

Rule 5160-46-10 | Ohio home care waiver: supplemental transportation service.

• Effective: September 22, 2025
• Promulgated Under: 119.03

This rule sets forth the definition of the supplemental transportation service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Supplemental transportation services" are transportation services that are not available through any other resources that enable an individual to access waiver services and other community resources specified on the individual's person-centered services plan (PCSP). Supplemental transportation services include but are not limited to assistance in transferring the individual from the point of pick-up to the vehicle and from the vehicle to the destination point.

(B) Supplemental transportation services do not include services, performed in excess of what is specified on the individual's person-centered services plan.

(C) Agency supplemental transportation service providers will:

(1) Maintain a current list of drivers.

(2) Ensure all drivers providing supplemental transportation services are age eighteen years or older.

(3) Maintain a copy of the valid driver's license for each driver.

(4) Maintain collision and liability insurance for each vehicle and driver used to provide supplemental transportation services.

(5) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(6) Obtain and maintain a certificate of completion of a course in first aid for each driver used to provide supplemental transportation services, that is not solely internet-based, that includes hands-on training by a certified first aid instructor and a successful return demonstration of what was learned in the course. Obtain certification that education was received from the authorizing health care professional about health and welfare considerations appropriate for an individual or group setting.

(7) Ensure drivers are not the individual's foster caregiver or legally responsible family member as defined in rule 5160-45-01 of the Administrative Code.

(D) Non-agency supplemental transportation service providers will:

(1) Be age eighteen years or older.

(2) Possess a valid driver's license.

(3) Maintain collision and liability insurance for each vehicle used to provide supplemental transportation services.

(4) Obtain and exhibit evidence of a valid motor vehicle inspection from the Ohio highway patrol for each vehicle used in the provision of supplemental transportation services.

(5) Complete and maintain a certificate of completion of first aid from a class that is not solely internet-based, that includes hands-on training by a certified first aid instructor, and a successful return demonstration of what was learned in the course. Obtain certification that education was received from the authorizing health care professional about health and welfare considerations appropriate for an individual or group setting.

(6) Not be the individual's foster caregiver or legally responsible family member as defined in rule 5160-45-01 of the Administrative Code.

(E) All supplemental transportation service providers will:

(1) Maintain documentation that, at a minimum, includes a log identifying the individual transported, the date of service, pick-up point, destination point, mileage for each trip, and the signature of the individual receiving supplemental transportation services, or the individual's authorized representative. The individual's or authorized representative's signature of choice will be documented on the individual's PCSP and will include any of the following: a handwritten signature, initials, a stamp or mark, or an electronic signature.

(2) Maintain a daily vehicle inspection log.

(3) Ensure a fire extinguisher is in each vehicle.

(4) Ensure potentially harmful items (such as lighters, sharp objects, etc.) are not left in vehicles.

(F) Supplemental transportation services will be provided in accordance with the individual's person-centered services plan.

Last updated September 22, 2025 at 7:45 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5162.03, 5164.02, 5166.02
Five Year Review Date: 9/22/2030

Rule 5160-46-11 | Ohio home care waiver: supplemental assistive and adaptive device service.

• Effective: September 22, 2025
• Promulgated Under: 119.03

This rule sets forth the definition of the supplemental assistive and adaptive devices service and provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Supplemental adaptive and assistive device services" are medical equipment, supplies, and devices that not otherwise available through any other funding source and that are suitable to enable the individual to function with greater independence, avoid institutionalization, and reduce the need for human assistance. All supplemental adaptive and assistive device services will be prior-approved by the Ohio department of medicaid (ODM) or its designee. ODM or its designee will only approve the lowest cost alternative that meets the individual's needs as determined during the assessment process.

(1) Reimbursement for medical equipment, supplies, and devices will not exceed a combined total of ten thousand dollars within a calendar year per individual. Supplemental adaptive and assistive device services in excess of the limit can be approved by ODM or its designee when there is a documented need.

(2) Supplemental adaptive and assistive device services do not include:

(a) Items considered by the federal food and drug administration as experimental or investigational;

(b) Funding of down payments toward the purchase or lease of any supplemental adaptive and assistive devices;

(c) Equipment, supplies, or services furnished in excess of what is approved in the individual's person-centered services plan (PCSP);

(d) Replacement of equipment or supplies, or repair of previously approved equipment or supplies that have been damaged as a result of perceived misuse, abuse, or negligence.

(B) In order to submit a claim for supplemental adaptive and assistive device services, the provider will:

(1) Ensure all manufacturer's rebates have been deducted before requesting reimbursement.

(2) Ensure the supplemental adaptive and assistive device was tested and is in proper working order, and is subject to warranty in accordance with industry standards.

(C) Providers of supplemental adaptive and assistive device services will maintain a clinical record for each individual they serve in a manner that protects confidentiality of these records. At a minimum, the clinical record will include:

(1) Identifying information of the individual including but not limited to name, address, age, date of birth, phone number(s), and health insurance identification numbers.

(2) The name of the individual's treating physician.

(3) A copy of the initial and all subsequent PCSP.

(4) Documentation verifying the date the supplemental adaptive and assistive device service was provided.

(D) The authorization of supplemental adaptive and assistive device services may be combined with other waiver services to meet the assessed needs of the individual. In such instances, the individual waiver service limits as described in paragraph (A)(1) of this rule still apply.

(E) Supplemental adaptive and assistive device services will be provided in accordance with the individual's person-centered services plan.

Last updated September 22, 2025 at 7:45 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5162.03, 5164.02, 5166.02
Five Year Review Date: 9/22/2030

Rule 5160-46-12 | Ohio home care waiver: adult day health center service.

• Effective: September 22, 2025
• Promulgated Under: 119.03

This rule sets forth the definition of the adult day health center service as well as the provider requirements and specifications for the delivery of the service. Providers are also subject to the conditions of participation set forth in rule 5160-44-31 of the Administrative Code. Services are reimbursed in accordance with rule 5160-46-06 of the Administrative Code.

(A) "Adult day health center services (ADHCS)" are regularly scheduled services delivered at an adult day health center to individuals who are age eighteen years or older. A qualifying adult day health center will be a freestanding building or a space within a building that is not a private residence and will not be used for other purposes during the provision of ADHCS.

(1) An adult day health center will provide:

(a) Waiver nursing services as set forth in rule 5160-44-22 of the Administrative Code or personal care aide services as set forth in rule 5160-46-04 of the Administrative Code;

(b) Recreational and educational activities; and

(c) At least one meal, but no more than two meals, per day that meet the individual's dietary needs.

(2) An adult day health center may also provide:

(a) Skilled therapy services as set forth in rule 5160-12-01 of the Administrative Code; and

(b) Transportation of the individual to and from ADHCS. The ADHCS will ensure the following for all vehicles used for transportation:

(i) Maintain a daily vehicle inspection log.

(ii) Ensure a fire extinguisher is in each vehicle.

(iii) Ensure potentially harmful items (such as lighters, sharp objects, etc.) are not left in vehicles.

(3) ADHCS are reimbursable at a full-day rate when five or more hours are provided to an individual in a day. ADHCS are reimbursable at a half-day rate when less than five hours are provided in a day.

(4) Services set forth in paragraphs (A)(1) and (A)(2) of this rule and delivered by an adult day health center will not be reimbursed as separate services.

(B) ADHCS do not include services performed in excess of what is approved pursuant to, and specified on, the individual's person-centered services plan (PCSP).

(C) Providers of ADHCS will operate the adult day health center in compliance with all federal, state, and local laws, rules, and regulations.

(D) All providers of ADHCS will:

(1) Comply with federal nondiscrimination regulations set forth in 45 C.F.R. part 80 (as in effect on October 1, 2024).

(2) Maintain a minimum of one million dollars in commercial liability insurance, which includes coverage for individual's losses due to theft or property damage and a written procedure identifying the steps an individual takes to file a liability claim.

(3) Maintain evidence of non-licensed direct care staff's completion of twelve hours of in-service training every twelve months.

(4) Ensure that any waiver nursing services provided are within the nurse's scope of practice set forth in rule 5160-44-22 of the Administrative Code.

(5) Provide task-based instruction to direct care staff providing personal care aide services set forth in rule 5160-46-04 of the Administrative Code.

(6) At all times, maintain a minimum of a one to six ratio of paid direct care staff to individuals.

(7) Maintain working fire pull stations, fire extinguishers, smoke detectors, and carbon monoxide detectors on each level of the building. Smoke detectors will be tested at least monthly. Fire extinguishers will be serviced at least annually. The provider will maintain documentation which demonstrates testing and service was performed.

(8) Store all cleaning supplies, flammables, combustible, and other potentially hazardous chemicals in a secured location away from furnace, hot water heater, open flame, or food.

(9) Store potentially harmful items (such as tools, knives, etc.), medications, and medical waste disposable bins in a secured location inaccessible to individuals.

(10) Maintain sufficient environmental conditions to ensure the safety of individuals served, including electrical systems and wiring, heating and cooling systems, private well and sewer systems, and secured access to mechanical rooms. All damage to walls, ceilings, windows, doors, and screens which could present a health and safety risk should be promptly repaired.

(11) Maintain an emergency preparedness plan to be used in instances of weather-related (i.e. tornado), fire, and other emergencies. The plan includes a pre-determined tornado shelter area and evacuation site. Ad hoc emergency drills will be conducted at least quarterly, with no more than ninety days between drills. Documentation of the drills, the date, and type will be maintained by the provider. Emergency exits will be readily accessible and unobstructed.

(12) Maintain an elopement policy describing actions of staff responsibilities, including notification to law enforcement in the event of an elopement.

(13) Provide the individual with phone access in a private space.

(14) Maintain evidence of passing a fire inspection completed by the local or state fire marshal.

(a) New service providers as of July 1, 2025: upon application to become an ADHCS service provider.

(b) Current service providers as of July 1, 2025: no later than December 31, 2025 and at least annually, with no more than three hundred sixty-five days between inspections thereafter.

(15) Publicly display the building floor plan displaying the location of fire extinguishers and emergency exits.

(16) Maintain a smoking policy.

(17) Adhere to criteria set forth in paragraph (C) of rule 5160-46-10 of the Administrative Code when providing transportation to individuals.

(E) Providers of ADHCS will maintain a clinical record for each individual served in a manner that protects the confidentiality of these records. At a minimum, the clinical record will contain the following:

(1) Identifying information for the individual including but not limited to name, address, age, date of birth, phone number(s), and health insurance identification numbers.

(2) The medical history of the individual.

(3) The name of the individual's treating physician.

(4) A copy of the initial and all subsequent all service plans.

(5) A copy of any advance directive including, but not limited to, do not resuscitate (DNR) order or medical power of attorney, if they exist.

(6) Documentation of all drug and food interactions, allergies, and dietary restrictions.

(7) Documentation that clearly shows the date of ADHCS delivery, including authorized tasks performed or not performed, and the individual's arrival and departure times.

(8) A discharge summary, signed and dated by the departing ADHCS provider, at the point the individual no longer needs ADHCS. The summary should include documentation regarding progress made toward goal achievement and indicate any recommended follow-ups or referrals.

(9) Documentation of the information set forth in rule 5160-44-22 of the Administrative Code when the individual is provided waiver nursing or skilled therapy services, or both.

(F) Adult day health center services will be provided in accordance with the individual's person-centered services plan.

Last updated September 22, 2025 at 7:45 AM

Supplemental Information

Authorized By: 5166.02
Amplifies: 5162.03, 5164.02, 5166.02
Five Year Review Date: 9/22/2030